tocilizumab (Rx)

Brand and Other Names:Actemra
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

injectable solution

  • 20mg/mL (4-, 10-, and 20-mL single-dose vials)

injection, single-use autoinjector (ACTPen) for SC

  • 162mg/0.9mL

injection, single-use prefilled syringe for SC

  • 162mg/0.9mL

Rheumatoid Arthritis

Indicated for adults with moderate-to-severe active rheumatoid arthritis with inadequate response to 1 or more disease modifying antirheumatic drugs (DMARDs)

May use alone or in combination with methotrexate or other DMARDs

IV infusion

4 mg/kg IV q4Weeks initially; may increase to 8 mg/kg q4Weeks based on clinical response  

Not to exceed 800 mg/dose q4weeks

SC injection

  • Weight <100 kg: 162 mg SC every other week, followed by an increase to weekly based on clinical response
  • Weight ≥100 kg: 162 mg SC weekly

Giant Cell Arteritis

Indicated for treatment of giant cell arteritis (GCA)

162 mg SC weekly in combination with a tapering course of glucocorticoids

Based on clinical considerations, may consider administering 162 mg SC every other week in combination with a tapering course of glucocorticoids

May be used alone following discontinuation of glucocorticoids (eg, interruption of dosing may be needed for management of dose-related laboratory abnormalities)

Not approved for IV administration

Interstitial Lung Disease

Indicated for slowing the rate of decline in pulmonary function in adults with systemic sclerosis-associated interstitial lung disease (SSc-ILD)

162 mg SC qWeek

SC administration with the prefilled ACTPen autoinjector has not been studied in SSc-ILD

IV administration not approved for SSc-ILD

Cytokine Release Syndrome

Indicated for the treatment of chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome (CRS)

8 mg/kg IV once; may be administered as alone or in combination with corticosteroids

If no clinical improvement in the signs and symptoms of CRS occurs after initial dose, may administer up to 3 additional doses; allow 8-hr interval between consecutive doses

Not approved for SC administration

COVID-19 (EUA)

June 24, 2021: Emergency use authorization (EUA) issued by the FDA for treatment of coronavirus disease 2019 (COVID-19) in hospitalized adults and pediatric patients (aged >2 years) who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or ECMO

8 mg/kg IV; not to exceed 800 mg/dose

May administer 1 additional IV infusion 8 hr after first infusion if clinical signs or symptoms worsen or unimproved

SC administration not authorized for treatment of COVID-19

Additional Medscape COVID-19 references are available

Dosage Modifications

Renal impairment

  • Mild-to-moderate (eGFR ≥30 mL/min): No dosage adjustment required
  • Severe (eGFR <30 mL/min): Not studied

Hepatic impairment

  • Not recommended with active hepatic disease or hepatic impairment

Liver enzyme abnormalities for RA, GCA, or SSc-ILD

  • >1 to ≤3x ULN
    • Modify dose concomitant DMARDs (RA, SSc-ILD) or immunomodulatory agents (GCA) if appropriate
    • Persistent increases (IV infusion): Reduce tocilizumab dose to 4 mg/kg OR hold dose and restart until ALT/AST return to normal
    • Persistent increases (SC injection): Reduce injection frequency to every other week OR hold dose until ALT/AST return to normal, resume at every other week and increase frequency to every week as clinically appropriate
  • >3 to ≤5x ULN
    • Hold dose until <3x ULN and follow recommendations above for >1 to ≤3x ULN
    • Persistent increases >3x ULN: Discontinue tocilizumab
  • >5x ULN
    • Discontinue therapy

Neutropenia for RA, GCA, or SSc-ILD

ANC >1000 cells/mm3: Maintain dose

  • ANC 500-1000 cells/mm3
    • Hold dose, resume when ANC >1000 cells/mm3
    • IV: Resume at 4 mg/kg and increase to 8 mg/kg as clinically appropriate
    • SC: Resume 162 mg at every other week and increase frequency to weekly as clinically appropriate
  • ANC <500 cell/mm3
    • Discontinue therapy

Thrombocytopenia for RA, GCA, SSc-ILD

  • 50,000-10,000 cells/mm3
    • Hold dose, resume when platelet count >100,000 cells/mm3
    • IV: Resume therapy at 4 mg/kg and increase to 8 mg/kg if clinically appropriate
    • SC: Resume at 162 mg every other week and increase frequency to weekly as clinically appropriate
  • <50,000 cells/mm3
    • Discontinue therapy

Systemic Sclerosis (Orphan)

Orphan designation for treatment of systemic sclerosis

Orphan sponsor

  • Genentech, Inc.; 1 DNA Way; South San Francisco, CA 94080-4990

Dosage Forms & Strengths

injectable solution

  • 20mg/mL (4-, 10-, and 20-mL single-dose vials)

injection, single-use prefilled syringe for SC

  • 162mg/0.9mL

Systemic Juvenile Idiopathic Arthritis

Indicated for the treatment of active systemic juvenile idiopathic arthritis (SJIA) in in patients ≥2 years

