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Instructions for Administration1

Recommended dosage

The recommended dosage for emergency use of ACTEMRA authorized under this EUA given as a single 60-minute intravenous infusion is:

If clinical signs or symptoms worsen or do not improve after the first dose, one additional infusion of ACTEMRA may be administered at least 8 hours after the initial infusion.

Maximum dosage in COVID-19 patients is 800 mg per infusion.

ACTEMRA subcutaneous administration is not authorized for the treatment of COVID-19 patients.

No dose adjustment is required in elderly patients >65 years of age or in patients with mild or moderate renal impairment.

Preparation and administration

ACTEMRA for intravenous infusion should be diluted by a healthcare professional using aseptic technique as follows:

  • Use a sterile needle and syringe to prepare ACTEMRA
  • Patients less than 30 kg: use a 50 mL infusion bag or bottle of 0.9% or 0.45% Sodium Chloride Injection, USP, and then follow steps 1 and 2 below
  • Patients at or above 30 kg weight: use a 100 mL infusion bag or bottle of 0.9% or 0.45% Sodium Chloride Injection, USP, and then follow steps 1 and 2 below
  • Step 1: Withdraw a volume of 0.9% or 0.45% Sodium Chloride Injection, USP, equal to the volume of the ACTEMRA injection required for the patient’s dose from the infusion bag or bottle (0.4 mL/kg and 0.6 mL/kg for 8 mg/kg and 12 mg/kg dosages, respectively)
  • Step 2: Withdraw the amount of ACTEMRA for intravenous infusion from the vial(s) and add slowly into the 0.9% or 0.45% Sodium Chloride Injection, USP infusion bag or bottle. To mix the solution, gently invert the bag to avoid foaming
    • The fully diluted ACTEMRA solutions for infusion using 0.9% Sodium Chloride Injection, USP may be stored at 36°F to 46°F (2°C to 8°C) or room temperature for up to 24 hours and should be protected from light
    • The fully diluted ACTEMRA solutions for infusion using 0.45% Sodium Chloride Injection, USP may be stored at 36°F to 46°F (2°C to 8°C) for up to 24 hours or room temperature for up to 4 hours and should be protected from light
    • ACTEMRA solutions do not contain preservatives; therefore, unused product remaining in the vials should not be used
    • Allow the fully diluted ACTEMRA solution to reach room temperature prior to infusion
    • The infusion should be administered over 60 minutes, and must be administered with an infusion set. Do not administer as an intravenous push or bolus
    • ACTEMRA should not be infused concomitantly in the same intravenous line with other drugs. No physical or biochemical compatibility studies have been conducted to evaluate the co-administration of ACTEMRA with other drugs
    • Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If particulates and discolorations are noted, the product should not be used
    • Fully diluted ACTEMRA solutions are compatible with polypropylene, polyethylene and polyvinyl chloride infusion bags and polypropylene, polyethylene and glass infusion bottles

Dosage forms and strengths

Injection: 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL as a clear, colorless to pale yellow solution in 20 mg/mL single-dose vials for further dilution prior to intravenous infusion.

Use in pediatric patients or specific populations

For information on use in pediatrics or specific populations, see section 8 of the Fact Sheet for Healthcare Professionals.

AUTHORIZED USE

ACTEMRA is authorized for use under an Emergency Use Authorization (EUA) for the treatment of coronavirus disease 2019 (COVID-19) in hospitalized adults and pediatric patients (2 years of age and older) who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).

ACTEMRA is not FDA-approved for this use.

ACTEMRA is authorized only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use of ACTEMRA under section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

ACTEMRA is contraindicated in patients with known hypersensitivity to ACTEMRA.

WARNINGS AND PRECAUTIONS

Serious Infections

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.

Gastrointestinal Perforations

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.

Hepatotoxicity

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.

Laboratory Parameters

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.

Demyelinating Disorders

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.

Vaccinations

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.

MOST COMMON ADVERSE REACTIONS

Most common adverse reactions (incidence ≥3%) are constipation, anxiety, diarrhea, insomnia, hypertension, and nausea.

DRUG INTERACTIONS

Inhibition of IL-6 may lead to increased metabolism of drugs that are CYP450 substrates. Caution should be exercised when co-administering ACTEMRA with CYP3A4 substrate drugs where decrease in effectiveness is undesirable. The effect of ACTEMRA on CYP450 enzyme activity may persist for several weeks after stopping therapy.

USE IN SPECIFIC POPULATIONS

Pregnancy

There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to ACTEMRA during pregnancy. Healthcare providers are encouraged to register patients and pregnant women are encouraged to register themselves by calling 1-877-311-8972.

The limited available data with ACTEMRA in pregnant women are not sufficient to determine whether there is a drug-associated risk for major birth defects and miscarriage. ACTEMRA should be used during pregnancy only if the potential benefit justifies the potential risk for the mother and the fetus.

Lactation

No information is available on the presence of tocilizumab in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. Breastfeeding individuals with COVID-19 should follow practices according to clinical guidelines to avoid exposing the infant to COVID-19.

You or your designee must report all SERIOUS ADVERSE EVENTS or MEDICATION ERRORS potentially related to ACTEMRA (1) by submitting FDA Form 3500 online, (2) by downloading this form and then submitting by mail or fax, or (3) contacting the FDA at 1-800-FDA-1088 to request this form. Please also provide a copy of this form to Genentech at [email protected] or call 1-888-835-2555.

Please see additional information in Fact Sheet for Healthcare Providers Fact Sheet for Patients and Parents/Caregivers , and FDA Letter of Authorization .

Please see additional Important Safety Information in full Prescribing Information , including BOXED WARNING and other risks associated with chronic use of ACTEMRA.

As a healthcare practitioner, you must communicate to the patient and/or caregiver information consistent with the Fact Sheet for Patients and Parents/Caregivers  and provide them with a copy of this Fact Sheet prior to administration of ACTEMRA. However, if providing this information will delay the administration of ACTEMRA to a degree that would endanger the life of a patient, the information must be provided to the parent and/or caregiver as soon as feasible after ACTEMRA administration.