Tocilizumab
ACTEMRA
Pronunciation: toe-si-LIZ-oo-mab (ak-TEM-ra)
What it isIL-6 receptor antibody; rheumatoid arthritis, giant cell arteritis and cytokine release syndrome.
Why this oneIt is the treatment for CAR-T cytokine release syndrome and is steroid-sparing in giant cell arteritis.
What limits it⚑ It suppresses CRP and fever, potentially masking infection. Diverticular GI perforation and transaminase elevation can stop therapy.
Pearls
- Monotherapy beat adalimumab; adding methotrexate may add little
- Monitor CBC, lipids and liver enzymes
- Response can begin within 2 weeks
FDA-approved for
- rheumatoid arthritis (2010)
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilitySerious infection, cytopenias, hepatic injury and malignancy risk require laboratory and clinical monitoring.
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Rheumatoid arthritis (IV) | Adult | 4 mg/kg q4wk | 8 mg/kg q4wk | 800 mg/infusion |
| Rheumatoid arthritis (SC) | Adult <100 kg | 162 mg SC every other week | 162 mg SC weekly | |
| Rheumatoid arthritis (SC) | Adult >=100 kg | 162 mg SC weekly | 162 mg SC weekly | |
| Giant cell arteritis | Adult | IV 6 mg/kg q4wk or SC 162 mg weekly | 600 mg/infusion | |
| Polyarticular JIA (IV) | Peds | 10 mg/kg (<30 kg) or 8 mg/kg (>=30 kg) q4wk | ||
| Systemic JIA (IV) | Peds | 12 mg/kg (<30 kg) or 8 mg/kg (>=30 kg) q2wk | ||
| Cytokine release syndrome | >=2 yr | 12 mg/kg (<30 kg) or 8 mg/kg (>=30 kg) IV | 800 mg/infusion | |
| COVID-19 (hospitalized) | Adult/peds | 8 mg/kg IV (12 mg/kg if <30 kg) | 800 mg/infusion |
Renal No adjustment in mild-moderate; not studied in severe
Hepatic Not studied; do not initiate if ALT/AST >1.5x ULN
IV doses >800 mg/infusion (>600 mg in GCA) not recommended
Instructions
- Do not initiate if ANC <2,000/mm3, platelets <100,000/mm3, or ALT/AST >1.5x ULN (RA/GCA/pJIA/sJIA).
- IV: infuse over 60 minutes; do not give as bolus or push.
- Not recommended for concomitant use with biologic DMARDs.
Available strengths
- inj 162 mg/.9 mL
- inj 200 mg/10 mL
- inj 400 mg/20 mL
- inj 80 mg/4 mL
Cautions
- Serious infections incl. TB - screen and interrupt during active infection
- GI perforation
- Hepatotoxicity - monitor LFTs
- Neutropenia, thrombocytopenia, lipid elevations
- Hypersensitivity/anaphylaxis
- Demyelinating disorders
Adverse reactions
- Upper respiratory tract infections
- Nasopharyngitis
- Headache
- Hypertension
- Increased ALT
Pregnancy Insufficient human data to assess drug-associated risk
Lactation No data on presence in human milk; maternal IgG is present in milk
Cost
| Strength | #/mo | generic $/unit | CostPlus | |
|---|---|---|---|---|
| 162 mg/.9 mL | inj | per unit | $821.00/mL | not offered |
| 200 mg/10 mL | inj | per unit | not offered | |
| 400 mg/20 mL | inj | per unit | not offered | |
| 80 mg/4 mL | inj | per unit | not offered |
Generic entry2024 (biosimilar)
Open Tocilizumab in the interactive console ↗
Memory aids: interaction avatars
Open Tocilizumab in the interactive console ↗
Self-check
- Which CAR-T complication is treated with tocilizumab?
Cytokine release syndrome. - How can tocilizumab mask infection?
Suppressing CRP and fever.