IV or SC may be administered as monotherapy or with methotrexate

<2 years: Safety and efficacy not established

IV infusion

  • ≥2 years (<30 kg): 12 mg/kg IV q2weeks  
  • ≥2 years (≥30 kg): 8 mg/kg IV q2weeks

SC injection

  • ≥2 years (<30 kg): 162 mg SC q2weeks
  • ≥2 years (≥30 kg): 162 mg SC weekly

Polyarticular Juvenile Idiopathic Arthritis

Indicated for active polyarticular juvenile idiopathic arthritis (PJIA) in patients ≥2 years

IV or SC may be administered as monotherapy or with methotrexate

<2 years: Safety and efficacy not established

IV infusion

  • ≥2 years (<30 kg): 10 mg/kg IV q4weeks  
  • ≥2 years (≥30 kg): 8 mg/kg IV q4weeks

SC injection

  • ≥2 years (<30 kg): 162 mg SC q3weeks
  • ≥2 years (≥30 kg): 162 mg SC q2weeks

Cytokine Release Syndrome (CRS)

Indicated for the treatment of chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome (CRS) in adults and pediatric patients aged ≥2 years

SC is not approved for CRS

<2 years: Safety and efficacy not established

≥2 years

  • <30 kg: 12 mg/kg IV once
  • ≥30 kg: 8 mg/kg IV once
  • May be administered as monotherapy or with corticosteroids
  • If no clinical improvement in the signs and symptoms of CRS occurs after initial dose, may administer up to 3 additional doses; allow 8-hr interval between consecutive doses
  • Not to exceed 800 mg/dose
  • Not approved for SC administration

COVID-19 (EUA)

June 24, 2021: Emergency use authorization (EUA) issued by the FDA for treatment of coronavirus disease 2019 (COVID-19) in hospitalized adults and pediatric patients (aged >2 years) who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or ECMO

<30 kg: 12 mg/kg IV

≥30 kg: 8 mg/kg IV; not to exceed 800 mg/dose

May administer 1 additional IV infusion 8 hr after first infusion if clinical signs or symptoms worsen or unimproved

SC administration not authorized for treatment of COVID-19

Dosage Modifications

Dose reduction has not been studied in PJIA and SJIA populations

PJIA or SJIA: Dose interruptions are recommended for liver enzyme abnormalities, low ANC, and low platelet counts in outlined for adults with RA and GCA

If appropriate, modify dose or stop concomitant methotrexate and/or other medications and hold tocilizumab until clinical situation has been evaluated

Discontinue tocilizumab should be based upon medical assessment of the patient

Renal impairment

  • Mild-to-moderate (eGFR ≥30 mL/min): No dosage adjustment required
  • Severe (eGFR <30 mL/min): Not studied

Hepatic impairment

  • Not recommended with active hepatic disease or hepatic impairment

Increased risk of serious infections in patient ≥65 years; use caution when treating the elderly

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Interactions

Interaction Checker

and tocilizumab

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    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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            Contraindicated (0)

              Serious - Use Alternative (64)

              • abatacept

                abatacept, tocilizumab. Mechanism: unspecified interaction mechanism. Contraindicated. Concomitant use not recommended (in mfr. info.).

              • adalimumab

                adalimumab and tocilizumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • adenovirus types 4 and 7 live, oral

                tocilizumab decreases effects of adenovirus types 4 and 7 live, oral by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressives may diminish therapeutic effects of vaccines and increase risk of adverse effects (increased risk of infection). Live-attenuated vaccines should be avoided for at least 3mo after cessation of immunosuppressive therapy.

              • alefacept

                alefacept and tocilizumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • anthrax vaccine

                tocilizumab decreases effects of anthrax vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • antithymocyte globulin equine

                tocilizumab and antithymocyte globulin equine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • antithymocyte globulin rabbit

                tocilizumab and antithymocyte globulin rabbit both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • azathioprine

                tocilizumab and azathioprine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • baricitinib

                baricitinib, tocilizumab. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Baricitinib is not recommended in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressives.

              • basiliximab

                tocilizumab and basiliximab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • BCG vaccine live

                tocilizumab decreases effects of BCG vaccine live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • canakinumab

                tocilizumab and canakinumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • certolizumab pegol

                tocilizumab and certolizumab pegol both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Avoid combination because of an increased risk of serious infection.

              • diphtheria & tetanus toxoids

                tocilizumab decreases effects of diphtheria & tetanus toxoids by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • diphtheria & tetanus toxoids/ acellular pertussis vaccine

                tocilizumab decreases effects of diphtheria & tetanus toxoids/ acellular pertussis vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine

                tocilizumab decreases effects of diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • etanercept

                tocilizumab and etanercept both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

                tocilizumab, etanercept. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Additive immunosuppression; risk of serious infection.

