WARNINGS AND PRECAUTIONS
In COVID-19 patients, ACTEMRA should not be administered if patients have any other concurrent active infection, including localized infection.
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 ACTEMRA. 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 ACTEMRA. Other serious infections, not reported in clinical studies, may also occur (e.g., histoplasmosis, coccidioidomycosis, listeriosis).
The risks and benefits of treatment should be considered prior to initiating ACTEMRA in patients with chronic or recurrent infection, or who have a history of a serious or an opportunistic infection.
Closely monitor patients for the development of signs and symptoms of infection during and after treatment with ACTEMRA, as signs and symptoms of acute inflammation may be lessened due to suppression of the acute phase reactants.
A patient who develops a new infection during treatment with ACTEMRA should undergo a prompt and complete diagnostic workup appropriate for an immunocompromised patient; initiate appropriate antimicrobial therapy, and closely monitor the patient.
Events of gastrointestinal perforation have been reported in clinical trials for chronic indications, primarily as complications of diverticulitis, in patients treated with ACTEMRA. Use ACTEMRA 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.
Patients hospitalized with COVID-19 may have elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels. Multi-organ failure with involvement of the liver is recognized as a complication of severe COVID-19.
During randomized, controlled studies, treatment with ACTEMRA was associated with a higher incidence of transaminase elevations. Serious cases of hepatic injury have been observed in patients taking intravenous or subcutaneous ACTEMRA chronically. In this setting, the time to onset for cases ranged from months to years after treatment initiation with ACTEMRA.
The decision to administer ACTEMRA should balance the potential benefit against the risks of acute treatment with ACTEMRA. ACTEMRA is not recommended in COVID-19 patients with elevated ALT or AST above 10 times the upper limit of the reference range. When ACTEMRA is used for treatment of COVID-19, ALT and AST should be monitored according to current standard clinical practice.
In randomized, controlled trials, patients receiving ACTEMRA had higher rates of neutropenia, thrombocytopenia, and elevations of ALT or AST.
ACTEMRA is not recommended in COVID-19 patients with an absolute neutrophil count (ANC) less than 1000 per mm3, platelet count below 50,000 per mm3, or ALT or AST above 10 times the upper limit of the reference range. Monitor ALT, AST, neutrophils, and platelet counts according to current standard clinical practice.
Hypersensitivity Reactions, Including Anaphylaxis
Hypersensitivity reactions, including anaphylaxis, have been reported in association with ACTEMRA and anaphylactic events with a fatal outcome have been reported with intravenous infusion of ACTEMRA. These events have occurred both with and without previous hypersensitivity reactions and as early as the first infusion of ACTEMRA. ACTEMRA for intravenous use should only be infused by a healthcare professional with appropriate medical support to manage anaphylaxis. If anaphylaxis or other hypersensitivity reaction occurs, stop administration of ACTEMRA immediately and discontinue ACTEMRA permanently. Do not administer ACTEMRA to patients with known hypersensitivity to ACTEMRA.
The impact of treatment with ACTEMRA on demyelinating disorders is not known, but multiple sclerosis and chronic inflammatory demyelinating polyneuropathy were reported rarely in rheumatoid arthritis clinical studies. Monitor patients for signs and symptoms potentially indicative of demyelinating disorders. Prescribers should exercise caution in considering the use of ACTEMRA in patients with preexisting or recent onset demyelinating disorders.
Active Hepatic Disease and Hepatic Impairment
ACTEMRA is not recommended in patients with active hepatic disease or hepatic impairment.
Avoid use of live vaccines concurrently with ACTEMRA as clinical safety has not been established. The interval between live vaccinations and initiation of ACTEMRA therapy should be in accordance with current vaccination guidelines regarding immunosuppressive agents.
No data are available on the secondary transmission of infection from persons receiving live vaccines to patients receiving ACTEMRA.
No data are available on the effectiveness of vaccination in patients receiving ACTEMRA.