From the Guidelines
Tocilizumab should not be used in patients with rheumatoid arthritis who have active serious infections, severe liver disease, or certain hematologic abnormalities, as indicated by the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. When considering the use of tocilizumab in patients with rheumatoid arthritis, it is essential to weigh the potential benefits against the risks, particularly in terms of morbidity, mortality, and quality of life. Key considerations include:
- Active serious infections, which could be exacerbated by the immunosuppressive effects of tocilizumab
- Severe liver disease, as tocilizumab may worsen liver function
- Hematologic abnormalities, such as an absolute neutrophil count below 2000/mm³ or a platelet count below 100,000/mm³, which could be indicative of a compromised immune system or bone marrow suppression
- Elevated liver enzymes (ALT/AST levels more than 1.5 times the upper limit of normal), suggesting potential liver injury
- History of gastrointestinal perforations or demyelinating disorders, which may be contraindications due to the potential for worsening these conditions
- Untreated hyperlipidemia, as tocilizumab may increase lipid levels
- Latent tuberculosis or hepatitis B, which should be screened for before initiating tocilizumab therapy The decision to use tocilizumab should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history, as well as the potential benefits of treatment, as outlined in the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1.
From the Research
Contraindications for Tocilizumab in Rheumatoid Arthritis
- Tocilizumab may not be suitable for patients with a history of diverticulitis or gastrointestinal perforation, as it has been associated with an increased risk of these conditions 2, 3.
- Patients with neutropenia or a history of neutropenia induced by previous DMARDs may require careful monitoring and potentially a reduced dosage of tocilizumab 4, 5.
- The presence of extra-articular manifestations and age over 60 years may increase the risk of infections during tocilizumab treatment, and therefore, caution should be exercised when prescribing tocilizumab to these patients 4.
- Tocilizumab may also increase the risk of serious bacterial infections, skin and soft tissue infections, and diverticulitis compared to other biologic drugs such as TNFi or abatacept 3.
Special Considerations
- Patients with rheumatoid arthritis who are initiating tocilizumab should be closely monitored for signs of infection, particularly those with a history of neutropenia or extra-articular manifestations 4, 3.
- The dosage of tocilizumab may need to be adjusted in patients who develop neutropenia, and concomitant use of other DMARDs may increase the risk of neutropenia 5.
- The benefits and risks of tocilizumab should be carefully weighed in patients with a history of diverticulitis or gastrointestinal perforation, and alternative treatments may be considered 2, 3.