Tocilizumab

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# Black Box Warning

# Overview
Tocilizumab is an interleukin-6 (IL-6) receptor antagonist that is FDA approved for the treatment of rheumatoid arthritis (RA), polyarticular juvenile idiopathic arthritis (PJIA), systemic juvenile idiopathic arthritis (SJIA). There is a Black Box Warning for this drug as shown here.  Common adverse reactions include upper respiratory tract infections, nasopharyngitis, headache, hypertension, increased ALT, injection site reactions.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Tocilizumab may be used as monotherapy or concomitantly with methotrexate or other non-biologic DMARDs as an intravenous infusion or as a subcutaneous injection.
- Recommended Intravenous (IV) Dosage Regimen:
- The recommended dosage of Tocilizumab for adult patients given as a 60-minute single intravenous drip infusion is 4 mg per kg every 4 weeks followed by an increase to 8 mg per kg every 4 weeks based on clinical response.
- Reduction of dose from 8 mg per kg to 4 mg per kg is recommended for management of certain dose-related laboratory changes including elevated liver enzymes, neutropenia, and thrombocytopenia.
- Recommended Subcutaneous (SC) Dosage Regimen:
- Patients less than 100 kg weight - 162 mg administered subcutaneously every other week, followed by an increase to every week based on clinical response
- Patients at or above 100 kg weight - 162 mg administered subcutaneously every week
- When transitioning from Tocilizumab intravenous therapy to subcutaneous administration administer the first subcutaneous dose instead of the next scheduled intravenous dose.
- Interruption of dose or reduction in frequency of administration of subcutaneous dose from every week to every other week dosing is recommended for management of certain dose-related laboratory changes including elevated liver enzymes, neutropenia, and thrombocytopenia.
- Tocilizumab may be used alone or in combination with methotrexate. The recommended dosage of Tocilizumab for PJIA patients given once every 4 weeks as a 60-minute single intravenous drip infusion is:
- Recommended Intravenous PJIA Dosage Every 4 Weeks
- Patients less than 30 kg weight - 10 mg per kg
- Patients at or above 30 kg weight - 8 mg per kg
- Do not change dose based solely on a single visit body weight measurement, as weight may fluctuate.
- Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia.
- Subcutaneous administration is not approved for PJIA.
- Tocilizumab may be used alone or in combination with methotrexate. The recommended dose of Tocilizumab for SJIA patients given once every 2 weeks as a 60-minute single intravenous drip infusion is:
- Recommended Intravenous SJIA Dosage Every 2 Weeks
- Patients less than 30 kg weight - 12 mg per kg
- Patients at or above 30 kg weight - 8 mg per kg
- Do not change a dose based solely on a single visit body weight measurement, as weight may fluctuate.
- Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia.
- Subcutaneous administration is not approved for SJIA.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Tocilizumab in adult patients.

### NonGuideline-Supported Use
- Tocilizumab 8 mg/kg IV every 4 weeks.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- Tocilizumab may be used alone or in combination with methotrexate. The recommended dosage of Tocilizumab for PJIA patients given once every 4 weeks as a 60-minute single intravenous drip infusion is:
- Recommended Intravenous PJIA Dosage Every 4 Weeks
- Patients less than 30 kg weight - 10 mg per kg
- Patients at or above 30 kg weight - 8 mg per kg
- Do not change dose based solely on a single visit body weight measurement, as weight may fluctuate.
- Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia.
- Subcutaneous administration is not approved for PJIA.
- Tocilizumab may be used alone or in combination with methotrexate. The recommended dose of Tocilizumab for SJIA patients given once every 2 weeks as a 60-minute single intravenous drip infusion is:
- Recommended Intravenous SJIA Dosage Every 2 Weeks
- Patients less than 30 kg weight - 12 mg per kg
- Patients at or above 30 kg weight - 8 mg per kg
- Do not change a dose based solely on a single visit body weight measurement, as weight may fluctuate.
- Interruption of dosing may be needed for management of dose-related laboratory abnormalities including elevated liver enzymes, neutropenia, and thrombocytopenia.
- Subcutaneous administration is not approved for SJIA

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Tocilizumab in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Tocilizumab in pediatric patients.

