Actemra (Tocilizumab) Dosing
For rheumatoid arthritis and most autoimmune indications, the standard intravenous dose of Actemra is 8 mg/kg (maximum 800 mg) infused over 1 hour every 4 weeks, while the subcutaneous formulation is 162 mg weekly. 1
Intravenous Dosing by Indication
Rheumatoid Arthritis
- Standard dose: 8 mg/kg IV every 4 weeks (maximum 800 mg per dose) 1, 2
- Starting dose option: 4 mg/kg IV every 4 weeks with increase to 8 mg/kg based on clinical response (US FDA recommendation) 1, 3
- Can be administered as monotherapy or in combination with methotrexate or other DMARDs 1, 4
- The 8 mg/kg dose demonstrates superior efficacy compared to 4 mg/kg, though both doses show similar responses when combined with methotrexate 2
Cytokine Release Syndrome (CRS) and Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS)
- Grade 1 CRS with concurrent neurotoxicity: 8 mg/kg IV over 1 hour (not to exceed 800 mg/dose) 5
- Repeat every 8 hours as needed for persistent symptoms 5
- Maximum: 3 doses in 24 hours; total maximum of 4 doses 5
- Use caution with repeated tocilizumab doses in patients with ICANS; consider adding corticosteroids after the first dose 5
- Under conditions of limited tocilizumab availability, limit use to maximum of 2 doses during a CRS episode 5
Pediatric COVID-19 with Hyperinflammation
- Body weight <30 kg: 12 mg/kg IV 5
- Body weight ≥30 kg: 8 mg/kg IV (maximum 800 mg) 5
- Monitor for liver function test abnormalities and elevated triglyceride levels 5
Juvenile Idiopathic Arthritis (JIA)
- Dosing follows weight-based protocols similar to adult RA 5
- Monitor CBC and liver function tests within first 1-2 months, then every 3-4 months 5
- Monitor lipids every 6 months as per package insert 5
Subcutaneous Dosing
Rheumatoid Arthritis
- 162 mg SC once weekly using prefilled syringe or autoinjector 1, 6
- Alternative: 162 mg SC every other week (less commonly used) 1
- Self-administered formulation provides convenience and flexibility 6
Dose Modifications
For Elevated Liver Function Tests
- 1-3 times upper limit of normal (ULN): Decrease dose or increase interval between doses 5
- >3 times ULN: Hold dose 5
- >5 times ULN: Discontinue treatment 5
- Do not initiate treatment if baseline LFTs >1.5 times ULN 5
For Neutropenia
- Absolute neutrophil count 500-1,000/mm³: Hold dose until recovery 5
- Neutrophil nadir typically occurs 3-5 days after administration with recovery toward baseline in dose-dependent manner 1
For Thrombocytopenia
- Platelet count 50,000-100,000/mm³: Hold dose until recovery 5
Administration Details
Intravenous Preparation
- Supplied as 20 mg/mL concentration in single-dose vials: 80 mg/4 mL, 200 mg/10 mL, or 400 mg/20 mL 1
- Must be diluted prior to intravenous infusion 1
- Infuse over 1 hour 5
Subcutaneous Preparation
Monitoring Requirements
Laboratory Monitoring
- CBC and liver function tests: Within first 1-2 months, then every 3-4 months 5
- Lipid panel: Every 6 months 5
- Serial monitoring during CRS/ICANS: CRP, ferritin, CBC, CMP, fibrinogen, PT/PTT 5
Infection Surveillance
- Patients treated with tocilizumab are at higher risk for bacterial and fungal infections 5
- Strongly consider antifungal prophylaxis when tocilizumab is combined with corticosteroids for CRS or neurotoxicity 5
Common Pitfalls and Caveats
- Do not exceed 800 mg per dose regardless of calculated weight-based dosing 5, 1
- Tocilizumab does not cross the blood-brain barrier effectively; it is not effective for treating ICANS itself but is used to treat concurrent CRS 5
- The decision to discontinue tocilizumab due to laboratory abnormalities should be based on medical assessment of the individual patient 5
- Gastrointestinal symptoms including abdominal pain and diarrhea may occur 7
- Desensitization protocols exist for patients with hypersensitivity reactions who require continued therapy 7
- No dose adjustment required for mild or moderate renal impairment; not studied in severe renal impairment 1
- Not studied in hepatic impairment including patients with positive HBV or HCV serology 1