Drug Detail:Actemra (Tocilizumab)
Generic Name: TOCILIZUMAB 80mg in 4mL
Dosage Form: injection, solution, concentrate
Drug Class: Interleukin inhibitors
General Considerations for Administration
Not Recommended for Concomitant Use with Biological DMARDs
ACTEMRA has not been studied in combination with biological DMARDs such as TNF antagonists, IL-1R antagonists, anti-CD20 monoclonal antibodies and selective co-stimulation modulators because of the possibility of increased immunosuppression and increased risk of infection. Avoid using ACTEMRA with biological DMARDs.
Baseline Laboratory Evaluation Prior to Treatment
Obtain and assess baseline complete blood count (CBC) and liver function tests prior to treatment.
- RA, GCA, SSc-ILD, PJIA and SJIA – It is recommended that ACTEMRA not be initiated in patients with an absolute neutrophil count (ANC) below 2000 per mm3, platelet count below 100,000 per mm3, or ALT or AST above 1.5 times the upper limit of normal (ULN) [see Warnings and Precautions (5.3, 5.4)].
- CRS – Patients with severe or life-threatening CRS frequently have cytopenias or elevated ALT or AST due to the lymphodepleting chemotherapy or the CRS. The decision to administer ACTEMRA should take into account the potential benefit of treating the CRS versus the risks of short-term treatment with ACTEMRA.
- COVID-19 – It is recommended that ACTEMRA not be initiated in patients with an absolute neutrophil count (ANC) below 1000 per mm3, platelet count below 50,000 mm3, or ALT or AST above 10 times ULN [see Warnings and Precautions (5.3, 5.4)].
Recommended Dosage for Rheumatoid Arthritis
ACTEMRA may be used as monotherapy or concomitantly with methotrexate or other non-biologic DMARDs as an intravenous infusion or as a subcutaneous injection.
Recommended Intravenous Dosage Regimen:
The recommended dosage of ACTEMRA for adult patients given as a 60-minute single intravenous drip infusion is 4 mg per kg every 4 weeks followed by an increase to 8 mg per kg every 4 weeks based on clinical response.
- Reduction of dose from 8 mg per kg to 4 mg per kg is recommended for management of certain dose-related laboratory changes including elevated liver enzymes, neutropenia, and thrombocytopenia [see Dosage and Administration (2.11), Warnings and Precautions (5.3, 5.4), and Adverse Reactions (6.1)].
- Doses exceeding 800 mg per infusion are not recommended in RA patients [see Clinical Pharmacology (12.3)].
Recommended Subcutaneous Dosage Regimen:
| Patients less than 100 kg weight | 162 mg administered subcutaneously every other week, followed by an increase to every week based on clinical response |
| Patients at or above 100 kg weight | 162 mg administered subcutaneously every week |
When transitioning from ACTEMRA intravenous therapy to subcutaneous administration administer the first subcutaneous dose instead of the next scheduled intravenous dose.
Interruption of dose or reduction in frequency of administration of subcutaneous dose from every week to every other week dosing is recommended for management of certain dose-related laboratory changes including elevated liver enzymes, neutropenia, and thrombocytopenia [see Dosage and Administration (2.11), Warnings and Precautions (5.3, 5.4), and Adverse Reactions (6.2)].
Recommended Dosage for Giant Cell Arteritis
Recommended Intravenous Dosage Regimen:
The recommended dosage of ACTEMRA for adult patients given as a 60-minute single intravenous drip infusion is 6 mg per kg every 4 weeks in combination with tapering course of glucocorticoids.
ACTEMRA can be used alone following discontinuation of glucocorticoids.
- Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia [see Dosage and Administration (2.11)].
- Doses exceeding 600 mg per infusion are not recommended in GCA patients [see Clinical Pharmacology (12.3)].
Recommended Subcutaneous Dosage Regimen:
The recommended dose of ACTEMRA for adult patients with GCA is 162 mg given once every week as a subcutaneous injection in combination with a tapering course of glucocorticoids.