# Contraindications
- Tocilizumab is contraindicated in patients with known hypersensitivity to Tocilizumab.

# Warnings

### Precautions
- Serious Infections
- Serious and sometimes fatal infections due to bacterial, mycobacterial, invasive fungal, viral, protozoal, or other opportunistic pathogens have been reported in patients receiving immunosuppressive agents including Tocilizumab for rheumatoid arthritis. The most common serious infections included pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and bacterial arthritis. Among opportunistic infections, tuberculosis, cryptococcus, aspergillosis, candidiasis, and pneumocystosis were reported with Tocilizumab. Other serious infections, not reported in clinical studies, may also occur (e.g., histoplasmosis, coccidioidomycosis, listeriosis). Patients have presented with disseminated rather than localized disease, and were often taking concomitant immunosuppressants such as methotrexate or corticosteroids which in addition to rheumatoid arthritis may predispose them to infections.
- Do not administer Tocilizumab in patients with an active infection, including localized infections. The risks and benefits of treatment should be considered prior to initiating Tocilizumab in patients:
with chronic or recurrent infection;
who have been exposed to tuberculosis;
with a history of serious or an opportunistic infection;
who have resided or traveled in areas of endemic tuberculosis or endemic mycoses; or
with underlying conditions that may predispose them to infection.
- with chronic or recurrent infection;
- who have been exposed to tuberculosis;
- with a history of serious or an opportunistic infection;
- who have resided or traveled in areas of endemic tuberculosis or endemic mycoses; or
- with underlying conditions that may predispose them to infection.
- Closely monitor patients for the development of signs and symptoms of infection during and after treatment with Tocilizumab, as signs and symptoms of acute inflammation may be lessened due to suppression of the acute phase reactants.
- Hold Tocilizumab if a patient develops a serious infection, an opportunistic infection, or sepsis. A patient who develops a new infection during treatment with Tocilizumab should undergo a prompt and complete diagnostic workup appropriate for an immunocompromised patient, initiate appropriate antimicrobial therapy, and closely monitor the patient.
- Tuberculosis
- Evaluate patients for tuberculosis risk factors and test for latent infection prior to initiating Tocilizumab.
- Consider anti-tuberculosis therapy prior to initiation of Tocilizumab in patients with a past 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. Consultation with a physician with expertise in the treatment of tuberculosis is recommended to aid in the decision whether initiating anti-tuberculosis therapy is appropriate for an individual patient.
- 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.
- It is recommended that patients be screened for latent tuberculosis infection prior to starting Tocilizumab. The incidence of tuberculosis in worldwide clinical development programs is 0.1%. Patients with latent tuberculosis should be treated with standard antimycobacterial therapy before initiating Tocilizumab.
- Viral Reactivation
- Viral reactivation has been reported with immunosuppressive biologic therapies and cases of herpes zoster exacerbation were observed in clinical studies with Tocilizumab. No cases of Hepatitis B reactivation were observed in the trials; however patients who screened positive for hepatitis were excluded.
- Gastrointestinal Perforations
- Events of gastrointestinal perforation have been reported in clinical trials, primarily as complications of diverticulitis in RA patients. Use Tocilizumab with caution in patients who may be at increased risk for gastrointestinal perforation. Promptly evaluate patients presenting with new onset abdominal symptoms for early identification of gastrointestinal perforation.
- Laboratory Parameters
- Rheumatoid Arthritis
- Neutropenia
- Treatment with Tocilizumab was associated with a higher incidence of neutropenia. Infections have been uncommonly reported in association with treatment-related neutropenia in long-term extension studies and postmarketing clinical experience.
- It is not recommended to initiate Tocilizumab treatment in patients with a low neutrophil count, i.e., absolute neutrophil count (ANC) less than 2000 per mm 3. In patients who develop an absolute neutrophil count less than 500 per mm 3 treatment is not recommended.
- Monitor neutrophils 4 to 8 weeks after start of therapy and every 3 months thereafter. For recommended modifications based on ANC results.
- Thrombocytopenia
- Treatment with Tocilizumab was associated with a reduction in platelet counts. Treatment-related reduction in platelets was not associated with serious bleeding events in clinical trials.
- It is not recommended to initiate Tocilizumab treatment in patients with a platelet count below 100,000 per mm 3. In patients who develop a platelet count less than 50,000 per mm 3 treatment is not recommended.
- Monitor platelets 4 to 8 weeks after start of therapy and every 3 months thereafter. For recommended modifications based on platelet counts.
- Elevated Liver Enzymes
- Treatment with Tocilizumab was associated with a higher incidence of transaminase elevations. These elevations did not result in apparent permanent or clinically evident hepatic injury in clinical trials. Increased frequency and magnitude of these elevations was observed when potentially hepatotoxic drugs (e.g., MTX) were used in combination with Tocilizumab.
- In one case, a patient who had received Tocilizumab 8 mg per kg monotherapy without elevations in transaminases experienced elevation in AST to above 10 ULN and elevation in ALT to above 16 ULN when MTX was initiated in combination with Tocilizumab. Transaminases normalized when both treatments were held, but elevations recurred when MTX and Tocilizumab were restarted at lower doses. Elevations resolved when MTX and Tocilizumab were discontinued.
- It is not recommended to initiate Tocilizumab treatment in patients with elevated transaminases ALT or AST greater than 1.5 ULN. In patients who develop elevated ALT or AST greater than 5 ULN treatment is not recommended.
- Monitor ALT and AST levels 4 to 8 weeks after start of therapy and every 3 months thereafter. When clinically indicated, other liver function tests such as bilirubin should be considered. For recommended modifications based on transaminases.
- Lipid Abnormalities
- Treatment with Tocilizumab 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 Tocilizumab therapy, then at approximately 24 week intervals.
- Manage patients according to clinical guidelines  for the management of hyperlipidemia.
- Polyarticular and Systemic Juvenile Idiopathic Arthritis
- A similar pattern of liver enzyme elevation, low neutrophil count, low platelet count and lipid elevations is noted with Tocilizumab treatment in the PJIA and SJIA populations. Monitor neutrophils, platelets, ALT and AST at the time of the second infusion and thereafter every 4 to 8 weeks for PJIA and every 2 to 4 weeks for SJIA. Monitor lipids as above for RA.
- Immunosuppression
- The impact of treatment with Tocilizumab on the development of malignancies is not known but malignancies were observed in clinical studies. Tocilizumab is an immunosuppressant, and treatment with immunosuppressants may result in an increased risk of malignancies.
- Hypersensitivity Reactions, Including Anaphylaxis
- Hypersensitivity reactions, including anaphylaxis, have been reported in association with Tocilizumab and anaphylactic events with a fatal outcome have been reported with intravenous infusion of Tocilizumab. Anaphylaxis and other hypersensitivity reactions that required treatment discontinuation were reported in 0.1% (3 out of 2644) of patients in the 6-month controlled trials of intravenous Tocilizumab, 0.2% (8 out of 4009) of patients in the intravenous all-exposure RA population, 0.7% (8 out of 1068) in the subcutaneous 6-month controlled RA trials, and in 0.7% (10 out of 1465) of patients in the subcutaneous all-exposure population. In the SJIA controlled trial with intravenous Tocilizumab, 1 out of 112 patients (0.9%) experienced hypersensitivity reactions that required treatment discontinuation. In the PJIA controlled trial with intravenous Tocilizumab, 0 out of 188 patients (0%) in the Tocilizumab all-exposure population experienced hypersensitivity reactions that required treatment discontinuation. Reactions that required treatment discontinuation included generalized erythema, rash, and urticaria. Injection site reactions were categorized separately.
- In the postmarketing setting, events of hypersensitivity reactions, including anaphylaxis and death have occurred in patients treated with a range of doses of intravenous Tocilizumab, with or without concomitant arthritis therapies. Events have occurred in patients who received premedication. Hypersensitivity, including anaphylaxis events, have occurred both with and without previous hypersensitivity reactions and as early as the first infusion of Tocilizumab. Tocilizumab for intravenous use should only be infused by a healthcare professional with appropriate medical support to manage anaphylaxis. For Tocilizumab subcutaneous injection, advise patients to seek immediate medical attention if they experience any symptoms of a hypersensitivity reaction. If anaphylaxis or other hypersensitivity reaction occurs, stop administration of Tocilizumab immediately and discontinue Tocilizumab permanently. Do not administer Tocilizumab to patients with known hypersensitivity to Tocilizumab.
- Demyelinating Disorders
- The impact of treatment with Tocilizumab on demyelinating disorders is not known, but multiple sclerosis and chronic inflammatory demyelinating polyneuropathy were reported rarely in RA clinical studies. Monitor patients for signs and symptoms potentially indicative of demyelinating disorders. Prescribers should exercise caution in considering the use of Tocilizumab in patients with preexisting or recent onset demyelinating disorders.
- Active Hepatic Disease and Hepatic Impairment
- Treatment with Tocilizumab is not recommended in patients with active hepatic disease or hepatic impairment.
- Vaccinations
- Avoid use of live vaccines concurrently with Tocilizumab as clinical safety has not been established. No data are available on the secondary transmission of infection from persons receiving live vaccines to patients receiving Tocilizumab.
- No data are available on the effectiveness of vaccination in patients receiving Tocilizumab. Because IL-6 inhibition may interfere with the normal immune response to new antigens, it is recommended that all patients, particularly PJIA and SJIA patients, if possible, be brought up to date with all immunizations in agreement with current immunization guidelines prior to initiating Tocilizumab therapy. The interval between live vaccinations and initiation of Tocilizumab therapy should be in accordance with current vaccination guidelines regarding immunosuppressive agents.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not predict the rates observed in a broader patient population in clinical practice.
- The Tocilizumab-IV data in rheumatoid arthritis (RA) includes 5 double-blind, controlled, multicenter studies. In these studies, patients received doses of Tocilizumab-IV 8 mg per kg monotherapy (288 patients), Tocilizumab-IV 8 mg per kg in combination with DMARDs (including methotrexate) (1582 patients), or Tocilizumab-IV 4 mg per kg in combination with methotrexate (774 patients).
- The all exposure population includes all patients in registration studies who received at least one dose of Tocilizumab-IV. Of the 4009 patients in this population, 3577 received treatment for at least 6 months, 3309 for at least one year; 2954 received treatment for at least 2 years and 2189 for 3 years.
- All patients in these studies had moderately to severely active rheumatoid arthritis. The study population had a mean age of 52 years, 82% were female and 74% were Caucasian.
- The most common serious adverse reactions were serious infections. The most commonly reported adverse reactions in controlled studies up to 24 weeks (occurring in at least 5% of patients treated with Tocilizumab-IV monotherapy or in combination with DMARDs) were upper respiratory tract infections, nasopharyngitis, headache, hypertension and increased ALT.
- The proportion of patients who discontinued treatment due to any adverse reactions during the double-blind, placebo-controlled studies was 5% for patients taking Tocilizumab-IV and 3% for placebo-treated patients. The most common adverse reactions that required discontinuation of Tocilizumab-IV were increased hepatic transaminase values (per protocol requirement) and serious infections.
- Overall Infections
- In the 24 week, controlled clinical studies, the rate of infections in the Tocilizumab-IV monotherapy group was 119 events per 100 patient-years and was similar in the methotrexate monotherapy group. The rate of infections in the 4 mg per kg and 8 mg per kg Tocilizumab-IV plus DMARD group was 133 and 127 events per 100 patient-years, respectively, compared to 112 events per 100 patient-years in the placebo plus DMARD group. The most commonly reported infections (5% to 8% of patients) were upper respiratory tract infections and nasopharyngitis.
- The overall rate of infections with Tocilizumab-IV in the all exposure population remained consistent with rates in the controlled periods of the studies.
- Serious Infections
- In the 24 week, controlled clinical studies, the rate of serious infections in the Tocilizumab-IV monotherapy group was 3.6 per 100 patient-years compared to 1.5 per 100 patient-years in the methotrexate group. The rate of serious infections in the 4 mg per kg and 8 mg per kg Tocilizumab-IV plus DMARD group was 4.4 and 5.3 events per 100 patient-years, respectively, compared to 3.9 events per 100 patient-years in the placebo plus DMARD group.
- In the all-exposure population, the overall rate of serious infections remained consistent with rates in the controlled periods of the studies. The most common serious infections included pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and bacterial arthritis. Cases of opportunistic infections have been reported.
- Gastrointestinal Perforations
- During the 24 week, controlled clinical trials, the overall rate of gastrointestinal perforation was 0.26 events per 100 patient-years with Tocilizumab-IV therapy.
- In the all-exposure population, the overall rate of gastrointestinal perforation remained consistent with rates in the controlled periods of the studies. Reports of gastrointestinal perforation were primarily reported as complications of diverticulitis including generalized purulent peritonitis, lower GI perforation, fistula and abscess. Most patients who developed gastrointestinal perforations were taking concomitant nonsteroidal anti-inflammatory medications (NSAIDs), corticosteroids, or methotrexate. The relative contribution of these concomitant medications versus Tocilizumab-IV to the development of GI perforations is not known.
- Infusion Reactions
- In the 24 week, controlled clinical studies, adverse events associated with the infusion (occurring during or within 24 hours of the start of infusion) were reported in 8% and 7% of patients in the 4 mg per kg and 8 mg per kg Tocilizumab-IV plus DMARD group, respectively, compared to 5% of patients in the placebo plus DMARD group. The most frequently reported event on the 4 mg per kg and 8 mg per kg dose during the infusion was hypertension (1% for both doses), while the most frequently reported event occurring within 24 hours of finishing an infusion were headache (1% for both doses) and skin reactions (1% for both doses), including rash, pruritus and urticaria. These events were not treatment limiting.
- Anaphylaxis
- Hypersensitivity reactions requiring treatment discontinuation, including anaphylaxis, associated with Tocilizumab-IV were reported in 0.1% (3 out of 2644) in the 24 week, controlled trials and in 0.2% (8 out of 4009) in the all-exposure population. These reactions were generally observed during the second to fourth infusion of Tocilizumab-IV. Appropriate medical treatment should be available for immediate use in the event of a serious hypersensitivity reaction.
- Laboratory Abnormalities
- Neutropenia
- In the 24 week, controlled clinical studies, decreases in neutrophil counts below 1000 per mm3 occurred in 1.8% and 3.4% of patients in the 4 mg per kg and 8 mg per kg Tocilizumab-IV plus DMARD group, respectively, compared to 0.1% of patients in the placebo plus DMARD group. Approximately half of the instances of ANC below 1000 per mm3 occurred within 8 weeks of starting therapy. Decreases in neutrophil counts below 500 per mm3 occurred in 0.4% and 0.3% of patients in the 4 mg per kg and 8 mg per kg Tocilizumab-IV plus DMARD, respectively, compared to 0.1% of patients in the placebo plus DMARD group. There was no clear relationship between decreases in neutrophils below 1000 per mm3 and the occurrence of serious infections.
- In the all-exposure population, the pattern and incidence of decreases in neutrophil counts remained consistent with what was seen in the 24 week controlled clinical studies.
- Thrombocytopenia
- In the 24 week, controlled clinical studies, decreases in platelet counts below 100,000 per mm3 occurred in 1.3% and 1.7% of patients on 4 mg per kg and 8 mg per kg Tocilizumab-IV plus DMARD, respectively, compared to 0.5% of patients on placebo plus DMARD, without associated bleeding events.
