Can Actemra (Tocilizumab) be taken with a steroid?

Tocilizumab (Actemra) Can Be Safely Taken with Steroids

Yes, tocilizumab (Actemra) can be safely taken with steroids, and in some clinical scenarios, the combination is recommended as standard treatment. 1, 2

Compatibility of Tocilizumab and Steroids

• Population pharmacokinetic analyses in rheumatoid arthritis patients showed no effect of corticosteroids on tocilizumab clearance, confirming their pharmacological compatibility 2
• In giant cell arteritis patients, no effect of concomitant corticosteroid on tocilizumab exposure was observed 2
• The FDA label for tocilizumab explicitly acknowledges the concurrent use of tocilizumab with corticosteroids in various clinical scenarios 2

Clinical Scenarios Where Combination is Recommended

Cytokine Release Syndrome (CRS)

• For moderate to severe CRS following CAR T-cell therapy, the combination of tocilizumab and corticosteroids is the standard of care 1
• The NCCN guidelines recommend tocilizumab as first-line therapy for CRS, with corticosteroids added for patients who don't respond to tocilizumab alone or who have severe CRS 1
• For grade 3-4 CRS, the recommended approach is tocilizumab 8 mg/kg IV plus high-dose corticosteroids (dexamethasone 10-20 mg IV every 6 hours) 1

COVID-19 Treatment

• In severe COVID-19 with hypoxic respiratory failure, the combination of tocilizumab with corticosteroids has shown improved 28-day survival compared to corticosteroids alone 3
• For patients with hyperinflammation in severe COVID-19, the combination of tocilizumab and corticosteroids is recommended 1

Rheumatologic Conditions

• In giant cell arteritis, tocilizumab plus a glucocorticoid taper has been shown to be effective in maintaining clinical remission 4
• For rheumatoid arthritis, tocilizumab can be used in combination with methotrexate and corticosteroids 5, 6

Dosing Considerations

• For CRS, tocilizumab is typically given at 8 mg/kg IV (maximum 800 mg) with dexamethasone 10 mg IV every 6 hours for 1-3 days 1
• In COVID-19, a regimen of tocilizumab 400 mg with the equivalent of dexamethasone 10 mg daily has shown benefit 3
• For giant cell arteritis, subcutaneous tocilizumab (162 mg weekly or every other week) is used with a prednisone taper 4

Potential Benefits of Combination Therapy

• Steroids can help manage the inflammatory response while tocilizumab targets IL-6 specifically 1
• The combination may allow for faster tapering of steroids, potentially reducing steroid-related adverse effects 4
• In CRS, the combination has shown better efficacy than either agent alone for severe cases 1

Precautions and Monitoring

• Antifungal prophylaxis should be strongly considered in patients receiving both steroids and tocilizumab for CRS or neurotoxicity 1
• Monitor for infections, as both medications are immunosuppressive 2
• For patients with CAR T-cell therapy, dexamethasone may be preferred over other steroids when neurologic symptoms are present due to better blood-brain barrier penetration 1

Common Pitfalls to Avoid

• Don't withhold steroids in severe CRS due to theoretical concerns about reducing CAR T-cell efficacy; studies have not supported this concern 1
• Avoid using tocilizumab alone for immune effector cell-associated neurotoxicity syndrome (ICANS), as there is no clear therapeutic role and it may potentially contribute to ICANS 1
• Be aware that the combination increases infection risk, so appropriate prophylaxis and monitoring are essential 1, 2

In summary, tocilizumab and steroids can be safely administered together, with their combination being standard practice in several clinical scenarios including CRS, COVID-19, and certain rheumatologic conditions.