              • everolimus

                tocilizumab and everolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • glatiramer

                tocilizumab and glatiramer both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • golimumab

                tocilizumab and golimumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • hepatitis A vaccine inactivated

                tocilizumab decreases effects of hepatitis A vaccine inactivated by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • hepatitis a/b vaccine

                tocilizumab decreases effects of hepatitis a/b vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • hepatitis a/typhoid vaccine

                tocilizumab decreases effects of hepatitis a/typhoid vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • hepatitis b vaccine

                tocilizumab decreases effects of hepatitis b vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • human papillomavirus vaccine, nonavalent

                tocilizumab decreases effects of human papillomavirus vaccine, nonavalent by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune responses to vaccines.

              • human papillomavirus vaccine, quadrivalent

                tocilizumab decreases effects of human papillomavirus vaccine, quadrivalent by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune responses to vaccines.

              • hydroxychloroquine sulfate

                tocilizumab and hydroxychloroquine sulfate both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • infliximab

                tocilizumab and infliximab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • influenza virus vaccine quadrivalent

                tocilizumab decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • influenza virus vaccine quadrivalent, adjuvanted

                tocilizumab decreases effects of influenza virus vaccine quadrivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.

              • influenza virus vaccine quadrivalent, cell-cultured

                tocilizumab decreases effects of influenza virus vaccine quadrivalent, cell-cultured by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • influenza virus vaccine quadrivalent, intranasal

                tocilizumab decreases effects of influenza virus vaccine quadrivalent, intranasal by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • influenza virus vaccine trivalent

                tocilizumab decreases effects of influenza virus vaccine trivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • influenza virus vaccine trivalent, adjuvanted

                tocilizumab decreases effects of influenza virus vaccine trivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.

              • Japanese encephalitis virus vaccine

                tocilizumab decreases effects of Japanese encephalitis virus vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • leflunomide

                tocilizumab and leflunomide both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • measles (rubeola) vaccine

                tocilizumab decreases effects of measles (rubeola) vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • measles mumps and rubella vaccine, live

                tocilizumab decreases effects of measles mumps and rubella vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • measles, mumps, rubella and varicella vaccine, live

                tocilizumab decreases effects of measles, mumps, rubella and varicella vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • meningococcal A C Y and W-135 polysaccharide vaccine combined

                tocilizumab decreases effects of meningococcal A C Y and W-135 polysaccharide vaccine combined by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • mercaptopurine

                tocilizumab and mercaptopurine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • methotrexate

                tocilizumab and methotrexate both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • muromonab CD3

                tocilizumab and muromonab CD3 both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • mycophenolate

                tocilizumab and mycophenolate both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • pneumococcal vaccine heptavalent

                tocilizumab decreases effects of pneumococcal vaccine heptavalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • rabies vaccine

                tocilizumab decreases effects of rabies vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants may interfere with development of active immunity.

              • rabies vaccine chick embryo cell derived

                tocilizumab decreases effects of rabies vaccine chick embryo cell derived by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • rilonacept

                tocilizumab and rilonacept both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • rotavirus oral vaccine, live

                tocilizumab decreases effects of rotavirus oral vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • rubella vaccine

                tocilizumab decreases effects of rubella vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • sirolimus

                tocilizumab and sirolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • smallpox (vaccinia) vaccine, live

                tocilizumab decreases effects of smallpox (vaccinia) vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • tacrolimus

                tocilizumab and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • temsirolimus

                tocilizumab and temsirolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • tetanus toxoid adsorbed or fluid

                tocilizumab decreases effects of tetanus toxoid adsorbed or fluid by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • thalidomide

                tocilizumab, thalidomide. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Additive immunosuppression; risk of serious infection.

              • tick-borne encephalitis vaccine

                tocilizumab decreases effects of tick-borne encephalitis vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • tongkat ali

                tocilizumab and tongkat ali both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • travelers diarrhea and cholera vaccine inactivated

                tocilizumab decreases effects of travelers diarrhea and cholera vaccine inactivated by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • typhoid polysaccharide vaccine

                tocilizumab decreases effects of typhoid polysaccharide vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • typhoid vaccine live

                tocilizumab decreases effects of typhoid vaccine live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • ustekinumab

                tocilizumab and ustekinumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              • varicella virus vaccine live

                tocilizumab decreases effects of varicella virus vaccine live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              • yellow fever vaccine

                tocilizumab decreases effects of yellow fever vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

              Monitor Closely (27)

              • astragalus

                tocilizumab increases and astragalus decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

              • belatacept

                belatacept and tocilizumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.

              • cyclosporine

                tocilizumab and cyclosporine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.

              • denosumab

                tocilizumab, denosumab. Other (see comment). Use Caution/Monitor. Comment: Caution should be taken in patients on concomitant immunosuppressants or with impaired immune systems because of increased risk for serious infections.