- In the all-exposure population, the pattern and incidence of decreases in platelet counts remained consistent with what was seen in the 24 week controlled clinical studies.
- Elevated Liver Enzymes
- Liver enzyme abnormalities are summarized in TABLE 1. In patients experiencing liver enzyme elevation, modification of treatment regimen, such as reduction in the dose of concomitant DMARD, interruption of Tocilizumab-IV, or reduction in Tocilizumab-IV dose, resulted in decrease or normalization of liver enzymes. These elevations were not associated with clinically relevant increases in direct bilirubin, nor were they associated with clinical evidence of hepatitis or hepatic insufficiency.
- Lipids
- Elevations in lipid parameters (total cholesterol, LDL, HDL, triglycerides) were first assessed at 6 weeks following initiation of Tocilizumab-IV in the controlled 24 week clinical trials. Increases were observed at this time point and remained stable thereafter. Increases in triglycerides to levels above 500 mg per dL were rarely observed. Changes in other lipid parameters from baseline to week 24 were evaluated and are summarized below:
Mean LDL increased by 13 mg per dL in the Tocilizumab 4 mg per kg+DMARD arm, 20 mg per dL in the Tocilizumab 8 mg per kg+DMARD, and 25 mg per dL in Tocilizumab 8 mg per kg monotherapy.
Mean HDL increased by 3 mg per dL in the Tocilizumab 4 mg per kg+DMARD arm, 5 mg per dL in the Tocilizumab 8 mg per kg+DMARD, and 4 mg per dL in Tocilizumab 8 mg per kg monotherapy.
Mean LDL/HDL ratio increased by an average of 0.14 in the Tocilizumab 4 mg per kg+DMARD arm, 0.15 in the Tocilizumab 8 mg per kg+DMARD, and 0.26 in Tocilizumab 8 mg per kg monotherapy.
ApoB/ApoA1 ratios were essentially unchanged in Tocilizumab-treated patients.
Elevated lipids responded to lipid lowering agents.
- Mean LDL increased by 13 mg per dL in the Tocilizumab 4 mg per kg+DMARD arm, 20 mg per dL in the Tocilizumab 8 mg per kg+DMARD, and 25 mg per dL in Tocilizumab 8 mg per kg monotherapy.
- Mean HDL increased by 3 mg per dL in the Tocilizumab 4 mg per kg+DMARD arm, 5 mg per dL in the Tocilizumab 8 mg per kg+DMARD, and 4 mg per dL in Tocilizumab 8 mg per kg monotherapy.
- Mean LDL/HDL ratio increased by an average of 0.14 in the Tocilizumab 4 mg per kg+DMARD arm, 0.15 in the Tocilizumab 8 mg per kg+DMARD, and 0.26 in Tocilizumab 8 mg per kg monotherapy.
- ApoB/ApoA1 ratios were essentially unchanged in Tocilizumab-treated patients.
- Elevated lipids responded to lipid lowering agents.
- In the all-exposure population, the elevations in lipid parameters remained consistent with what was seen in the 24 week, controlled clinical trials.
- Immunogenicity
- In the 24 week, controlled clinical studies, a total of 2876 patients have been tested for anti-tocilizumab antibodies. Forty-six patients (2%) developed positive anti-tocilizumab antibodies, of whom 5 had an associated, medically significant, hypersensitivity reaction leading to withdrawal. Thirty patients (1%) developed neutralizing antibodies.
- The data reflect the percentage of patients whose test results were positive for antibodies to tocilizumab in specific assays. The observed incidence of antibody positivity in an assay is highly dependent on several factors, including assay sensitivity and specificity, assay methodology, sample handling, timing of sample collection, concomitant medication, and underlying disease. For these reasons, comparison of the incidence of antibodies to tocilizumab with the incidence of antibodies to other products may be misleading.
- Malignancies
- During the 24 week, controlled period of the studies, 15 malignancies were diagnosed in patients receiving Tocilizumab-IV, compared to 8 malignancies in patients in the control groups. Exposure-adjusted incidence was similar in the Tocilizumab-IV groups (1.32 events per 100 patient-years) and in the placebo plus DMARD group (1.37 events per 100 patient-years).
- In the all-exposure population, the rate of malignancies remained consistent with the rate observed in the 24 week, controlled period.
- Other Adverse Reactions
- Adverse reactions occurring in 2% or more of patients on 4 or 8 mg per kg Tocilizumab-IV plus DMARD and at least 1% greater than that observed in patients on placebo plus DMARD are summarized in TABLE 2.
- Other infrequent and medically relevant adverse reactions occurring at an incidence less than 2% in rheumatoid arthritis patients treated with Tocilizumab-IV in controlled trials were:
Oral herpes simplex
Stomatitis, gastric ulcer
Weight increased, total bilirubin increased
Leukopenia
Peripheral edema
Dyspnea, cough
Conjunctivitis
Nephrolithiasis
Hypothyroidism
- The Tocilizumab-SC data in rheumatoid arthritis (RA) includes 2 double-blind, controlled, multicenter studies. Study SC-I was a non-inferiority study that compared the efficacy and safety of tocilizumab 162 mg administered every week subcutaneously (SC) and 8 mg/kg intravenously (IV) every four weeks in 1262 adult subjects with rheumatoid arthritis. Study SC-II was a placebo controlled superiority study that evaluated the safety and efficacy of tocilizumab 162 mg administered every other week SC or placebo in 656 patients. All patients in both studies received background non-biologic DMARDs.
- The safety observed for Tocilizumab administered subcutaneously was consistent with the known safety profile of intravenous Tocilizumab, with the exception of injection site reactions, which were more common with Tocilizumab-SC compared with placebo SC injections (IV arm).
- Injection Site Reactions
- In the 6-month control period, in SC-I, the frequency of injection site reactions was 10.1% (64/631) and 2.4% (15/631) for the weekly Tocilizumab-SC and placebo SC (IV-arm) groups, respectively. In SC-II, the frequency of injection site reactions was 7.1% (31/437) and 4.1% (9/218) for the every other week SC Tocilizumab and placebo groups, respectively. These injection site reactions (including erythema, pruritus, pain and hematoma) were mild to moderate in severity. The majority resolved without any treatment and none necessitated drug discontinuation.
- Immunogenicity
- In the 6-month control period in SC-I, 0.8% (5/625) in the Tocilizumab-SC arm and 0.8% (5/627) in the IV arm developed anti-tocilizumab antibodies; of these, all developed neutralizing antibodies. In SC-II, 1.6% (7/434) in the Tocilizumab-SC arm compared with 1.4 % (3/217) in the placebo arm developed anti- tocilizumab antibodies; of these, 1.4% (6/434) in the Tocilizumab-SC arm and 0.5% (1/217) in the placebo arm also developed neutralizing antibodies.
- A total of 1454 (>99%) patients who received Tocilizumab-SC in the all exposure group have been tested for anti-tocilizumab antibodies. Thirteen patients (0.9%) developed anti-tocilizumab antibodies, and, of these, 12 patients (0.8%) developed neutralizing antibodies.
- The rate is consistent with previous intravenous experience. No correlation of antibody development to adverse events or loss of clinical response was observed.
- Laboratory Abnormalities
- Neutropenia
- During routine laboratory monitoring in the 6-month controlled clinical trials, a decrease in neutrophil count below 1  109/L occurred in 2.9% and 3.7% of patients receiving Tocilizumab-SC weekly and every other week, respectively.
- There was no clear relationship between decreases in neutrophils below 1  109/L and the occurrence of serious infections.
- Thrombocytopenia
- During routine laboratory monitoring in the Tocilizumab-SC 6-month controlled clinical trials, none of the patients had a decrease in platelet count to 50  103/mcL.
- Elevated Liver Enzymes
- During routine laboratory monitoring in the 6-month controlled clinical trials, elevation in ALT or AST 3  ULN occurred in 6.5% and 1.4% of patients, respectively, receiving Tocilizumab-SC weekly and 3.4% and 0.7% receiving Tocilizumab SC every other week.
- Lipids
- During routine laboratory monitoring in the Tocilizumab-SC 6-month clinical trials, 19% of patients dosed weekly and 19.6% of patients dosed every other week and 10.2% of patients on placebo experienced sustained elevations in total cholesterol > 6.2 mmol/l (240 mg/dL), with 9%, 10.4% and 5.1% experiencing a sustained increase in LDL to 4.1 mmol/l (160 mg/dL) receiving Tocilizumab-SC weekly, every other week and placebo, respectively.
- The safety of Tocilizumab-IV was studied in 188 pediatric patients 2 to 17 years of age with PJIA who had an inadequate clinical response or were intolerant to methotrexate. The total patient exposure in the Tocilizumab-IV all exposure population (defined as patients who received at least one dose of Tocilizumab-IV) was 184.4 patient years. At baseline, approximately half of the patients were taking oral corticosteroids and almost 80% were taking methotrexate. In general, the types of adverse drug reactions in patients with PJIA were consistent with those seen in RA and SJIA patients.
- Infections
- The rate of infections in the Tocilizumab-IV all exposure population was 163.7 per 100 patient years. The most common events observed were nasopharyngitis and upper respiratory tract infections. The rate of serious infections was numerically higher in patients weighing less than 30 kg treated with 10 mg/kg tocilizumab (12.2 per 100 patient years) compared to patients weighing at or above 30 kg, treated with 8 mg/kg tocilizumab (4.0 per 100 patient years). The incidence of infections leading to dose interruptions was also numerically higher in patients weighing less than 30 kg treated with 10 mg/kg tocilizumab (21%) compared to patients weighing at or above 30 kg, treated with 8 mg/kg tocilizumab (8%).
- Infusion Reactions
- In PJIA patients, infusion-related reactions are defined as all events occurring during or within 24 hours of an infusion. In the Tocilizumab-IV all exposure population, 11 patients (6%) experienced an event during the infusion, and 38 patients (20.2%) experienced an event within 24 hours of an infusion. The most common events occurring during infusion were headache, nausea and hypotension, and occurring within 24 hours of infusion were dizziness and hypotension. In general, the adverse drug reactions observed during or within 24 hours of an infusion were similar in nature to those seen in RA and SJIA patients.
- No clinically significant hypersensitivity reactions associated with tocilizumab and requiring treatment discontinuation were reported.
- Immunogenicity
- One patient, in the 10 mg/kg less than 30 kg group, developed positive anti-tocilizumab antibodies without developing a hypersensitivity reaction and subsequently withdrew from the study.
- Laboratory Abnormalities
- Neutropenia
- During routine laboratory monitoring in the Tocilizumab-IV all exposure population, a decrease in neutrophil counts below 1  109 per L occurred in 3.7% of patients.
- There was no clear relationship between decreases in neutrophils below 1  109 per L and the occurrence of serious infections.
- Thrombocytopenia
- During routine laboratory monitoring in the Tocilizumab-IV all exposure population, 1% of patients had a decrease in platelet count at or less than 50  103 per mcL without associated bleeding events.
- Elevated Liver Enzymes
- During routine laboratory monitoring in the Tocilizumab-IV all exposure population, elevation in ALT or AST at or greater than 3  ULN occurred in 4% and less than 1% of patients, respectively.
- Lipids
- During routine laboratory monitoring in the tocilizumab all exposure population, elevation in total cholesterol greater than 1.5-2  ULN occurred in one patient (0.5%) and elevation in LDL greater than 1.5-2  ULN occurred in one patient (0.5%).
- The data described below reflect exposure to Tocilizumab-IV in one randomized, double-blind, placebo-controlled trial of 112 pediatric patients with SJIA 2 to 17 years of age who had an inadequate clinical response to nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids due to toxicity or lack of efficacy. At baseline, approximately half of the patients were taking 0.3 mg/kg/day corticosteroids or more, and almost 70% were taking methotrexate. The trial included a 12 week controlled phase followed by an open-label extension. In the 12 week double-blind, controlled portion of the clinical study 75 patients received treatment with Tocilizumab-IV (8 or 12 mg per kg based upon body weight). After 12 weeks or at the time of escape, due to disease worsening, patients were treated with Tocilizumab-IV in the open-label extension phase.
- The most common adverse events (at least 5%) seen in Tocilizumab-IV treated patients in the 12 week controlled portion of the study were: upper respiratory tract infection, headache, nasopharyngitis and diarrhea.
- Infections
- In the 12 week controlled phase, the rate of all infections in the Tocilizumab-IV group was 345 per 100 patient-years and 287 per 100 patient-years in the placebo group. In the open label extension over an average duration of 73 weeks of treatment, the overall rate of infections was 304 per 100 patient-years.
- In the 12 week controlled phase, the rate of serious infections in the Tocilizumab-IV group was 11.5 per 100 patient years. In the open label extension over an average duration of 73 weeks of treatment, the overall rate of serious infections was 11.4 per 100 patient years. The most commonly reported serious infections included pneumonia, gastroenteritis, varicella, and otitis media.
- Macrophage Activation Syndrome
- In the 12 week controlled study, no patient in any treatment group experienced macrophage activation syndrome (MAS) while on assigned treatment; 3 per 112 (3%) developed MAS during open-label treatment with Tocilizumab-IV. One patient in the placebo group escaped to Tocilizumab-IV 12 mg per kg at Week 2 due to severe disease activity, and ultimately developed MAS at Day 70. Two additional patients developed MAS during the long-term extension. All 3 patients had Tocilizumab-IV dose interrupted (2 patients) or discontinued (1 patient) for the MAS event, received treatment, and the MAS resolved without sequelae. Based on a limited number of cases, the incidence of MAS does not appear to be elevated in the Tocilizumab-IV SJIA clinical development experience; however no definitive conclusions can be made.
- Infusion Reactions
- Patients were not premedicated, however most patients were on concomitant corticosteroids as part of their background treatment for SJIA. Infusion related reactions were defined as all events occurring during or within 24 hours after an infusion. In the 12 week controlled phase, 4% of Tocilizumab-IV and 0% of placebo treated patients experienced events occurring during infusion. One event (angioedema) was considered serious and life-threatening, and the patient was discontinued from study treatment.
- Within 24 hours after infusion, 16% of patients in the Tocilizumab-IV treatment group and 5% of patients in the placebo group experienced an event. In the Tocilizumab-IV group the events included rash, urticaria, diarrhea, epigastric discomfort, arthralgia and headache. One of these events, urticaria, was considered serious.
- Anaphylaxis
- Anaphylaxis was reported in 1 out of 112 patients (less than 1%) treated with Tocilizumab-IV during the controlled and open label extension study.
- Immunogenicity
- All 112 patients were tested for anti-tocilizumab antibodies at baseline. Two patients developed positive anti-tocilizumab antibodies: one of these patients experienced serious adverse events of urticaria and angioedema consistent with an anaphylactic reaction which led to withdrawal; the other patient developed macrophage activation syndrome while on escape therapy and was discontinued from the study.
- Laboratory Abnormalities
- Neutropenia
- During routine monitoring in the 12 week controlled phase, a decrease in neutrophil below 1  109 per L occurred in 7% of patients in the Tocilizumab-IV group, and in no patients in the placebo group. In the open label extension over an average duration of 73 weeks of treatment, a decreased neutrophil count occurred in 17% of the Tocilizumab-IV group. There was no clear relationship between decrease in neutrophils below 1  109 per L and the occurrence of serious infections.
- Thrombocytopenia
- During routine monitoring in the 12 week controlled phase, 1% of patients in the Tocilizumab-IV group and 3% in the placebo group had a decrease in platelet count to no more than 100  103 per mcL.
- In the open label extension over an average duration of 73 weeks of treatment, decreased platelet count occurred in 4% of patients in the Tocilizumab-IV group, with no associated bleeding.
- Elevated Liver Enzymes
- During routine laboratory monitoring in the 12 week controlled phase, elevation in ALT or AST at or above 3 ULN occurred in 5% and 3% of patients, respectively in the Tocilizumab-IV group and in 0% of placebo patients.
- In the open label extension over an average duration of 73 weeks of treatment, the elevation in ALT or AST at or above 3 ULN occurred in 13% and 5% of Tocilizumab-IV treated patients, respectively.
- Lipids
- During routine laboratory monitoring in the 12 week controlled phase, elevation in total cholesterol greater than 1.5 ULN  2x ULN occurred in 1.5% of the Tocilizumab-IV group and in 0% of placebo patients. Elevation in LDL greater than 1.5 ULN  2x ULN occurred in 1.9% of patients in the Tocilizumab-IV group and 0% of the placebo group.
- In the open label extension study over an average duration of 73 weeks of treatment, the pattern and incidence of elevations in lipid parameters remained consistent with the 12 week controlled study data.

