From the Research
Tocilizumab should generally be withheld in patients experiencing significant diarrhea and vomiting due to concerns about dehydration, electrolyte imbalances, and potential exacerbation of gastrointestinal symptoms. For patients with mild symptoms, clinical judgment is required, but moderate to severe diarrhea and vomiting warrants temporary discontinuation until symptoms resolve. Before restarting tocilizumab, ensure the patient is adequately hydrated, electrolytes are normalized, and the cause of the gastrointestinal symptoms has been identified and addressed. The rationale for withholding tocilizumab during significant D&V includes the risk of worsening dehydration, the potential for altered drug absorption and metabolism during gastrointestinal distress, and the possibility that the D&V could be a manifestation of infection or gastrointestinal perforation, which are contraindications for tocilizumab, as highlighted in a case report from 1. Additionally, tocilizumab itself can cause gastrointestinal side effects in some patients, so continuing the medication could potentially worsen the existing symptoms. Once the patient has recovered, tocilizumab can typically be resumed at the previous dose without the need for retitration. It is essential to consider the potential for gastrointestinal perforation, a rare but serious side effect of tocilizumab, as reported in 1, and to be aware of the importance of fluid therapy in managing vomiting and diarrhea, as discussed in 2. However, the most recent and highest quality study 1 takes precedence in guiding the decision to withhold tocilizumab in patients with significant D&V.
Some key points to consider when managing patients with D&V on tocilizumab include:
- Ensuring adequate hydration and electrolyte balance
- Identifying and addressing the underlying cause of gastrointestinal symptoms
- Monitoring for signs of gastrointestinal perforation or other serious complications
- Resuming tocilizumab at the previous dose once the patient has recovered, if deemed necessary and safe by the treating physician. The use of anti-emetic medications, as discussed in 3, may also be considered to facilitate oral rehydration therapy and minimize the risk of dehydration and electrolyte imbalances. However, the primary concern in patients with significant D&V on tocilizumab is to prioritize their safety and prevent potential complications, as emphasized in 1.