A dose of 162 mg given once every other week as a subcutaneous injection in combination with a tapering course of glucocorticoids may be prescribed based on clinical considerations.
ACTEMRA can be used alone following discontinuation of glucocorticoids.
When transitioning from ACTEMRA intravenous therapy to subcutaneous administration, administer the first subcutaneous dose instead of the next scheduled intravenous dose.
Interruption of dose or reduction in frequency of administration of subcutaneous dose from every week to every other week dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia [see Dosage and Administration (2.11)].
Recommended Dosage for Systemic Sclerosis-Associated Interstitial Lung Disease
The recommended dose of ACTEMRA for adult patients with SSc-ILD is 162 mg given once every week as a subcutaneous injection.
- Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia [see Dosage and Administration (2.11)].
- Subcutaneous administration with the prefilled ACTPen® autoinjector has not been studied in SSc-ILD.
- Intravenous administration is not approved for SSc-ILD.
Recommended Dosage for Polyarticular Juvenile Idiopathic Arthritis
ACTEMRA may be used as an intravenous infusion or as a subcutaneous injection alone or in combination with methotrexate. Do not change dose based solely on a single visit body weight measurement, as weight may fluctuate.
Recommended Intravenous Dosage Regimen:
The recommended dosage of ACTEMRA for PJIA patients given once every 4 weeks as a 60-minute single intravenous drip infusion is:
| Recommended Intravenous PJIA Dosage Every 4 Weeks | |
|---|---|
| Patients less than 30 kg weight | 10 mg per kg |
| Patients at or above 30 kg weight | 8 mg per kg |
Recommended Subcutaneous Dosage Regimen:
| Recommended Subcutaneous PJIA Dosage | |
|---|---|
| Patients less than 30 kg weight | 162 mg once every 3 weeks |
| Patients at or above 30 kg weight | 162 mg once every 2 weeks |
When transitioning from ACTEMRA intravenous therapy to subcutaneous administration, administer the first subcutaneous dose instead of the next scheduled intravenous dose.
Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia [see Dosage and Administration (2.11].
Recommended Dosage for Systemic Juvenile Idiopathic Arthritis
ACTEMRA may be used as an intravenous infusion or as a subcutaneous injection alone or in combination with methotrexate. Do not change a dose based solely on a single visit body weight measurement, as weight may fluctuate.
Recommended Intravenous Dosage Regimen:
The recommended dose of ACTEMRA for SJIA patients given once every 2 weeks as a 60-minute single intravenous drip infusion is:
| Recommended Intravenous SJIA Dosage Every 2 Weeks | |
|---|---|
| Patients less than 30 kg weight | 12 mg per kg |
| Patients at or above 30 kg weight | 8 mg per kg |
Recommended Subcutaneous Dosage Regimen:
| Recommended Subcutaneous SJIA Dosage | |
|---|---|
| Patients less than 30 kg weight | 162 mg once every two weeks |
| Patients at or above 30 kg weight | 162 mg once every week |
When transitioning from ACTEMRA intravenous therapy to subcutaneous administration, administer the first subcutaneous dose when the next scheduled intravenous dose is due.
Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia [see Dosage and Administration (2.11)].
Recommended Dosage for Cytokine Release Syndrome (CRS)
Use only the intravenous route for treatment of CRS. The recommended dose of ACTEMRA for treatment of CRS given as a 60-minute intravenous infusion is:
| Recommended Intravenous CRS Dosage | |
|---|---|
| Patients less than 30 kg weight | 12 mg per kg |
| Patients at or above 30 kg weight | 8 mg per kg |
| Alone or in combination with corticosteroids | |
- If no clinical improvement in the signs and symptoms of CRS occurs after the first dose, up to 3 additional doses of ACTEMRA may be administered. The interval between consecutive doses should be at least 8 hours.
- Doses exceeding 800 mg per infusion are not recommended in CRS patients.
- Subcutaneous administration is not approved for CRS.
Coronavirus Disease 2019 (COVID-19)
Administer ACTEMRA by intravenous infusion only.