## Postmarketing Experience
- The following adverse reactions have been identified during postapproval use of intravenous Tocilizumab. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
- Fatal anaphylaxis
- Stevens-Johnson Syndrome

# Drug Interactions
- Other Drugs for Treatment of Rheumatoid Arthritis
- Population pharmacokinetic analyses did not detect any effect of methotrexate (MTX), non-steroidal anti-inflammatory drugs or corticosteroids on tocilizumab clearance.
- Concomitant administration of a single intravenous dose of 10 mg per kg Tocilizumab with 10-25 mg MTX once weekly had no clinically significant effect on MTX exposure.
- Tocilizumab has not been studied in combination with biological DMARDs such as TNF antagonists.
- Interactions with CYP450 Substrates
- 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 may restore CYP450 activities to higher levels than those in the absence of tocilizumab leading to increased metabolism of drugs that are CYP450 substrates. In vitro studies showed that tocilizumab has the potential to affect expression of multiple CYP enzymes including CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6 and CYP3A4. Its effects on CYP2C8 or transporters is unknown. In vivo studies with omeprazole, metabolized by CYP2C19 and CYP3A4, and simvastatin, metabolized by CYP3A4, showed up to a 28% and 57% decrease in exposure one week following a single dose of Tocilizumab, respectively. The effect of tocilizumab on CYP enzymes may be clinically relevant for CYP450 substrates with narrow therapeutic index, where the dose is individually adjusted. Upon initiation or discontinuation of Tocilizumab, in patients being treated with these types of medicinal products, perform therapeutic monitoring of effect (e.g., warfarin) or drug concentration (e.g., cyclosporine or theophylline) and the individual dose of the medicinal product adjusted as needed. Exercise caution when coadministering Tocilizumab with CYP3A4 substrate drugs where decrease in effectiveness is undesirable, e.g., oral contraceptives, lovastatin, atorvastatin, etc. The effect of tocilizumab on CYP450 enzyme activity may persist for several weeks after stopping therapy.
- Live Vaccines
- Avoid use of live vaccines concurrently with Tocilizumab

