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Biologic DMARD — IL-6 Receptor Antagonist Pregnancy: Avoid — insufficient data; animal studies show no teratogenicity but human data lacking

Sarilumab

Brand names: Kevzara

Adult dose

Dose: 200 mg subcutaneous injection
Route: Subcutaneous
Frequency: Every 2 weeks
Max: 200 mg every 2 weeks
May reduce to 150 mg every 2 weeks if dose reduction required due to neutropenia or elevated LFTs. Can be used as monotherapy (unlike most biologics in RA).

Paediatric dose

Route:
Not licensed for paediatric use — seek specialist opinion

Dose adjustments

Renal

No dose adjustment required

Hepatic

Use with caution in hepatic impairment; LFT monitoring required

Clinical pearls

  • MONARCH trial (Ann Rheum Dis 2017): sarilumab monotherapy superior to adalimumab monotherapy for RA — unique head-to-head result; sarilumab showed superior DAS28-ESR reduction
  • Like tocilizumab, sarilumab masks fever and CRP as markers of infection — must have high clinical suspicion for serious infection despite normal inflammatory markers
  • Bowel perforation risk: particular concern in patients with diverticulosis on concurrent NSAIDs or steroids — counsel patients about abdominal pain
  • NICE TA485: approved for moderate to severe RA after inadequate response to DMARDs
  • Can be used as monotherapy — unlike most TNF inhibitors, which require co-administration with methotrexate for optimal efficacy

Contraindications

  • Active serious infection
  • Neutrophil count <2.0 × 10⁹/L before starting
  • Platelet count <150 × 10⁹/L before starting
  • ALT/AST >1.5× ULN before starting
  • Live vaccines

Side effects

  • Neutropenia — most common laboratory abnormality
  • Elevated liver enzymes
  • Injection site reactions
  • Upper respiratory tract infections
  • Hypertriglyceridaemia
  • Bowel perforation (rare — especially with diverticulitis or NSAIDs)

Interactions

  • CYP450 substrates: IL-6 inhibition restores CYP activity — warfarin and other CYP substrates may require dose re-titration
  • Live vaccines — contraindicated
  • Other immunosuppressants — increased infection risk

Monitoring

  • Neutrophil count before each injection
  • LFTs at 4–8 weeks then 3-monthly
  • Lipid panel at 4–8 weeks
  • Signs of infection

Reference: BNFc; BNF 90; NICE TA485; MONARCH Trial (Ann Rheum Dis 2017); SPC Kevzara. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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