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Patients treated with tocilizumab products, including TOFIDENCE, are at increased risk for developing serious infections that may lead to hospitalization or death, including tuberculosis (TB), bacterial, invasive fungal, viral, or other opportunistic infections. If a serious infection develops, interrupt TOFIDENCE until the infection is controlled.
Reported infections include:
Do not administer TOFIDENCE in patients with an active infection, including localized infections. The risks and benefits of treatment with TOFIDENCE should be carefully considered prior to initiating therapy in patients:
Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with TOFIDENCE, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.
Hold TOFIDENCE if a patient develops a serious infection, an opportunistic infection, or sepsis. A patient who develops a new infection during treatment with TOFIDENCE should undergo a prompt and complete diagnostic workup appropriate for an immunocompromised patient, initiate appropriate antimicrobial therapy, and closely monitor the patient.
COVID-19
In patients with COVID-19, monitor for signs and symptoms of new infections during and after treatment with TOFIDENCE.
Tuberculosis
Evaluate patients for tuberculosis risk factors and test for latent infection prior to initiating TOFIDENCE.
Consider anti-tuberculosis therapy prior to initiation of TOFIDENCE in patients with a history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed, and for patients with a negative test for latent tuberculosis but having risk factors for tuberculosis infection.
Closely monitor patients for the development of signs and symptoms of tuberculosis including patients who tested negative for latent tuberculosis infection prior to initiating therapy.
Patients with latent tuberculosis should be treated with standard antimycobacterial therapy before initiating TOFIDENCE.
Viral Reactivation
Viral reactivation has been reported with immunosuppressive biologic therapies and cases of herpes zoster exacerbation were observed in clinical studies with tocilizumab.
TOFIDENCE is contraindicated in patients with known hypersensitivity to tocilizumab products.
Use TOFIDENCE with caution in patients who may be at increased risk for gastrointestinal perforation. Promptly evaluate patients presenting with fever, new onset abdominal symptoms, and change in bowel habits for early identification of gastrointestinal perforation.
Serious cases of hepatic injury have been observed in patients taking intravenous tocilizumab products. Some of these cases have resulted in liver transplant or death.
For RA and GCA patients, obtain a liver test panel (serum alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase, and total bilirubin) before initiating TOFIDENCE routinely. It is not recommended to initiate TOFIDENCE treatment in RA and GCA patients with elevated transaminases, ALT or AST greater than 1.5 x ULN. In patients who develop elevated ALT or AST greater than 5 x ULN, discontinue TOFIDENCE.
It is not recommended to initiate TOFIDENCE treatment in COVID-19 patients with elevated ALT or AST above 10 x ULN. Monitor ALT and AST during treatment.
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 the patient is found to have abnormal liver tests, TOFIDENCE treatment should be interrupted and investigation done to establish the probable cause. TOFIDENCE should only be restarted in patients with another explanation for the liver test abnormalities after normalization of the liver tests.
A similar pattern of liver enzyme elevation is noted with tocilizumab products treatment in the PJIA and SJIA populations. Monitor liver test panel at the time of the second administration and thereafter every 4 to 8 weeks for PJIA and every 2 to 4 weeks for SJIA.
Patients with RA, GCA, and COVID-19:
Neutropenia
Treatment with tocilizumab products was associated with a higher incidence of neutropenia.
It is not recommended to initiate TOFIDENCE treatment in RA and GCA patients with a low neutrophil count, i.e., absolute neutrophil count (ANC) less than 2000 per mm3. In patients who develop an absolute neutrophil count less than 500 per mm3, treatment is not recommended. It is not recommended to initiate TOFIDENCE treatment in COVID-19 patients with an ANC less than 1000 per mm3. Neutrophils should be monitored.
Monitor neutrophils 4 to 8 weeks after start of therapy and every 3 months thereafter.
Thrombocytopenia
Treatment with tocilizumab products was associated with a reduction in platelet counts.
It is not recommended to initiate TOFIDENCE treatment in RA and GCA patients with a platelet count below 100,000 per mm3. In patients who develop a platelet count less than 50,000 per mm3, treatment is not recommended.
Monitor platelets 4 to 8 weeks after start of therapy and every 3 months thereafter.
In COVID-19 patients with a platelet count less than 50,000 per mm3, treatment is not recommended.
Elevated Liver Enzymes
Refer to Hepatotoxicity. (See above.)
Lipid Abnormalities
Treatment with tocilizumab products was associated with increases in lipid parameters such as total cholesterol, triglycerides, LDL cholesterol, and/or HDL cholesterol.
Assess lipid parameters approximately 4 to 8 weeks following initiation of TOFIDENCE therapy.
A similar pattern of liver enzyme elevation, low neutrophil count, low platelet count, and lipid elevations is noted with tocilizumab products treatment in the PJIA and SJIA populations. Monitor neutrophils, platelets, ALT, and AST at the time of the second administration and thereafter every 4 to 8 weeks for PJIA and every 2 to 4 weeks for SJIA. Monitor lipids as above for approved adult indications.
TOFIDENCE is an immunosuppressant, and treatment with immunosuppressants may result in an increased risk of malignancies.
Hypersensitivity reactions, including anaphylaxis, have been reported in association with tocilizumab products and anaphylactic events with a fatal outcome have been reported with intravenous infusion of tocilizumab products. Reactions that required treatment discontinuation included generalized erythema, rash, and urticaria.
TOFIDENCE for intravenous use should only be infused by a healthcare professional with appropriate medical support to manage anaphylaxis. If a hypersensitivity reaction occurs, immediately discontinue TOFIDENCE; treat promptly, and monitor until signs and symptoms resolve.
Prescribers should exercise caution in considering the use of TOFIDENCE in patients with preexisting or recent onset demyelinating disorders.
Treatment with TOFIDENCE is not recommended in patients with active hepatic disease or hepatic impairment.
Avoid use of live vaccines concurrently with TOFIDENCE as clinical safety has not been established.
No data are available on the effectiveness of vaccination in patients receiving tocilizumab products. Because IL-6 inhibition may interfere with the normal immune response to new antigens, it is recommended that all patients, particularly pediatric or elderly patients, if possible, be brought up to date with all immunizations in agreement with current immunization guidelines prior to initiating TOFIDENCE therapy.
The most common adverse reactions (incidence of at least 5%) associated with tocilizumab-IV were upper respiratory tract infections, nasopharyngitis, headache, hypertension, and increased ALT.
Cytochrome P450s in the liver are down-regulated by infection and inflammation stimuli including cytokines such as IL-6. Inhibition of IL-6 signaling in RA patients treated with tocilizumab products may restore CYP450 activities to higher levels than those in the absence of tocilizumab products leading to increased metabolism of drugs that are CYP450 substrates.
Exercise caution when coadministering TOFIDENCE with CYP3A4 substrate drugs where decrease in effectiveness is undesirable, e.g., oral contraceptives, lovastatin, atorvastatin, etc.
Pregnancy
The available data with tocilizumab products from a pregnancy exposure registry, retrospective cohort study, pharmacovigilance, and published literature are insufficient to draw conclusions about a drug-associated risk of major birth defects, miscarriage, or other adverse maternal or fetal outcomes. Based on the animal data, there may be a potential risk to the fetus.
Lactation
No information is available on the presence of tocilizumab products in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. Discontinue drug or nursing, taking into consideration the importance of the drug to the mother.
Before prescribing TOFIDENCE, please read the accompanying Prescribing Information, including the Boxed Warning about serious infections. The Medication Guide also is available.