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):
- Pregnancy Category C
- Pregnancy Exposure Registry
- There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to Tocilizumab during pregnancy. Physicians are encouraged to register patients and pregnant women are encouraged to register themselves by calling 1-877-311-8972.
- Risk Summary
- Adequate and well-controlled studies with Tocilizumab have not been conducted in pregnant women. In animal reproduction studies, administration of tocilizumab to cynomolgus monkeys during organogenesis caused abortion/embryo-fetal death at dose exposures 1.25 times the human dose exposure of 8 mg per kg every 2 to 4 weeks. The incidence of malformations and pregnancy loss in human pregnancies has not been established for Tocilizumab. However, all pregnancies, regardless of drug exposure, have a background rate of 2 to 4% for major malformations, and 15 to 20% for pregnancy loss. Tocilizumab should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
- Clinical Considerations
- In general, monoclonal antibodies are transported across the placenta in a linear fashion as pregnancy progresses, with the largest amount transferred during the third trimester.
- Animal Data
- An embryo-fetal developmental toxicity study was performed in which pregnant cynomolgus monkeys were treated intravenously with tocilizumab (daily doses of 2, 10, or 50 mg per kg from gestation day 20-50) during organogenesis. Although there was no evidence for a teratogenic/dysmorphogenic effect at any dose, tocilizumab produced an increase in the incidence of abortion/embryo-fetal death at 10 mg per kg and 50 mg per kg doses (1.25 and 6.25 times the human dose of 8 mg per kg every 2 to 4 weeks based on a mg per kg comparison). Testing of a murine analogue of tocilizumab in mice did not yield any evidence of harm to offspring during the pre- and postnatal development phase when dosed at 50 mg per kg intravenously with treatment every three days from implantation until day 21 after delivery (weaning). There was no evidence for any functional impairment of the development and behavior, learning ability, immune competence and fertility of the offspring.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Tocilizumab in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Tocilizumab during labor and delivery.

### Nursing Mothers
- It is not known whether tocilizumab is present in human milk or if it would be absorbed systemically in a breastfed infant after ingestion. IgG is excreted in human milk and therefore it is expected that tocilizumab could be present in human milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants from Tocilizumab, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

### Pediatric Use
- Tocilizumab by intravenous use is indicated for the treatment of pediatric patients with:
- Active systemic juvenile idiopathic arthritis in patients 2 years of age and older
- Active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older
- Safety and effectiveness of Tocilizumab in pediatric patients with conditions other than PJIA or SJIA have not been established. Children under the age of two have not been studied. SC administration has not been studied in pediatric patients. Testing of a murine analogue of tocilizumab did not exert toxicity in juvenile mice. In particular, there was no impairment of skeletal growth, immune function and sexual maturation.

### Geriatic Use
- Of the 2644 patients who received Tocilizumab in Studies I to V, a total of 435 rheumatoid arthritis patients were 65 years of age and older, including 50 patients 75 years and older. Of the 1069 patients who received Tocilizumab-SC in studies SC-I and SC-II there were 295 patients 65 years of age and older, including 41 patients 75 years and older. The frequency of serious infection among Tocilizumab treated subjects 65 years of age and older was higher than those under the age of 65. As there is a higher incidence of infections in the elderly population in general, caution should be used when treating the elderly.

### Gender
There is no FDA guidance on the use of Tocilizumab with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Tocilizumab with respect to specific racial populations.

### Renal Impairment
- No dose adjustment is required in patients with mild renal impairment. Tocilizumab has not been studied in patients with moderate to severe renal impairment.

### Hepatic Impairment
- The safety and efficacy of Tocilizumab have not been studied in patients with hepatic impairment, including patients with positive HBV and HCV serology.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Tocilizumab in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Tocilizumab in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intravenous
- Subcutaneous

### Monitoring
There is limited information regarding Monitoring of Tocilizumab in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Tocilizumab in the drug label.

# Overdosage

## Acute Overdose

### Signs and Symptoms
- There are limited data available on overdoses with Tocilizumab. One case of accidental overdose was reported with intravenous Tocilizumab in which a patient with multiple myeloma received a dose of 40 mg per kg. No adverse drug reactions were observed. No serious adverse drug reactions were observed in healthy volunteers who received single doses of up to 28 mg per kg, although all 5 patients at the highest dose of 28 mg per kg developed dose-limiting neutropenia.

### Management
- In case of an overdose, it is recommended that the patient be monitored for signs and symptoms of adverse reactions. Patients who develop adverse reactions should receive appropriate symptomatic treatment.

## Chronic Overdose
There is limited information regarding Chronic Overdose of Tocilizumab in the drug label.

# Pharmacology
There is limited information regarding Tocilizumab Pharmacology in the drug label.

## Mechanism of Action
- Tocilizumab binds specifically to both soluble and membrane-bound IL-6 receptors (sIL-6R and mIL-6R), and has been shown to inhibit IL-6-mediated signaling through these receptors. IL-6 is a pleiotropic pro-inflammatory 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 such as rheumatoid arthritis.

## Structure
- Tocilizumab (tocilizumab) is a recombinant humanized anti-human interleukin 6 (IL-6) receptor monoclonal antibody of the immunoglobulin IgG1 (gamma 1, kappa) subclass with a typical H2L2 polypeptide structure. Each light chain and heavy chain consists of 214 and 448 amino acids, respectively. The four polypeptide chains are linked intra- and inter-molecularly by disulfide bonds. Tocilizumab has a molecular weight of approximately 148 kDa.
- Tocilizumab is supplied as a sterile, preservative-free solution for intravenous (IV) infusion at a concentration of 20 mg per mL. Tocilizumab is a colorless to pale yellow liquid, with a pH of about 6.5. Single-use vials are available for intravenous administration containing 80 mg per 4 mL, 200 mg per 10 mL, or 400 mg per 20 mL of Tocilizumab. Injectable solutions of Tocilizumab are formulated in an aqueous solution containing disodium phosphate dodecahydrate and sodium dihydrogen phosphate dehydrate (as a 15 mmol per L phosphate buffer), polysorbate 80 (0.5 mg per mL), and sucrose (50 mg per mL).
- Tocilizumab solution for subcutaneous administration is supplied as a sterile, colorless to yellowish, preservative-free liquid solution of approximately pH 6.0. It is supplied in a 1 mL ready-to-use, single-use prefilled syringe (PFS) with a needle safety device. Each device delivers 0.9 mL (162 mg) of Tocilizumab, in a histidine buffered solution composed of Tocilizumab (180 mg/mL), polysorbate 80, L-histidine and L-histidine monohydrochloride, L-arginine and L-arginine hydrochloride, L-methionine, and water for injection.

## Pharmacodynamics
- In clinical studies with the 4 mg per kg and 8 mg per kg IV doses or the 162 mg weekly and every other weekly SC doses of Tocilizumab, decreases in levels of C-reactive protein (CRP) to within normal ranges were seen as early as week 2. Changes in pharmacodynamic parameters were observed (i.e., decreases in rheumatoid factor, erythrocyte sedimentation rate (ESR), serum amyloid A and increases in hemoglobin) with doses, however the greatest improvements were observed with 8 mg per kg Tocilizumab. Pharmacodynamic changes were also observed to occur after Tocilizumab administration in PJIA and SJIA patients (decreases in CRP, ESR, and increases in hemoglobin). The relationship between these pharmacodynamic findings and clinical efficacy is not known.
- In healthy subjects administered Tocilizumab in doses from 2 to 28 mg per kg intravenously and 81 to 162 mg subcutaneously, absolute neutrophil counts decreased to the nadir 3 to 5 days following Tocilizumab administration. Thereafter, neutrophils recovered towards baseline in a dose dependent manner. Rheumatoid arthritis patients demonstrated a similar pattern of absolute neutrophil counts following Tocilizumab administration.