              • echinacea

                tocilizumab increases and echinacea decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

              • fingolimod

                tocilizumab increases effects of fingolimod by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects. .

              • haemophilus influenzae type b vaccine

                tocilizumab decreases effects of haemophilus influenzae type b vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Avoid vaccination during chemotherapy or radiation therapy if possible because antibody response might be suboptimal. Patients vaccinated within a 14-day period before starting or during immunosuppressive therapy should be revaccinated =3 months after therapy is discontinued if immune competence has been restored. .

              • hydroxyurea

                hydroxyurea, tocilizumab. Other (see comment). Use Caution/Monitor. Comment: Combination may increase risk of infection.

              • influenza virus vaccine quadrivalent, recombinant

                tocilizumab decreases effects of influenza virus vaccine quadrivalent, recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immune response to vaccine may be decreased in immunocompromised individuals.

              • influenza virus vaccine trivalent, recombinant

                tocilizumab decreases effects of influenza virus vaccine trivalent, recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immune response to vaccine may be decreased in immunocompromised individuals.

              • isavuconazonium sulfate

                tocilizumab and isavuconazonium sulfate both decrease immunosuppressive effects; risk of infection. Use Caution/Monitor.

              • maitake

                tocilizumab increases and maitake decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor. .

              • maraviroc

                tocilizumab decreases levels of maraviroc by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • mechlorethamine

                mechlorethamine, tocilizumab. Either increases levels of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution should be taken in patients on concomitant immunosuppressants or with impaired immune systems because of increased risk for serious infections.

              • meningococcal group B vaccine

                tocilizumab decreases effects of meningococcal group B vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Individuals with altered immunocompetence may have reduced immune responses to the vaccine.

              • ocrelizumab

                tocilizumab and ocrelizumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Coadministration of ocrelizumab with high doses of corticosteroids is expected to increase the risk of immunosuppression.

              • ofatumumab SC

                ofatumumab SC, tocilizumab. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Consider the risk of additive immune system effects when coadministering immunosuppressive therapies with coadministration. When switching from therapies with immune effects, take into account the duration and mechanism of action of these therapies when initiating ofatumumab SC.

              • olaparib

                tocilizumab and olaparib both increase pharmacodynamic synergism. Use Caution/Monitor. Coadministration with other other myelosuppressive anticancer agents, including DNA damaging agents, may potentiate and prolongate the myelosuppressive toxicity.

              • oxaliplatin

                oxaliplatin and tocilizumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Use of oxaliplatin with concomitant immunosuppressants or with impaired immune systems may increased risk for serious infections.

              • poliovirus vaccine inactivated

                tocilizumab decreases effects of poliovirus vaccine inactivated by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Avoid vaccination during chemotherapy or radiation therapy if possible because antibody response might be suboptimal. Patients vaccinated within a 14-day period before starting or during immunosuppressive therapy should be revaccinated =3 months after therapy is discontinued if immune competence has been restored. .

              • siponimod

                siponimod and tocilizumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution if coadministered because of additive immunosuppressive effects during such therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs to avoid unintended additive immunosuppressive effects.

              • sipuleucel-T

                tocilizumab decreases effects of sipuleucel-T by pharmacodynamic antagonism. Modify Therapy/Monitor Closely.

              • trastuzumab

                trastuzumab, tocilizumab. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .

              • trastuzumab deruxtecan

                trastuzumab deruxtecan, tocilizumab. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .

              • zidovudine

                tocilizumab decreases levels of zidovudine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Interaction applies to inflammatory conditions, such as rheumatoid arthritis, associated with increased levels of IL-6.

              • zoster vaccine live

                tocilizumab decreases effects of zoster vaccine live by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressive therapies may reduce the effectiveness of zoster vaccine recombinant.

              • zoster vaccine recombinant

                tocilizumab decreases effects of zoster vaccine recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressive therapies may reduce the effectiveness of zoster vaccine recombinant.

              Minor (2)

              • cat's claw

                cat's claw, tocilizumab. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Possible additive immunosuppr'n.

              • lenalidomide

                tocilizumab, lenalidomide. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive immunosuppression; risk of serious infection. (Theoretical interaction).

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              Adverse Effects

              >10%

              SC injection site reactions (7.1-10.1%)

              COVID-19 EUA

              • Constipation (13%)

              1-10%

              Upper respiratory tract infection (6-8%)

              Nasopharyngitis (4-7%)

              Headache (3-7%)

              Hypertension (3-6%)

              ALT increased (1-6%)

              Bronchitis (2-4%)

              Rash (1-4%)

              Dizziness (1-3%)

              Mouth ulceration (1-2%)

              Upper abdominal pain (2-3%)

              Gastritis (1-2%)

              Oral herpes simplex (<2%)

              Stomatitis (<2%)

              Gastric ulcer (<2%)

              Increased weight (<2%)

              Total bilirubin increased (<2%)

