Correspondence to Dr Giustino Parruti, Infectious Diseases Unit, Pescara Hospital, Pescara 65124, Italy; parrutig@gmail.com Many patients with severe COVID-19 rapidly progress to critical disease with refractory hypoxemia requiring invasive mechanical ventilation (IMV).1 Elevated levels of C reactive protein (CRP) and interleukin-6 (IL-6), reflecting an hyperinflammatory response, identify patients at risk of progression to refractory hypoxemia and death.2 Recent evidences suggested that high-dose intravenous tocilizumab (TCZ), a humanised anti-IL-6 receptor antibody, may rapidly reduce fever and inflammatory markers, and improve oxygenation in severe to critical COVID-19.3–5 Data on the safety and efficacy of subcutaneous TCZ, already approved for the treatment of rheumatoid arthritis, are limited. In this retrospective case–control study, we treated with TCZ 324 mg, given as two concomitant subcutaneous injections, all consecutive patients at Pescara General Hospital, Italy between 28 March and 21 April 2020, with laboratory-confirmed COVID-19 pneumonia (involving ≥20% of lung parenchyma on chest CT), hyperinflammation (CRP ≥20 mg/dL), hypoxemia (oxygen saturation <90% on room air) requiring supplemental oxygen through nasal cannulas or mask, who had no contraindications to treatment such as bacterial or fungal infection, neutropenia or liver injury. None of the patients experienced neutropenia (absolute neutrophil count <1000/mm3), one (2.5%) developed bacterial pneumonia while on IMV, as compared with three (7.5%) in the SOC group, and one (2.5%) had transient moderate liver injury (elevation in alanine aminotransferase five times above the upper limit of normal value), as compared with none in the SOC group (online supplementary table 2).