## Pharmacokinetics
- The pharmacokinetics characterized in healthy subjects and RA patients suggested that PK is similar between the two populations. The clearance (CL) of tocilizumab decreased with increased doses. At the 10 mg per kg single dose in RA patients, mean CL was 0.29  0.10 mL per hr per kg and mean apparent terminal t1/2 was 151  59 hours (6.3 days).
- The pharmacokinetics of tocilizumab were determined using a population pharmacokinetic analysis of 1793 rheumatoid arthritis patients treated with Tocilizumab 4 and 8 mg per kg every 4 weeks for 24 weeks.
- The pharmacokinetic parameters of tocilizumab did not change with time. A more than dose-proportional increase in area under the curve (AUC) and trough concentration (Cmin) was observed for doses of 4 and 8 mg per kg every 4 weeks. Maximum concentration (Cmax) increased dose-proportionally. At steady-state, estimated AUC and Cmin were 2.7 and 6.5-fold higher at 8 mg per kg as compared to 4 mg per kg, respectively. In a long-term study with dosing for 104 weeks, observed Cmin was sustained over time.
- For doses of Tocilizumab 4 mg per kg given every 4 weeks, the estimated mean ( SD) steady-state AUC, Cmin and Cmax of tocilizumab were 13000  5800 mcgh per mL, 1.49  2.13 mcg per mL, and 88.3  41.4 mcg per mL, respectively. The accumulation ratios for AUC and Cmax were 1.11 and 1.02, respectively. The accumulation ratio was higher for Cmin (1.96). Steady-state was reached following the first administration for Cmax and AUC, respectively, and after 16 weeks Cmin. For doses of Tocilizumab 8 mg per kg given every 4 weeks, the estimated mean ( SD) steady-state AUC, Cmin and Cmax of tocilizumab were 35000  15500 mcgh per mL, 9.74  10.5 mcg per mL, and 183  85.6 mcg per mL, respectively. The accumulation ratios for AUC and Cmax were 1.22 and 1.06, respectively. The accumulation ratio was higher for Cmin (2.35). Steady-state was reached following the first administration and after 8 and 20 weeks for Cmax, AUC, and Cmin, respectively. Tocilizumab AUC, Cmin and Cmax increased with increase of body weight. At body weight at or above 100 kg, the estimated mean ( SD) steady-state AUC, Cmin and Cmax of tocilizumab were 55500  14100 mcgh per mL, 19.0  12.0 mcg per mL, and 269  57 mcg per mL, respectively, which are higher than mean exposure values for the patient population. Therefore, Tocilizumab doses exceeding 800 mg per infusion are not recommended.
- The pharmacokinetics of tocilizumab was characterized using a population pharmacokinetic analysis using a database composed of 1759 rheumatoid arthritis patients treated with 162 mg SC every week, 162 mg SC every other week, and 8 mg/kg every 4 weeks for 24 weeks.
- The pharmacokinetic parameters of tocilizumab did not change with time. For the 162 mg every week dose, the estimated mean (SD) steady-state AUC1week, Cmin and Cmax of tocilizumab were 8200  3600 mcgh/mL, 44.6  20.6 mcg/mL, and 50.9  21.8 mcg/mL, respectively. The accumulation ratios for AUC, Cmin, and Cmax were 6.83, 6.37, and 5.47, respectively. Steady state was reached after 12 weeks for AUC, Cmin, and Cmax.
- For the 162 mg every other week dose, the estimated mean (SD) steady-state AUC2week, Cmin, and Cmax of tocilizumab were 3200  2700 mcgh/mL, 5.6  7.0 mcg/mL, and 12.3  8.7 mcg/mL, respectively. The accumulation ratios for AUC, Cmin, and Cmax were 2.67, 5.6, and 2.12, respectively. Steady state was reached after 12 weeks for AUC and Cmin, and after 10 weeks for Cmax.
- The pharmacokinetics of tocilizumab was determined using a population pharmacokinetic analysis on a database composed of 188 patients with polyarticular juvenile idiopathic arthritis.
- For doses of 8 mg/kg tocilizumab (patients with a body weight at or above 30 kg) given every 4 weeks, the estimated mean ( SD) AUC4weeks, Cmax and Cmin of tocilizumab were 29500  8660 mcghr/mL, 182  37 mcg/mL and 7.49  8.2 mcg/mL, respectively.
- For doses of 10 mg/kg tocilizumab (patients with a body weight less than 30 kg) given every 4 weeks, the estimated mean ( SD) AUC4weeks, Cmax and Cmin of tocilizumab were 23200  6100 mcghr/mL, 175  32 mcg/mL and 2.35  3.59 mcg/mL, respectively.
- The accumulation ratios were 1.05 and 1.16 for AUC4weeks, and 1.43 and 2.22 for Cmin for 10 mg/kg (BW less than 30 kg) and 8 mg/kg (BW at or above 30 kg) doses, respectively. No accumulation for Cmax was observed.
- The pharmacokinetics of tocilizumab were determined using a population pharmacokinetic analysis on a database composed of 75 patients with SJIA treated with 8 mg per kg (patients with a body weight at or above 30 kg) or 12 mg per kg (patients with a body weight less than 30 kg), given every 2 weeks. The estimated mean ( SD) AUC2 weeks, Cmax and Cmin of tocilizumab were 32200  9960 mcghr per mL, 245  57.2 mcg per mL and 57.5  23.3 mcg per mL, respectively. The accumulation ratio for Cmin (week 12 over week 2) was 3.2  1.3. Steady state was reached on or after week 12. Mean estimated tocilizumab exposure parameters were similar between the two dose groups defined by body weight.
- Absorption
- Following SC dosing in rheumatoid arthritis patients, the absorption half-life was around 4 days. The bioavailability for the SC formulation was 0.8.
- Distribution
- Following intravenous dosing, tocilizumab undergoes biphasic elimination from the circulation. In rheumatoid arthritis patients the central volume of distribution was 3.5 L and the peripheral volume of distribution was 2.9 L, resulting in a volume of distribution at steady state of 6.4 L.
- In pediatric patients with PJIA, the central volume of distribution was 1.98 L, the peripheral volume of distribution was 2.1 L, resulting in a volume of distribution at steady state of 4.08 L.
- In pediatric patients with SJIA, the central volume of distribution was 0.94 L, the peripheral volume of distribution was 1.60 L resulting in a volume of distribution at steady state of 2.54 L.
- Elimination
- The total clearance of tocilizumab is concentration-dependent and is the sum of the linear clearance and the nonlinear clearance. The linear clearance in the population pharmacokinetic analysis was estimated to be 12.5 mL per h in RA, 5.8 mL per h in pediatric patients with PJIA, and 7.1 mL per h in pediatric patients with SJIA. The concentration-dependent nonlinear clearance plays a major role at low tocilizumab concentrations. Once the nonlinear clearance pathway is saturated, at higher tocilizumab concentrations, clearance is mainly determined by the linear clearance.
- The t1/2 of tocilizumab is concentration-dependent. For IV administration, the concentration-dependent apparent t1/2 is up to 11 days for 4 mg per kg and up to 13 days for 8 mg per kg every 4 weeks in patients with RA at steady-state. For SC administration, the concentration-dependent apparent t1/2 is up to 13 days for 162 mg every week and 5 days for 162 mg every other week in patients with RA at steady-state.
- The t1/2 of tocilizumab in children with PJIA is up to 16 days for the two body weight categories (8 mg/kg for body weight at or above 30 kg or 10 mg/kg for body weight less than 30 kg) during a dosing interval at steady state.
- The t1/2 of tocilizumab in pediatric patients with SJIA is up to 23 days for the two body weight categories at week 12.
- Pharmacokinetics in Special Populations
- Population pharmacokinetic analyses in adult rheumatoid arthritis patients showed that age, gender and race did not affect the pharmacokinetics of tocilizumab. Linear clearance was found to increase with body size. The body weight-based dose (8 mg per kg) resulted in approximately 86% higher exposure in patients who are greater than 100 kg in comparison to patients who are less than 60 kg. There was an inverse relationship between tocilizumab exposure and body weight for flat dose SC regimens.
- Hepatic Impairment
- No formal study of the effect of hepatic impairment on the pharmacokinetics of tocilizumab was conducted.
- Renal Impairment
- No formal study of the effect of renal impairment on the pharmacokinetics of tocilizumab was conducted.
- Most of the RA patients in the population pharmacokinetic analysis had normal renal function or mild renal impairment. Mild renal impairment (creatinine clearance less than 80 mL per min and at or above 50 mL per min based on Cockcroft-Gault) did not impact the pharmacokinetics of tocilizumab. No dose adjustment is required in patients with mild renal impairment.
- Drug Interactions
- In vitro data suggested that IL-6 reduced mRNA expression for several CYP450 isoenzymes including CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6 and CYP3A4, and this reduced expression was reversed by co-incubation with tocilizumab at clinically relevant concentrations. Accordingly, 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 leading to increased metabolism of drugs that are CYP450 substrates. Its effect on CYP2C8 or transporters (e.g., P-gp) is unknown. This is clinically relevant for CYP450 substrates with a narrow therapeutic index, where the dose is individually adjusted. Upon initiation of Tocilizumab, in patients being treated with these types of medicinal products, therapeutic monitoring of the effect (e.g., warfarin) or drug concentration (e.g., cyclosporine or theophylline) should be performed and the individual dose of the medicinal product adjusted as needed. Caution should be exercised when Tocilizumab is coadministered with drugs where decrease in effectiveness is undesirable, e.g., oral contraceptives (CYP3A4 substrates).
- Simvastatin
- Simvastatin is a CYP3A4 and OATP1B1 substrate. In 12 RA patients not treated with Tocilizumab, receiving 40 mg simvastatin, exposures of simvastatin and its metabolite, simvastatin acid, was 4- to 10-fold and 2-fold higher, respectively, than the exposures observed in healthy subjects. One week following administration of a single infusion of Tocilizumab (10 mg per kg), exposure of simvastatin and simvastatin acid decreased by 57% and 39%, respectively, to exposures that were similar or slightly higher than those observed in healthy subjects. Exposures of simvastatin and simvastatin acid increased upon withdrawal of Tocilizumab in RA patients. Selection of a particular dose of simvastatin in RA patients should take into account the potentially lower exposures that may result after initiation of Tocilizumab (due to normalization of CYP3A4) or higher exposures after discontinuation of Tocilizumab.
- Omeprazole
- Omeprazole is a CYP2C19 and CYP3A4 substrate. In RA patients receiving 10 mg omeprazole, exposure to omeprazole was approximately 2 fold higher than that observed in healthy subjects. In RA patients receiving 10 mg omeprazole, before and one week after Tocilizumab infusion (8 mg per kg), the omeprazole AUCinf decreased by 12% for poor (N=5) and intermediate metabolizers (N=5) and by 28% for extensive metabolizers (N=8) and were slightly higher than those observed in healthy subjects.
- Dextromethorphan
- Dextromethorphan is a CYP2D6 and CYP3A4 substrate. In 13 RA patients receiving 30 mg dextromethorphan, exposure to dextromethorphan was comparable to that in healthy subjects. However, exposure to its metabolite, dextrorphan (a CYP3A4 substrate), was a fraction of that observed in healthy subjects. One week following administration of a single infusion of Tocilizumab (8 mg per kg), dextromethorphan exposure was decreased by approximately 5%. However, a larger decrease (29%) in dextrorphan levels was noted after Tocilizumab infusion.