              Leukopenia (<2%)

              Peripheral edema (<2%)

              Dyspnea (<2%)

              Cough (<2%)

              Conjunctivitis (<2%)

              COVID-19 EUA

              • Pneumonia (8%)
              • Septic shock (6%)
              • Hypokalemia (5%)
              • Hyperglycemia (5%)
              • Insomnia (5%)
              • Nausea (4%)
              • Anxiety (3%)
              • Hypoglycemia (3%)
              • Thrombocytopenia (3%)
              • Pain (3%)

              Postmarketing Reports

              Stevens-Johnson syndrome

              Pancreatitis

              Fatal anaphylaxis

              Drug-induced liver injury, hepatitis, hepatic failure, jaundice

              Rheumatoid arthritis, giant cell arteritis, and systemic sclerosis-associated interstitial lung disease

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              Warnings

              Black Box Warnings

              Risk of serious infections

              • Increased risk for developing serious infections that may lead to hospitalization or death
              • Most patients who developed these infections were taking concomitant immunosuppressants (eg, methotrexate, corticosteroids)
              • If a serious infection develops, interrupt therapy until the infection is controlled
              • Reported infections include
                • Active tuberculosis, which may present with pulmonary or extrapulmonary disease
                • Test for latent tuberculosis before tocilizumab use and during therapy; initiate treatment for latent infection prior to use Invasive fungal infections (eg, candidiasis, aspergillosis, pneumocystis); patients with invasive fungal infections may present with disseminated, rather than localized, disease
                • Bacterial, viral and other infections due to opportunistic pathogens
              • Carefully consider risks and benefits of treatment prior to initiating therapy in patients with chronic or recurrent infection
              • Closely monitor signs and symptoms of infection during and after treatment, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy

              Contraindications

              Hypersensitivity

              Cautions

              May cause neutropenia, decreased platelets, elevated liver transaminases, and increased lipid parameters; monitor neutrophils, platelets, lipids, and liver function tests every 4-8 weeks

              Impact of treatment is unknown regarding development of malignancies, but malignancies were observed in clinical studies; treatment with immunosuppressants may increase risk of malignancies

              Anaphylaxis or serious hypersensitivity reactions have occurred, including fatalities, with or without concomitant arthritis therapies

              Impact of treatment with tocilizumab on demyelinating disorders is unknown, but multiple sclerosis and chronic inflammatory demyelinating polyneuropathy were reported rarely in RA clinical studies; monitor for signs and symptoms potentially indicative of demyelinating disorders

              Caution if increased risk for GI perforation; gastrointestinal perforation reported, primarily as complications of diverticulitis; promptly evaluate patients presenting with new onset abdominal symptoms for early identification of gastrointestinal perforation

              Serioius infections

              Do not administer in patients with an active infection, including localized infections

              Consider risk versus benefits before initiating in patients with chronic or recurrent infection, expososure to tuberculosis, history of serious or an opportunistic infection, have resided or traveled in areas of endemic tuberculosis or endemic mycoses, or who have underlying conditions predisposing them to infection

              Not studied in combination with biological DMARDs (eg, TNF antagonists, IL-1R antagonists, anti-CD20 monoclonal antibodies, selective costimulation modulators); avoid in combination with these agents because of increased immunosuppression and infection risk

              Viral reactivation reported; cases of herpes zoster exacerbation observed in clinical studies; unknown if associated with hepatitis B reactivation; not studied

              Hepatic injury

              • RA or GCA
                • Serious cases of hepatic injury with IV or SC therapy; some cases have resulted in liver transplant or death; onset for cases ranged from months to years after initiating tocilizumab
                • For RA and GCA patients, obtain a liver test panel (ALT, AST, alkaline phosphatase, and total bilirubin) before initiating therapy, every 4-8 weeks after start of therapy for the first 6 months of treatment and every 3 months thereafter
                • Not recommended to initiate in RA or GCA patients with elevated transaminases ALT or AST greater than 1.5x ULN
                • In patients who develop elevated ALT or AST greater than 5x ULN, discontinue therapy; for recommended modifications based upon increase in transaminases
                • Measure liver tests promptly in patients who report symptoms that may indicate liver injury, such as fatigue, anorexia, right upper abdominal discomfort, dark urine or jaundice; if patient is found to have abnormal liver tests (eg, ALT >3x ULN, total bilirubin >2x ULN)
                • Interrupt treatment and establish probable cause; once liver tests normalize, restart in patients with another explanation for liver test abnormalities
              • PJIA or SJIA
                • A similar pattern of liver enzyme elevation is noted with in the PJIA and SJIA populations
                • Monitor liver test panel at the time of the second administration and thereafter every 4-8 weeks for PJIA and every 2-4 weeks for SJIA
              • COVID-19
                • Patients hospitalized with COVID-19 may have elevated ALT or AST levels
                • Multiorgan failure with liver involvement has been recognized as a complication of severe COVID-19
                • During randomized, controlled studies, tocilizumab was associated with increased incidence of transaminase elevations
                • When deciding to administer tocilizumab, balance potential benefit against risks of acute treatment
                • Not recommended in patients with COVID-19 who have elevated ALT or AST >10x ULN
                • Monitor ALT/AST when used for COVID-19 according to current standard clinical practice