The recommended dosage of ACTEMRA for treatment of adult patients with COVID-19 is 8 mg per kg administered as a single 60-minute intravenous infusion. If clinical signs or symptoms worsen or do not improve after the first dose, one additional infusion of ACTEMRA may be administered at least 8 hours after the initial infusion.
- Doses exceeding 800 mg per infusion are not recommended in patients with COVID-19.
- Subcutaneous administration is not approved for COVID-19.
Preparation and Administration Instructions for Intravenous Infusion
ACTEMRA for intravenous infusion should be diluted by a healthcare professional using aseptic technique as follows:
- Use a sterile needle and syringe to prepare ACTEMRA.
- Patients less than 30 kg: use a 50 mL infusion bag or bottle of 0.9% or 0.45% Sodium Chloride Injection, USP, and then follow steps 1 and 2 below.
- Patients at or above 30 kg weight: use a 100 mL infusion bag or bottle, and then follow steps 1 and 2 below.
- Step 1. Withdraw a volume of 0.9% or 0.45% Sodium Chloride Injection, USP, equal to the volume of the ACTEMRA injection required for the patient's dose from the infusion bag or bottle [see Dosage and Administration (2.2, 2.5, 2.6, 2.7)].
| For Intravenous Use: Volume of ACTEMRA Injection per kg of Body Weight | ||
|---|---|---|
| Dosage | Indication | Volume of ACTEMRA injection per kg of body weight |
| 4 mg/kg | Adult RA | 0.2 mL/kg |
| 6 mg/kg | Adult GCA | 0.3 mL/kg |
| 8 mg/kg | Adult RA Adult COVID-19 SJIA, PJIA and CRS (greater than or equal to 30 kg of body weight) |
0.4 mL/kg |
| 10 mg/kg | PJIA (less than 30 kg of body weight) | 0.5 mL/kg |
| 12 mg/kg | SJIA and CRS (less than 30 kg of body weight) | 0.6 mL/kg |
- Step 2. Withdraw the amount of ACTEMRA for intravenous infusion from the vial(s) and add slowly into the 0.9% or 0.45% Sodium Chloride Injection, USP infusion bag or bottle. To mix the solution, gently invert the bag to avoid foaming.
- The fully diluted ACTEMRA solutions for infusion using 0.9% Sodium Chloride Injection, USP may be stored at 36°F to 46°F (2°C to 8°C) or room temperature for up to 24 hours and should be protected from light.
- The fully diluted ACTEMRA solutions for infusion using 0.45% Sodium Chloride Injection, USP may be stored at 36°F to 46°F (2°C to 8°C) for up to 24 hours or room temperature for up to 4 hours and should be protected from light.
- ACTEMRA solutions do not contain preservatives; therefore, unused product remaining in the vials should not be used.
- Allow the fully diluted ACTEMRA solution to reach room temperature prior to infusion.
- The infusion should be administered over 60 minutes, and must be administered with an infusion set. Do not administer as an intravenous push or bolus.
- ACTEMRA should not be infused concomitantly in the same intravenous line with other drugs. No physical or biochemical compatibility studies have been conducted to evaluate the co-administration of ACTEMRA with other drugs.
- Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If particulates and discolorations are noted, the product should not be used.
- Fully diluted ACTEMRA solutions are compatible with polypropylene, polyethylene and polyvinyl chloride infusion bags and polypropylene, polyethylene and glass infusion bottles.
Preparation and Administration Instructions for Subcutaneous Injection
- ACTEMRA for subcutaneous injection is not intended for intravenous drip infusion.
- Assess suitability of patient for subcutaneous home use and instruct patients to inform a healthcare professional before administering the next dose if they experience any symptoms of allergic reaction. Patients should seek immediate medical attention if they develop symptoms of serious allergic reactions. ACTEMRA subcutaneous injection is intended for use under the guidance of a healthcare practitioner. After proper training in subcutaneous injection technique, a patient may self-inject ACTEMRA or the patient's caregiver may administer ACTEMRA if a healthcare practitioner determines that it is appropriate. PJIA and SJIA patients may self-inject with the ACTEMRA prefilled syringe or ACTPen® autoinjector, or the patient's caregiver may administer ACTEMRA if both the healthcare practitioner and the parent/legal guardian determines it is appropriate [see Use in Specific Populations (8.4)]. Patients, or patient caregivers, should be instructed to follow the directions provided in the Instructions for Use (IFU) for additional details on medication administration.
- Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Do not use ACTEMRA prefilled syringes (PFS) or prefilled ACTPen® autoinjectors exhibiting particulate matter, cloudiness, or discoloration. ACTEMRA for subcutaneous administration should be clear and colorless to pale yellow. Do not use if any part of the PFS or ACTPen® autoinjector appears to be damaged.
- Patients using ACTEMRA for subcutaneous administration should be instructed to inject the full amount in the syringe (0.9 mL) or full amount in the ACTPen® autoinjector (0.9 mL), which provides 162 mg of ACTEMRA, according to the directions provided in the IFU.
- Injection sites should be rotated with each injection and should never be given into moles, scars, or areas where the skin is tender, bruised, red, hard, or not intact.
Dosage Modifications due to Serious Infections or Laboratory Abnormalities
Serious Infections
Hold ACTEMRA treatment if a patient develops a serious infection until the infection is controlled.
Laboratory Abnormalities
Rheumatoid Arthritis, Giant Cell Arteritis and Systemic Sclerosis-Associated Interstitial Lung Disease
| Liver Enzyme Abnormalities [see Warnings and Precautions (5.3,5.4)] | ||
|---|---|---|
| Lab Value | Recommendation for RA and SSc-ILD | Recommendation for GCA |
| Greater than 1 to 3× ULN | Dose modify concomitant DMARDs if appropriate For persistent increases in this range:
|
Dose modify immunomodulatory agents if appropriate For persistent increases in this range:
|
| Greater than 3 to 5× ULN (confirmed by repeat testing) |
Hold ACTEMRA dosing until less than 3× ULN and follow recommendations above for greater than 1 to 3× ULN For persistent increases greater than 3× ULN, discontinue ACTEMRA |
Hold ACTEMRA dosing until less than 3x ULN and follow recommendations above for greater than 1 to 3x ULN For persistent increases greater than 3x ULN, discontinue ACTEMRA |
| Greater than 5× ULN | Discontinue ACTEMRA | Discontinue ACTEMRA |
| Low Absolute Neutrophil Count (ANC) [see Warnings and Precautions (5.4)] | ||
|---|---|---|
| Lab Value (cells per mm3) |
Recommendation for RA and SSc-ILD | Recommendation for GCA |
| ANC greater than 1000 | Maintain dose | Maintain dose |
| ANC 500 to 1000 | Hold ACTEMRA dosing When ANC greater than 1000 cells per mm3:
|
Hold ACTEMRA dosing When ANC greater than 1000 cells per mm3:
|
| ANC less than 500 | Discontinue ACTEMRA | Discontinue ACTEMRA |
| Low Platelet Count [see Warnings and Precautions (5.4)] | ||
|---|---|---|
| Lab Value (cells per mm3) |
Recommendation for RA and SSc-ILD | Recommendation for GCA |
| 50,000 to 100,000 | Hold ACTEMRA dosing When platelet count is greater than 100,000 cells per mm3:
|
Hold ACTEMRA dosing When platelet count is greater than 100,000 cells per mm3:
|
| Less than 50,000 | Discontinue ACTEMRA | Discontinue ACTEMRA |
Polyarticular and Systemic Juvenile Idiopathic Arthritis
Dose reduction of ACTEMRA has not been studied in the PJIA and SJIA populations. Dose interruptions of ACTEMRA are recommended for liver enzyme abnormalities, low neutrophil counts, and low platelet counts in patients with PJIA and SJIA at levels similar to what is outlined above for patients with RA and GCA. If appropriate, dose modify or stop concomitant methotrexate and/or other medications and hold ACTEMRA dosing until the clinical situation has been evaluated. In PJIA and SJIA the decision to discontinue ACTEMRA for a laboratory abnormality should be based upon the medical assessment of the individual patient.