## Nonclinical Toxicology
- Carcinogenesis
- No long-term animal studies have been performed to establish the carcinogenicity potential of tocilizumab.
- Impairment of Fertility
- Fertility studies conducted in male and female mice using a murine analogue of tocilizumab administered by the intravenous route at a dose of 50 mg/kg every three days showed no impairment of fertility.

# Clinical Studies
- The efficacy and safety of intravenously administered Tocilizumab was assessed in five randomized, double-blind, multicenter studies in patients greater than 18 years with active rheumatoid arthritis diagnosed according to American College of Rheumatology (ACR) criteria. Patients had at least 8 tender and 6 swollen joints at baseline. Tocilizumab was given intravenously every 4 weeks as monotherapy (Study I), in combination with methotrexate (MTX) (Studies II and III) or other disease-modifying anti-rheumatic drugs (DMARDs) (Study IV) in patients with an inadequate response to those drugs, or in combination with MTX in patients with an inadequate response to TNF antagonists (Study V).
- Study I evaluated patients with moderate to severe active rheumatoid arthritis who had not been treated with MTX within 24 weeks prior to randomization, or who had not discontinued previous methotrexate treatment as a result of clinically important toxic effects or lack of response. In this study, 67% of patients were MTX-naive, and over 40% of patients had rheumatoid arthritis less than 2 years. Patients received Tocilizumab 8 mg per kg monotherapy or MTX alone (dose titrated over 8 weeks from 7.5 mg to a maximum of 20 mg weekly). The primary endpoint was the proportion of Tocilizumab patients who achieved an ACR 20 response at Week 24.
- Study II was a 104-week study with an ongoing optional 156-week extension phase that evaluated patients with moderate to severe active rheumatoid arthritis who had an inadequate clinical response to MTX. Patients received Tocilizumab 8 mg per kg, Tocilizumab 4 mg per kg, or placebo every four weeks, in combination with MTX (10 to 25 mg weekly). Upon completion of 52-weeks, patients received open-label treatment with Tocilizumab 8 mg per kg through 104 weeks or they had the option to continue their double-blind treatment if they maintained a greater than 70% improvement in swollen/tender joint count. Two pre-specified interim analyses at week 24 and week 52 were conducted. The primary endpoint at week 24 was the proportion of patients who achieved an ACR 20 response. At weeks 52 and 104, the primary endpoints were change from baseline in modified total Sharp-Genant score and the area under the curve (AUC) of the change from baseline in HAQ-DI score.
- Study III evaluated patients with moderate to severe active rheumatoid arthritis who had an inadequate clinical response to MTX. Patients received Tocilizumab 8 mg per kg, Tocilizumab 4 mg per kg, or placebo every four weeks, in combination with MTX (10 to 25 mg weekly). The primary endpoint was the proportion of patients who achieved an ACR 20 response at week 24.
- Study IV evaluated patients who had an inadequate response to their existing therapy, including one or more DMARDs. Patients received Tocilizumab 8 mg per kg or placebo every four weeks, in combination with the stable DMARDs. The primary endpoint was the proportion of patients who achieved an ACR 20 response at week 24.
- Study V evaluated patients with moderate to severe active rheumatoid arthritis who had an inadequate clinical response or were intolerant to one or more TNF antagonist therapies. The TNF antagonist therapy was discontinued prior to randomization. Patients received Tocilizumab 8 mg per kg, Tocilizumab 4 mg per kg, or placebo every four weeks, in combination with MTX (10 to 25 mg weekly). The primary endpoint was the proportion of patients who achieved an ACR 20response at week 24.
- Clinical Response
- The percentages of intravenous Tocilizumab-treated patients achieving ACR 20, 50 and 70 responses are shown in TABLE 3. In all intravenous studies, patients treated with 8 mg per kg Tocilizumab had higher ACR 20, ACR 50, and ACR 70 response rates versus MTX- or placebo-treated patients at week 24.
- During the 24 week controlled portions of Studies I to V, patients treated with Tocilizumab at a dose of 4 mg per kg in patients with inadequate response to DMARDs or TNF antagonist therapy had lower response rates compared to patients treated with Tocilizumab 8 mg per kg.
- In study II, a greater proportion of patients treated with 4 mg per kg and 8 mg per kg Tocilizumab + MTX achieved a low level of disease activity as measured by a DAS 28-ESR less than 2.6 compared with placebo +MTX treated patients at week 52. The proportion of Tocilizumab-treated patients achieving DAS 28-ESR less than 2.6, and the number of residual active joints in these responders in Study II are shown in TABLE 4.
- The results of the components of the ACR response criteria for Studies III and V are shown in TABLE 5. Similar results to Study III were observed in Studies I, II and IV.
- The percent of ACR 20 responders by visit for Study III is shown in FIGURE 1. Similar response curves were observed in studies I, II, IV, and V.
- Radiographic Response
- In Study II, structural joint damage was assessed radiographically and expressed as change in total Sharp-Genant score and its components, the erosion score and joint space narrowing score. Radiographs of hands/wrists and forefeet were obtained at baseline, 24 weeks, 52 weeks, and 104 weeks and scored by readers unaware of treatments group and visit number. The results from baseline to week 52 are shown in TABLE 6. Tocilizumab 4 mg per kg slowed (less than 75% inhibition compared to the control group) and Tocilizumab 8 mg per kg inhibited (at least 75% inhibition compared to the control group) the progression of structural damage compared to placebo plus MTX at week 52.
- The mean change from baseline to week 104 in Total Sharp-Genant Score for the Tocilizumab 4 mg per kg groups was 0.47 (SD = 1.47) and for the 8 mg per kg groups was 0.34 (SD = 1.24). By the week 104, most patients in the control (placebo + MTX) group had crossed over to active treatment, and results are therefore not included for comparison. Patients in the active groups may have crossed over to the alternate active dose group, and results are reported per original randomized dose group.
- In the placebo group, 66% of patients experienced no radiographic progression (Total Sharp-Genant Score change  0) at week 52 compared to 78% and 83% in the Tocilizumab 4 mg per kg and 8 mg per kg, respectively. Following 104 weeks of treatment, 75% and 83% of patients initially randomized to Tocilizumab 4 mg per kg and 8 mg per kg, respectively, experienced no progression of structural damage compared to 66% of placebo treated patients.
- Health Related Outcomes
- In Study II, physical function and disability were assessed using the Health Assessment Questionnaire Disability Index (HAQ-DI). Both dosing groups of Tocilizumab demonstrated a greater improvement compared to the placebo group in the AUC of change from baseline in the HAQ-DI through week 52. The mean change from baseline to week 52 in HAQ-DI was 0.6, 0.5, and 0.4 for Tocilizumab 8 mg per kg, Tocilizumab 4 mg per kg, and placebo treatment groups, respectively. Sixty-three percent (63%) and sixty percent (60%) of patients in the Tocilizumab 8 mg per kg and Tocilizumab 4 mg per kg treatment groups, respectively, achieved a clinically relevant improvement in HAQ-DI (change from baseline of  0.3 units) at week 52 compared to 53% in the placebo treatment group.
- The efficacy and safety of subcutaneously administered Tocilizumab was assessed in two double-blind, controlled, multicenter studies in patients with active RA. One study (SC-I) was a non-inferiority study that compared the efficacy and safety of Tocilizumab 162 mg administered every week subcutaneously (SC) to 8 mg per kg intravenously every four weeks. The second study (SC-II) was a placebo controlled superiority study that evaluated the safety and efficacy of Tocilizumab 162 mg administered every other week SC to placebo. Both SC-I and SC-II required patients to be >18 years of age with moderate to severe active rheumatoid arthritis diagnosed according to ACR criteria who had at least 4 tender and 4 swollen joints at baseline (SC-I) or at least 8 tender and 6 swollen joints at baseline (SC-II), and an inadequate response to their existing DMARD therapy, where approximately 20% also had a history of inadequate response to at least one TNF inhibitor. All patients in both SC studies received background non-biologic DMARD(s).
- In SC-I, 1262 patients were randomized 1:1 to receive Tocilizumab SC 162 mg every week or Tocilizumab intravenous 8 mg/kg every four weeks in combination with DMARD(s). In SC-II, 656 patients were randomized 2:1 to Tocilizumab SC 162 mg every other week or placebo, in combination with DMARD(s). The primary endpoint in both studies was the proportion of patients who achieved an ACR20 response at Week 24.
- The clinical response to 24 weeks of Tocilizumab SC therapy is shown in TABLE 7. In SC-I, the primary outcome measure was ACR20 at Week 24. The pre-specified non-inferiority margin was a treatment difference of 12%. The study demonstrated non-inferiority of Tocilizumab with respect to ACR20 at Week 24; ACR50, ACR70, and DAS28 responses are also shown in TABLE 7. In SC-II, a greater portion of patients treated with Tocilizumab 162 mg SC every other week achieved ACR20, ACR50, and ACR70 responses compared to placebo-treated patients (TABLE 7). Further, a greater proportion of patients treated with Tocilizumab 162 mg SC every other week achieved a low level of disease activity as measured by a DAS28-ESR less than 2.6 at Week 24 compared to those treated with placebo (TABLE 7).
- The results of the components of the ACR response criteria and the percent of ACR20 responders by visit for Tocilizumab-SC in Studies SC-I and SC-II were consistent with those observed for Tocilizumab-IV.
- Radiographic Response
- In study SC-II, the progression of structural joint damage was assessed radiographically and expressed as a change from baseline in the van der Heijde modified total Sharp score (mTSS). At week 24, significantly less radiographic progression was observed in patients receiving Tocilizumab SC every other week plus DMARD(s) compared to placebo plus DMARD(s); mean change from baseline in mTSS of 0.62 vs. 1.23, respectively, with an adjusted mean difference of -0.60 (-1.1, -0.1). These results are consistent with those observed in patients treated with intravenous Tocilizumab.
- Health Related Outcomes
- In studies SC-I and SC-II, the mean decrease from baseline to week 24 in HAQ-DI was 0.6, 0.6, 0.4 and 0.3, and the proportion of patients who achieved a clinically relevant improvement in HAQ-DI (change from baseline of  0.3 units) was 65%, 67%, 58% and 47%, for the SC every week, IV 8 mg/kg, SC every other week, and placebo treatment groups, respectively.
- The efficacy of Tocilizumab was assessed in a three-part study including an open-label extension in children 2 to 17 years of age with active polyarticular juvenile idiopathic arthritis (PJIA), who had an inadequate response to methotrexate or inability to tolerate methotrexate. Patients had at least 6 months of active disease (mean disease duration of 4.2  3.7 years), with at least five joints with active arthritis (swollen or limitation of movement accompanied by pain and/or tenderness) and/or at least 3 active joints having limitation of motion (mean, 20  14 active joints). The patients treated had subtypes of JIA that at disease onset included Rheumatoid Factor Positive or Negative Polyarticular JIA, or Extended Oligoarticular JIA. Treatment with a stable dose of methotrexate was permitted but was not required during the study. Concurrent use of disease modifying antirheumatic drugs (DMARDs), other than methotrexate, or other biologics (e.g., TNF antagonists or T cell costimulation modulator) were not permitted in the study.
- Part I consisted of a 16-week active Tocilizumab treatment lead-in period (n=188) followed by Part II, a 24-week randomized double-blind placebo-controlled withdrawal period, followed by Part III, a 64-week open-label period. Eligible patients weighing at or above 30 kg received Tocilizumab at 8 mg/kg IV once every four weeks. Patients weighing less than 30 kg were randomized 1:1 to receive either Tocilizumab 8 mg/kg or 10 mg/kg IV every four weeks. At the conclusion of the open-label Part I, 91% of patients taking background MTX in addition to tocilizumab and 83% of patients on tocilizumab monotherapy achieved an ACR 30 response at week 16 compared to baseline and entered the blinded withdrawal period (Part II) of the study. The proportions of patients with JIA ACR 50/70 responses in Part I were 84.0%, and 64%, respectively for patients taking background MTX in addition to tocilizumab and 80% and 55% respectively for patients on tocilizumab monotherapy.
- In Part II, patients (ITT, n=163) were randomized to Tocilizumab (same dose received in Part I) or placebo in a 1:1 ratio that was stratified by concurrent methotrexate use and concurrent corticosteroid use. Each patient continued in Part II of the study until Week 40 or until the patient satisfied JIA ACR 30 flare criteria (relative to Week 16) and qualified for escape.
- The primary endpoint was the proportion of patients with a JIA ACR 30 flare at week 40 relative to week 16. JIA ACR 30 flare was defined as 3 or more of the 6 core outcome variables worsening by at least 30% with no more than 1 of the remaining variables improving by more than 30% relative to Week 16.
- Tocilizumab treated patients experienced significantly fewer disease flares compared to placebo-treated patients (26%  versus 48% ; adjusted difference in proportions -21%, 95% CI: -35%, -8%).
- During the withdrawal phase (Part II), more patients treated with Tocilizumab showed JIA ACR 30/50/70 responses at Week 40 compared to patients withdrawn to placebo.
- The efficacy of Tocilizumab for the treatment of active SJIA was assessed in a 12-week randomized, double blind, placebo-controlled, parallel group, 2-arm study. Patients treated with or without MTX, were randomized (Tocilizumab:placebo = 2:1) to one of two treatment groups: 75 patients received Tocilizumab infusions every two weeks at either 8 mg per kg for patients at or above 30 kg or 12 mg per kg for patients less than 30 kg and 37 were randomized to receive placebo infusions every two weeks. Corticosteroid tapering could occur from week six for patients who achieved a JIA ACR 70 response. After 12 weeks or at the time of escape, due to disease worsening, patients were treated with Tocilizumab in the open-label extension phase at weight appropriate dosing.
- The primary endpoint was the proportion of patients with at least 30% improvement in JIA ACR core set (JIA ACR 30 response) at Week 12 and absence of fever (no temperature at or above 37.5C in the preceding 7 days). JIA ACR (American College of Rheumatology) responses are defined as the percentage improvement (e.g., 30%, 50%, 70%) in 3 of any 6 core outcome variables compared to baseline, with worsening in no more than 1 of the remaining variables by 30% or more. Core outcome variables consist of physician global assessment, parent per patient global assessment, number of joints with active arthritis, number of joints with limitation of movement, erythrocyte sedimentation rate (ESR), and functional ability (childhood health assessment questionnaire-CHAQ).
- Primary endpoint result and JIA ACR response rates at Week 12 are shown in TABLE 8.
- The treatment effect of Tocilizumab was consistent across all components of the JIA ACR response core variables. JIA ACR scores and absence of fever responses in the open label extension were consistent with the controlled portion of the study (data available through 44 weeks).
- Systemic Features
- Of patients with fever or rash at baseline, those treated with Tocilizumab had fewer systemic features; 35 out of 41 (85%) became fever free (no temperature recording at or above 37.5C in the preceding 14 days) compared to 5 out of 24 (21%) of placebo-treated patients, and 14 out of 22 (64%) became free of rash compared to 2 out of 18 (11%) of placebo-treated patients. Responses were consistent in the open label extension (data available through 44 weeks).
- Corticosteroid Tapering
- Of the patients receiving oral corticosteroids at baseline, 8 out of 31 (26%) placebo and 48 out of 70 (69%), Tocilizumab patients achieved a JIA ACR 70 response at week 6 or 8 enabling corticosteroid dose reduction. Seventeen (24%) Tocilizumab patients versus 1 (3%) placebo patient were able to reduce the dose of corticosteroid by at least 20% without experiencing a subsequent JIA ACR 30 flare or occurrence of systemic symptoms to week 12. In the open label portion of the study, by week 44, there were 44 out of 103 (43%) Tocilizumab patients off oral corticosteroids. Of these 44 patients 50% were off corticosteroids 18 weeks or more.
- Health Related Outcomes
- Physical function and disability were assessed using the Childhood Health Assessment Questionnaire Disability Index (CHAQ-DI). Seventy-seven percent (58 out of 75) of patients in the Tocilizumab treatment group achieved a minimal clinically important improvement in CHAQ-DI (change from baseline of  0.13 units) at week 12 compared to 19% (7 out of 37) in the placebo treatment group.

