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Biologic DMARD (IL-6 receptor antagonist) Pregnancy: Avoid unless essential. Use effective contraception during treatment and for 3 months after stopping.

Tocilizumab

Brand names: RoActemra, Tyenne (biosimilar)

Adult dose

Dose: RA: 8 mg/kg IV every 4 weeks (max 800 mg); 162 mg SC every week or every 2 weeks; GCA: 162 mg SC weekly
Route: IV infusion (over 1 hour) or SC injection
Frequency: IV: every 4 weeks; SC: weekly or every 2 weeks
Max: 800 mg IV per dose; 162 mg SC
RA (IV): 4 mg/kg every 4 weeks; increase to 8 mg/kg if needed (max 800 mg). RA (SC): 162 mg every 2 weeks; increase to weekly if needed. GCA: 162 mg SC weekly for 52 weeks with steroid taper. Severe COVID-19 (RECOVERY trial): 8 mg/kg (max 800 mg) IV single dose.

Paediatric dose

Dose: 8 mg/kg
Route: IV
Frequency: Every 2 weeks (<30 kg) or every 4 weeks (≥30 kg)
Max: 800 mg/dose
Concentration: 20 mg/ml
sJIA (≥2 years): 8 mg/kg (≥30 kg) or 12 mg/kg (<30 kg) every 2 weeks IV. pJIA (≥2 years): 8 mg/kg (≥30 kg) or 10 mg/kg (<30 kg) every 4 weeks IV.

Dose adjustments

Renal

No dose adjustment required for mild-moderate renal impairment; limited data for severe.

Hepatic

Use with caution in active hepatic disease. Avoid if LFTs >5× ULN.

Paediatric weight-based calculator

sJIA (≥2 years): 8 mg/kg (≥30 kg) or 12 mg/kg (<30 kg) every 2 weeks IV. pJIA (≥2 years): 8 mg/kg (≥30 kg) or 10 mg/kg (<30 kg) every 4 weeks IV.

Clinical pearls

  • IL-6 inhibition normalises CRP — unreliable biomarker during tocilizumab treatment (does not rise with infection)
  • GCA: 52-week tocilizumab + 26-week steroid taper vs 26-week steroid taper alone — superior (GiACTA trial)
  • RECOVERY trial: tocilizumab 8 mg/kg IV single dose reduces mortality in hospitalised COVID-19 (with dexamethasone)
  • Cholesterol increases on initiation — check fasting lipids at baseline and 4–8 weeks
  • Monitor LFTs and FBC before each infusion

Contraindications

  • Active serious infections
  • Active hepatic disease (LFTs >5× ULN)
  • Neutropenia (ANC <2×10⁹/L)
  • Thrombocytopenia (platelets <100×10⁹/L)
  • Live vaccines

Side effects

  • Increased infection risk
  • Elevated LFTs (common — often transient)
  • Neutropenia
  • Dyslipidaemia (LDL and total cholesterol increase)
  • GI perforation (rare — especially in patients with diverticulitis or on corticosteroids)
  • Hypersensitivity reactions

Interactions

  • Live vaccines — contraindicated
  • CYP450 substrates (warfarin, ciclosporin, statins) — tocilizumab reverses IL-6 effects on CYP enzymes; levels may change on initiation/dose change
  • Other biologics — increased infection risk

Monitoring

  • FBC (before each dose)
  • LFTs (before each dose)
  • Fasting lipids (baseline, 4–8 weeks, then annually)
  • Signs of infection

Reference: BNFc; BNF; NICE TA715; BSR Biologic Guidelines; GiACTA trial; RECOVERY trial. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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