              Drug interactions overview

              • Vaccines
                • Do not coadminister with live vaccines (eg, MMR, intranasal influenza)
                • IL-6 inhibition may interfere with the normal immune response to new antigens
                • All patients, particularly those with PJIA and SJIA, should be current with their immunizations before initiating therapy
              • CYP450
                • Inhibition of IL-6 signaling in RA patients treated with tocilizumab may restore CYP450 activities to higher levels than those in the absence of tocilizumab, and thereby increases metabolism of drugs that are CYP450 substrates
                • Exercise caution when coadministering tocilizumab with drugs that are substrates of CYP3A4 where decrease in effectiveness is undesirable, (eg, oral contraceptives, lovastatin, atorvastatin)
                • Effect of tocilizumab on CYP450 enzyme activity may persist for several weeks after stopping therapy
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              Pregnancy & Lactation

              Pregnancy

              Insufficient data available in pregnant women to determine whether there is a drug-associated risk for major birth defects and miscarriage

              Pregnancy registry

              • Monitors pregnancy outcomes in women exposed to tocilizumab during pregnancy
              • Register or encourage patients and pregnant women to register themselves by calling 1-877-311-8972

              Fetal/neonatal adverse reactions

              • Monoclonal antibodies (eg, tocilizumab) are actively transported across the placenta during the third trimester of pregnancy and may affect immune response in the in utero exposed infant
              • Consider risks and benefits before administering live or live-attenuated vaccines to infants exposed in utero

              Lactation

              No data available on the presence of tocilizumab in human milk, effects of the drug on the breastfed infant, or effects of the drug on milk production

              Maternal immunoglobulin G (IgG) is present in human milk

              If tocilizumab is transferred into human milk, effects of local exposure in the gastrointestinal tract and potential limited systemic exposure in the infant to tocilizumab are unknown

              Pregnancy Categories

              A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

              B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

              C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

              D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

              X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

              NA: Information not available.

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              Pharmacology

              Mechanism of Action

              Interleukin-6 receptor antagonist; IL-6 is a pleiotropic proinflammatory cytokine produced by a variety of cell types including T- and B-cells, lymphocytes, monocytes, and fibroblasts

              IL-6 has been shown to be involved in diverse physiological processes such as T-cell activation, induction of immunoglobulin secretion, initiation of hepatic acute phase protein synthesis, and stimulation of hematopoietic precursor cell proliferation and differentiation

              IL-6 is also produced by synovial and endothelial cells leading to local production of IL-6 in joints affected by inflammatory processes

              Absorption

              Peak plasma concentration

              • RA (4 mg/kg IV q4Weeks): 86.1 mcg/mL
              • RA (8 mg/kg IV q4Weeks): 176 mcg/mL
              • RA (162 mg SC every other week): 12.1 mcg/mL
              • RA (162 mg SC weekly): 49.8 mcg/mL
              • GCA (162 SC every other week): 17.2 mcg/mL
              • GCA (162 SC weekly): 72.1 mcg/mL
              • PJIA (8 mg/kg IV q4Weeks): 181 mcg/mL
              • PJIA (10 mg/kg IV q4Weeks): 167 mcg/mL
              • PJIA (162 mg SC q2Weeks): 29.7 mcg/mL
              • PJIA (162 mg SC q3Weeks): 62.4 mcg/mL
              • SJIA (8 mg/kg IV q2Weeks): 253 mcg/mL
              • SJIA (12 mg/kg IV q2Weeks): 274 mcg/mL
              • SJIA (162 mg SC weekly): 89.8 mcg/mL
              • SJIA (162 mg SC q2Weeks): 127 mcg/mL

              Plasma trough concentration

              • RA (4 mg/kg IV q4Weeks): 0.1 mcg/mL
              • RA (8 mg/kg IV q4Weeks): 13.4 mcg/mL
              • RA (162 mg SC every other week): 4.1 mcg/mL
              • RA (162 mg SC weekly): 42.9 mcg/mL
              • GCA (162 SC every other week): 7.7 mcg/mL
              • GCA (162 SC weekly): 9.6 mcg/mL
              • PJIA (8 mg/kg IV q4Weeks): 3.28 mcg/mL
              • PJIA (10 mg/kg IV q4Weeks): 0.35 mcg/mL
              • PJIA (162 mg SC q2Weeks): 12.7 mcg/mL
              • PJIA (162 mg SC q3Weeks): 13.4 mcg/mL
              • SJIA (8 mg/kg IV q2Weeks): 70.7 mcg/mL
              • SJIA (12 mg/kg IV q2Weeks): 65.9 mcg/mL
              • SJIA (162 mg SC weekly): 72.4 mcg/mL
              • SJIA (162 mg SC q2Weeks): 64.2 mcg/mL

