Tocilizumab Administration Guide

TOCILIZUMAB 400 MG  / 20 ML (20 MG/ML) ACTEMRA®			FRIDGE item NOT in HKGU Formulary
ROUTE	DILUTION	INFUSION RATE
INTRAVENOUS	Dilute to final volume of 100 ml NS 2,3	Infused over 1 hr 2,3 (using a dedicated IV line) 3
	Allow diluted solution for infusion to reach room temperature prior to administration 3
DILUENT	NS 1
STABILITY	·       For vials: Store at 2-8ºC. DO NOT freeze. Keep container in outer carton to protect from light 1 ·       For prepared infusion solution: Physically and chemically stable in 0.9% NaCl at 30ºC for 24 hrs (provided aseptic techniques applied). 1 ·       Only solutions which are clear to opalescent, colourless to pale yellow and free of visible particles must be infused. 1,3
DOSING	·       Limited data available; dosing used in clinical trials includes the following: 3 §  4-8 mg/kg (usual dose: 400 mg/dose; max: 800 mg/dose) as a single dose; may repeat dose in ≥12 hours in patients who remain febrile within 24 hours of initial dose (NIH 2020c). §  8 mg/kg (max: 800 mg/dose) as a single dose; may repeat dose in 8-12 hours if signs/symptoms worsen or do not improve (Genentech 2020). §  8 mg/kg (max: 800 mg/dose) every 12 hours for 2 doses (NIH 2020a). §  8 mg/kg as a single dose (NIH 2020b; NIH 2020e). HOWEVER, LATEST SLIDE available from ID Team, HQE @ 28.08.2020: Dose recommended: 8 mg/kg single dose (MAX: 800 mg/dose). ·       Tocilizumab may reduce the serum concentration of chloroquine and ritonavir (component of Kaletra). 4 ·       The renal dosing recommendations are based upon the best available evidence and clinical expertise: 3 CrCl (mL/min) Suggested Renal Adjustment ≥30 No dosage adjustment necessary. <30 There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); however, based on tocilizumab's molecular weight (148 kDa), it is unlikely to be significantly renally eliminated (expert opinion).
ADVERSE REACTIONS	>10% 1-10% o Increased serum cholesterol (20%) o Increased ALT (≤36%) o Increased AST (≤22%) o Infusion-related reaction (4-20%) o Hypertension (6%) o Peripheral edema (<2%) o Skin rash (2%) o Leukopenia (<2%) o Thrombocytopenia (1%) o Increased serum bilirubin (<2%) o Herpes simplex infection (<2%) o  Headache (7%) o  Nasopharyngitis (7%) o  URTI (7%) o  Conjunctivitis (<2%) o Hypothyroidism (<2%) o Increased LDL (9%) o Nephrolithiasis (<2%) o Gastric ulcer (<2%) o Oral mucosa ulcer (2%) o Stomatitis (<2%) o Upper abdominal pain (2%) o Weight gain (<2%) o Bronchitis (3%) o Cough (<2%) o Dyspnea (<2%)
REFERENCES	1.     Product Leaflet (Actemra - Roche). 2.     COVID-19 treatment and drug doses [Sarawak General Hospital, updated 23.03.2020] 3.     UptoDate: Tocilizumab: Drug information [Accessed online on 8 May 2020] 4.     UptoDate: Drug Interaction Checker [Accessed online on 8 May 2020]
Prepared by J. Ho [8 May 2020]