Can Actemra (Tocilizumab) cause foot pain?

Actemra (Tocilizumab) and Foot Pain

Actemra (tocilizumab) is not specifically associated with foot pain as a common adverse effect, though it may occur as part of joint pain which is a known side effect of the medication.

Adverse Effects Profile of Tocilizumab

Tocilizumab (Actemra) is a humanized anti-interleukin-6 receptor antibody used in treating conditions like rheumatoid arthritis and giant cell arteritis. While foot pain is not specifically listed among its common adverse effects, joint pain in general can occur.

The most common adverse effects of tocilizumab include:

• Upper respiratory tract infections
• Nasopharyngitis
• Headache
• Hypertension
• Elevated liver enzymes
• Neutropenia
• Thrombocytopenia
• Hypercholesterolemia
• Infusion reactions

Musculoskeletal Effects

Joint pain can occur with tocilizumab, though it's not specifically highlighted as a primary concern in the available guidelines. In clinical trials evaluating tocilizumab:

• Early effects of tocilizumab showed improvement in patient-reported disease activity and pain as early as day 7 after first infusion 1
• Comparative effectiveness studies have shown greater pain reduction with baricitinib monotherapy compared to tocilizumab monotherapy 2

Differential Diagnosis of Foot Pain in Patients on Tocilizumab

If a patient on tocilizumab experiences foot pain, consider these potential causes:

1. Underlying rheumatoid arthritis: Foot involvement is common in RA, affecting approximately 14-42% of adults with the condition 3

2. Medication-induced palmoplantar reactions: Several medications can cause foot pain through mechanisms like:

   • Hand-foot skin reaction (HFSR)
   • Palmar-plantar erythrodysesthesia syndrome (PPES)
   • Periarticular thenar erythema with oncolysis (PATEO) syndrome 4

3. Other medication effects: Certain anticancer agents and kinase inhibitors are more commonly associated with foot pain:

   • VEGFR inhibitors like sorafenib (10-62%), cabozantinib (40-60%), sunitinib (10-50%), and regorafenib (47%) can cause hand-foot skin reactions 3
   • Chemotherapy agents including 5-fluorouracil, capecitabine, doxorubicin, and docetaxel can cause palmar-plantar erythrodysesthesia 3

Management Approach

If a patient on tocilizumab reports foot pain:

1. Evaluate the underlying condition: Determine if the pain is related to the primary disease being treated (e.g., rheumatoid arthritis)

2. Consider orthotic intervention: Custom-designed foot orthoses have shown effectiveness in reducing foot pain by 19.1% and foot disability by 30.8% in rheumatoid arthritis patients 5

3. Assess for medication-induced reactions: If the pain appears to be related to a hand-foot skin reaction:

   • For mild reactions: Urea 10% cream three times daily
   • For moderate reactions: Consider dose interruption if symptoms worsen 3

4. Medication adjustment: If tocilizumab is suspected as the cause of significant foot pain, discuss with the rheumatologist about potential alternatives or temporary discontinuation

Important Considerations

• Perioperative management: If foot surgery is needed, tocilizumab is typically stopped 4 weeks prior to surgery according to British Society for Rheumatology guidelines to reduce infection risk 6

• Cost-effectiveness: While not directly related to foot pain, be aware that tocilizumab therapy is significantly more expensive than some alternatives, which may factor into treatment decisions 7

Conclusion

While foot pain is not a prominently reported adverse effect of tocilizumab, it may occur as part of generalized joint pain. When evaluating foot pain in patients taking tocilizumab, consider both the underlying disease process and potential medication effects, with appropriate management strategies based on the identified cause.