              Peak plasma time

              • RA (weekly): 2.8 days
              • RA (every other week): 4.7 days
              • GCA (weekly): 3 days
              • GCA (every other week): 4.5 days

              Distribution

              Vd: 6.4L (RA); 7.46 L (GCA); 4.08 L (PJIA); 2.54 L (SJIA)

              Elimination

              Half-life: up to 11 days (4 mg/kg); up to 13 days (8 mg/kg)

              Half-life in RA patients: 13 days (162 mg every week); 5 days (162 mg every other week)

              Half-life in GCA patients: 18.3-18.9 days (162 mg SC every week); 4.2-7.9 days (162 mg SC every other week)

              Clearance: 0.0125 L/hr

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              Administration

              IV Compatibility

              0.9% or 0.45% NaCl

              IV Preparation

              Withdraw a volume of 0.9% or 0.45% NaCl from bag/bottle equal to volume of the solution required for the patient's dose

              Adults and children weighing ≥30 kg: Dilute to 100 mL in 0.9% or 0.45% NaCl

              Children <30 kg: Dilute to 50 mL in 0.9% or 0.45% NaCl

              Slowly add dose to infusion bag or bottle and gently invert to mix (prevent foaming)

              IV Administration

              Administer as single IV infusion over 1 hr

              Do NOT administer as bolus or push

              Do not infuse with any other drugs as no compatibility studies have been conducted

              SC Preparation

              Remove prefilled SC syringe/autoinjector from refrigerator 30 minutes before administration

              SC injection is not intended for IV drip infusion

              Do not use prefilled syringes or autoinjectors exhibiting particulate matter, cloudiness, or discoloration; solution for SC administration should appear clear and colorless to pale yellow

              SC Administration

              Rotate SC injection sites (ie, thighs, abdomen, outer area of upper arm [caregiver only]) and inject full amount of the syringe (0.9 mL)

              Transition from IV to SC (adult or pediatric arthritis indications): Administer first SC dose instead of next scheduled IV dose

              Storage

              Undiluted vials and prefilled SC syringes/autoinjectors: Store refrigerated between 2-8ºC (36-46ºF) in original container and protect from light

              After dilution for IV administration: Store refrigerated between 2-8ºC (36-46ºF) or room temperature for up to 24 hr; protect from light

              Do not freeze

              Do not save unused, reconstituted drug in vials because product contains no preservatives

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              Images

              BRAND FORM. UNIT PRICE PILL IMAGE
              Actemra intravenous
              -
              200 mg/10 mL (20 mg/mL) vial
              Actemra intravenous
              -
              80 mg/4 mL (20 mg/mL) vial
              Actemra intravenous
              -
              400 mg/20 mL (20 mg/mL) vial

              Copyright © 2010 First DataBank, Inc.

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              Patient Handout

              Select a drug:
              Patient Education
              tocilizumab subcutaneous

              TOCILIZUMAB - SUBCUTANEOUS INJECTION

              (TOE-si-LIZ-ue-mab)

              COMMON BRAND NAME(S): Actemra

              WARNING: This medication may lower your ability to fight an infection. This may make you more likely to get a serious (rarely fatal) infection or make any infection you have worse. Your risk may be increased if you are also taking other drugs that can lower your ability to fight an infection (such as methotrexate or corticosteroids). Before using tocilizumab, tell your doctor your medical history, especially of any kind of infection. During treatment, tell your doctor right away if you develop any signs of infection (such as cough, sore throat, fever, chills, pain when urinating).Before and during treatment with this medication, your doctor will test you for tuberculosis (TB). Your doctor should also monitor you for symptoms of TB during and after treatment with this drug. If needed, treatment for tuberculosis or other infections should be given before receiving this medication.

              USES: This medication is used alone or with other medications to treat moderate to severe rheumatoid arthritis in adults. It is also used to treat rheumatoid arthritis in children (such as polyarticular juvenile idiopathic arthritis-PJIA, systemic juvenile idiopathic arthritis-SJIA). It helps to reduce pain and swelling due to rheumatoid arthritis. Tocilizumab is used to treat giant cell arteritis. It helps to reduce swelling in your blood vessels so blood can flow more easily. This medication is also used to slow down the decrease in lung function in people with a certain type of lung disease (systemic sclerosis-associated interstitial lung disease - SSc-ILD). Tocilizumab belongs to a class of drugs known as Interleukin-6 (IL-6) blockers. It works by blocking IL-6, a substance made by the body that causes swelling (inflammation).

