What to do with tocilizumab (Interleukin-6 receptor inhibitor) in a patient with a superficial wound?

From the Guidelines

For patients with superficial wounds who are on tocilizumab, it is generally recommended to continue the medication unless there are signs of infection in the wound. Tocilizumab, an interleukin-6 receptor inhibitor commonly used for rheumatoid arthritis and other inflammatory conditions, does not typically need to be discontinued for minor, clean wounds. However, careful wound monitoring is essential as tocilizumab can mask signs of infection by suppressing fever and inflammatory markers. The wound should be properly cleaned, dressed, and monitored for signs of infection such as increasing redness, warmth, pain, purulent discharge, or spreading erythema. If infection is suspected, consider temporarily holding tocilizumab until the infection is controlled with appropriate antibiotics, as suggested by guidelines for managing skin and soft tissue infections 1. This cautious approach is necessary because tocilizumab affects the immune response and can potentially increase infection risk or delay wound healing. For surgical wounds or more significant injuries, consultation with the prescribing physician is advisable to determine if a temporary pause in therapy is warranted based on the individual's specific condition and wound characteristics.

Some key points to consider in managing superficial wounds in patients on tocilizumab include:

• Proper wound care, including irrigation and dressing, as outlined in first aid guidelines 1
• Monitoring for signs of infection, which may be masked by tocilizumab
• Selecting appropriate antibiotic therapy if infection is suspected, based on guidelines for diabetic foot infections 1 and skin and soft tissue infections 1
• Considering the severity of the infection and the likely etiologic agent when selecting an empiric antibiotic regimen 1
• Basing the route of therapy on infection severity, with parenteral therapy preferred for severe infections and oral agents for mild to moderate infections 1

Overall, the management of superficial wounds in patients on tocilizumab requires careful consideration of the potential risks and benefits of continuing or discontinuing therapy, as well as close monitoring for signs of infection and appropriate wound care.

From the Research

Tocilizumab and Superficial Wounds

• Tocilizumab is an Interleukin-6 receptor inhibitor used to treat various conditions, including rheumatoid arthritis and multicentric Castleman disease.
• The use of tocilizumab may increase the risk of infections, including those related to superficial wounds, as it suppresses the body's inflammatory response 2.
• A case study reported a patient with multicentric Castleman disease who developed a disseminated Staphylococcus aureus infection after a superficial skin wound while being treated with tocilizumab 2.

Perioperative Considerations

• Studies have investigated the perioperative use of tocilizumab in patients undergoing orthopaedic surgery, including the risk of postoperative infections and delayed wound healing 3.
• The results suggest that while the incidence of postoperative infections may not be high, the risk of delayed wound healing is significant, particularly in patients undergoing certain types of surgery, such as spinal surgery 3.
• It is essential to monitor patients closely for signs of infection and wound complications when using tocilizumab in the perioperative period 3, 4.

Wound Infection Prevention and Management

• Wound infection can lead to delayed healing, chronicity, and increased healthcare costs 5.
• Early identification and management of wound infection are crucial to prevent negative outcomes 5.
• The use of tocilizumab may mask the signs of infection, making it challenging to diagnose and manage wound infections 6.

Clinical Implications

• Clinicians should be aware of the potential risks of infection and delayed wound healing when using tocilizumab, particularly in patients with superficial wounds 2, 3.
• Close monitoring of patients for signs of infection and wound complications is essential when using tocilizumab in the perioperative period or in patients with superficial wounds 3, 4.
• The masking effect of tocilizumab on inflammatory markers, such as CRP, should be considered when diagnosing and managing infections in patients treated with this medication 6.