# How Supplied
- For Intravenous Infusion
- Tocilizumab (tocilizumab) is supplied in single-use vials as a preservative-free, sterile concentrate (20 mg per mL) solution for intravenous infusion. The following packaging configurations are available:
- Individually packaged, single-use vials:
- NDC 50242-135-01 providing 80 mg per 4 mL
- NDC 50242-136-01 providing 200 mg per 10 mL
- NDC 50242-137-01 providing 400 mg per 20 mL
- For Subcutaneous Injection
- Tocilizumab (tocilizumab) for subcutaneous administration is supplied as a sterile preservative-free liquid solution in a single-use prefilled syringe. The following packaging configurations are available:
- NDC 50242-138-01 prefilled syringe providing 162 mg per 0.9mL
- Storage and Stability: Do not use beyond expiration date on the container, package or prefilled syringe. Tocilizumab must be refrigerated at 2oC to 8oC (36F to 46F). Do not freeze. Protect the vials and syringes from light by storage in the original package until time of use, and keep syringes dry. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If visibly opaque particles, discoloration or other foreign particles are observed, the solution should not be used.

## Storage
There is limited information regarding Tocilizumab Storage in the drug label.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Advise patients and parents or guardians of minors with PJIA or SJIA of the potential benefits and risks of Tocilizumab. Physicians should instruct their patients to read the Medication Guide before starting Tocilizumab therapy.
- Infections:
- Inform patients that Tocilizumab may lower their resistance to infections. Instruct the patient of the importance of contacting their doctor immediately when symptoms suggesting infection appear in order to assure rapid evaluation and appropriate treatment.
- Gastrointestinal Perforation:
- Inform patients that some patients who have been treated with Tocilizumab have had serious side effects in the stomach and intestines. Instruct the patient of the importance of contacting their doctor immediately when symptoms of severe, persistent abdominal pain appear to assure rapid evaluation and appropriate treatment.
- Hypersensitivity and Serious Allergic Reactions
- Assess patient suitability for home use for SC injection. Inform patients that some patients who have been treated with Tocilizumab have developed serious allergic reactions, including anaphylaxis. Advise patients to seek immediate medical attention if they experience any symptom of serious allergic reactions.
- Instruction on Injection Technique
- Perform the first injection under the supervision of a qualified healthcare professional. If a patient or caregiver is to administer subcutaneous Tocilizumab, instruct him/her in injection techniques and assess his/her ability to inject subcutaneously to ensure proper administration of subcutaneous Tocilizumab and the suitability for home use .
- Prior to use, remove the prefilled syringe from the refrigerator and allow to sit at room temperature outside of the carton for 30 minutes, out of the reach of children. Do not warm Tocilizumab in any other way.
- Advise patients to consult their healthcare provider if the full dose is not received.
- A puncture-resistant container for disposal of needles and syringes should be used and should be kept out of the reach of children. Instruct patients or caregivers in the technique as well as proper syringe and needle disposal, and caution against reuse of these items.

# Precautions with Alcohol
- Alcohol-Tocilizumab interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- Tocilizumab

# Look-Alike Drug Names
There is limited information regarding Tocilizumab Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price