              HOW TO USE: Read the Medication Guide and Instructions for Use provided by your pharmacist before you start using tocilizumab and each time you get a refill. If you have any questions, ask your doctor or pharmacist.If you are using this medication at home, learn all preparation and usage instructions from your health care professional and the product package.Before use, take this medication out of the refrigerator. If you are using the prefilled syringe, let it warm up to room temperature for at least 30 minutes. If you are using the autoinjector, let it warm up to room temperature for at least 45 minutes. Do not heat this medication any other way, such as by heating in the microwave or placing in hot water. Do not leave in direct sunlight. Check this product visually for particles or discoloration. If either is present, do not use the liquid.If you are using this medication to treat rheumatoid arthritis in adults, inject this medication under the skin as directed by your doctor, usually starting with once every 2 weeks, then increasing to once a week.If you are using this medication to treat PJIA in children, give this medication by injection under the skin as directed by the doctor, usually once every 2 or 3 weeks, based on your child's weight.If you are using this medication to treat SJIA in children, give this medication by injection under the skin as directed by the doctor, usually once every 1 or 2 weeks, based on your child's weight.If you are using this medication to treat giant cell arteritis or for SSc-ILD, inject this medication under the skin as directed by your doctor, usually once a week.Recommended injection sites include the abdomen or the front of your thigh. The outer area of the upper arms may also be used if another person is giving you the injection. Before injecting each dose, clean the injection site with rubbing alcohol. Change the injection site each time to lessen injury under the skin. Do not inject into moles, scars, bruises, or areas where the skin is tender, red, hard, or broken.Learn how to store and discard medical supplies safely.The dosage is based on your weight, laboratory tests, and response to treatment.Use this medication regularly to get the most benefit from it. To help you remember, mark the days you need to inject the medication on a calendar.Tell your doctor if your condition does not get better or if it gets worse.

              SIDE EFFECTS: See also Warning section.Headache or irritation/redness/pain at the injection site may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: stomach/abdominal pain.Tocilizumab has rarely caused very serious (possibly fatal) liver disease. This effect may occur months to years after starting this medication. Tell your doctor right away if you develop symptoms of liver disease, such as nausea/vomiting that doesn't stop, loss of appetite, yellowing eyes/skin, dark urine.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

              PRECAUTIONS: Before using tocilizumab, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: diabetes, infections (including past/current/returning), liver problems, low blood cell count, nervous system problems (such as multiple sclerosis), stomach/abdominal problems (such as ulcers, diverticulitis).Tocilizumab can make you more likely to get infections or may worsen any current infections. Avoid contact with people who have infections that may spread to others (such as chickenpox, measles, tuberculosis, flu). Tell your doctor if you live in, have lived in, or have traveled to certain areas where there is an increased chance of getting certain kinds of fungal infections (blastomycosis, coccidioidomycosis, histoplasmosis). Consult your doctor if you have been exposed to an infection or for more details.Do not have immunizations/vaccinations without the consent of your doctor. Avoid contact with people who have recently received live vaccines (such as flu vaccine inhaled through the nose).Drugs that affect the immune system (such as tocilizumab) may increase your risk of certain cancers. Tell your doctor if you have ever had any type of cancer.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.It is unknown if this drug passes into breast milk. Consult your doctor before breast-feeding.

              DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug include: other drugs that can affect the immune system (such as certolizumab, corticosteroids including prednisone).This medication can speed up the removal of other medications from your body, which may affect how they work. Examples of affected drugs include omeprazole, warfarin, and some cholesterol drugs such as atorvastatin/lovastatin/simvastatin, among others.This medication may decrease the effectiveness of hormonal birth control such as pills, patch, or ring. This could cause pregnancy. Discuss with your doctor or pharmacist if you should use additional reliable birth control methods while using this medication. Also tell your doctor if you have any new spotting or breakthrough bleeding, because these may be signs that your birth control is not working well.

              OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

              NOTES: Do not share this medication with others.Laboratory and/or medical tests (such as complete blood counts, liver function, cholesterol tests) should be performed before you start treatment, periodically to monitor your progress, or to check for side effects. Consult your doctor for more details.

              MISSED DOSE: It is important to get each dose of this medication as scheduled. If you miss a dose, ask your doctor or pharmacist right away for a new dosing schedule.

              STORAGE: Store in the original package in the refrigerator away from moisture. Do not freeze. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

              Information last revised September 2021. Copyright(c) 2021 First Databank, Inc.

              IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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              Formulary

              FormularyPatient Discounts

              Adding plans allows you to compare formulary status to other drugs in the same class.

              To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

              Adding plans allows you to:

              • View the formulary and any restrictions for each plan.
              • Manage and view all your plans together – even plans in different states.
              • Compare formulary status to other drugs in the same class.
              • Access your plan list on any device – mobile or desktop.

              The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

              Tier Description
              1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
              2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
              3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
              4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              NC NOT COVERED – Drugs that are not covered by the plan.
              Code Definition
              PA Prior Authorization
              Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
              QL Quantity Limits
              Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
              ST Step Therapy
              Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
              OR Other Restrictions
              Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.