Actemra (Tocilizumab) - Intravenous, Subcutaneous

What Is Actemra?

Actemra (tocilizumab) is an injection given every one to four weeks to treat several types of arthritis (an autoimmune disease).

This drug is called an interleukin-6 (IL-6) receptor antagonist. IL-6 is an excess protein in people with arthritis and other inflammatory conditions. Actemra works by preventing these proteins from binding to their receptors, ultimately decreasing the downstream effects of inflammation and joint pain.

The generic name for Actemra is tocilizumab. Actemra is a biologic drug, which means it is made of proteins derived from a living thing. Because of how it's manufactured, it can be an expensive medication. However, manufacturer coupons and patient assistance programs are available to improve affordability.

Actemra is considered a specialty drug; you must get it from a specialty pharmacy. It can be self-administered through a subcutaneous (under the skin) injection or received in a medical office intravenously (IV, into the vein).

What Is Actemra Used For?

The Food and Drug Administration (FDA) approved Actemra to treat a few different types of arthritis and other inflammatory conditions, such as:

• Rheumatoid arthritis (RA) that is moderate to severe in adults who have tried one or more other disease-modifying anti-rheumatic drugs (DMARDs) with not enough improvement
• Polyarticular juvenile idiopathic arthritis (pJIA) in children 2 years and older
• Systemic juvenile idiopathic arthritis (SJIA) in people 2 years and older
• Giant cell arteritis (GCA), or inflammation in the lining of the arteries, commonly in arteries in the head
• Systemic sclerosis-associated interstitial lung disease (SSc-ILD), or lung disease brought about by a disease of connective tissue
• Cytokine release syndrome (CRS), also called cytokine storm, in adults and children at least 2 years old
  

How to Take Actemra

You will receive Actemra once every one to four weeks, depending on what you’re taking it for.

You may receive the injection intravenously (into your vein) at an outpatient clinic or office. In this case, a nurse or healthcare provider will take care of preparing and giving the medication. Infusions usually last one hour.

Actemra may also be given subcutaneously, which means the medicine is injected right under your skin. You may eventually be able to do subcutaneous injections yourself at home if you and your healthcare provider feel it’s appropriate. While it can be intimidating or scary to think about injecting yourself, Actemra comes in devices that make the process simple. It’s available in prefilled syringes and prefilled ACTPen autoinjectors. Neither of these requires you to attach needles or draw up liquid.

The needles are small, only about a quarter of an inch long. You can use your thighs or stomach area (except for the 2-inch space around your belly button), as these areas commonly have the most fat. Do not inject into cut, tender, bruised, or scarred skin, and do not inject through clothing.

Before taking subcutaneous Actemra, ask your healthcare provider to show you how to use it. Below are general steps for how to administer Actemra.

For ACTPen autoinjectors:

1. Remove one autoinjector from your refrigerator and let it come to room temperature for 45 minutes. This will make injecting more comfortable. Have your sharps container handy. Do not try to warm the medicine up by shaking it or using any external heating source.
2. Hold the pen injector in the middle of the body with the green cap pointing down. You can take a look at the medicine through the small window to make sure it is clear to pale yellow in color. Do not use it if it’s cloudy or has large lumps or flakes.
3. Wash your hands and clean the area of skin you plan to inject with an alcohol swab. Then, allow your skin to dry without blowing on it or touching it again.
4. Once you’re ready to inject, remove the cap by twisting it and pulling it off. Do not try to put the cap back on. Use the injector within three minutes of removing the cap.
5. Hold the injector in your fist by the upper part of it so that you can still see the viewing window of the medicine. Then, gently pinch a small area of skin at the injection site with your other hand.
6. Hold the injector against your skin at a 90-degree angle. Then press down firmly against your skin and click the green activation button until you hear a click. The first click indicates that the injection has started.
7. Keep the green button pressed and continue holding the injector against your skin. You’ll see the purple indicator move along the viewing window throughout the injection, which can take up to 10 seconds. You may hear a second click, but keep pressing until the purple indicator stops moving.
8. Release the green button and lift the injector off your skin, then place the entire injector into your sharps container.
9. If you see any blood, you can lightly press a cotton ball over the injection site, but do not rub your skin.
10. Keep track of where you inject each dose of Actemra, as you’ll want to rotate sites each time you administer the drug.

For Actemra prefilled syringe injection:

1. Remove the syringe from your refrigerator and let it come to room temperature for 30 minutes. This will make injecting more comfortable. Have your sharps container handy. Do not try to warm the medicine up by shaking it or using any external heating source.
2. Hold the syringe at the clear part where you can see the medicine. Take a quick look to ensure the medicine is clear to pale yellow in color. Do not use it if it’s cloudy or has large lumps or flakes.
3. Wash your hands and clean the area of skin you plan to inject with an alcohol swab. Then, allow your skin to dry without blowing on it or touching it again.
4. Remove the needle cap with the needle pointing away from yourself. You may see a drop of liquid at the end of the needle. This is normal. The syringe must be used within five minutes of removing the needle cap.
5. Hold the syringe like a pencil in one hand. With the other hand, pinch a section of your skin between your thumb and other fingers, and insert the needle completely between a 45 to 90-degree angle. 
6. Relax the hand that is pinching the skin and slowly push the plunger down all the way to inject the medicine. Hold the syringe in place for five seconds.
7. Keep the plunger fully pressed and carefully pull the needle straight from the injection site.
8. Carefully release the plunger, allowing the needle guard to cover the exposed needle.
9. Place the entire syringe into your sharps container.
10. If you see any blood, you can lightly press a cotton ball over the injection site, but do not rub your skin.
11. Keep track of where you inject each dose of Actemra, as you’ll want to rotate sites each time you administer the drug.
    

Storage

Keep your unused autoinjectors and syringes in their original cartons in the refrigerator (36 F to 46 F). Do not freeze Actemra.

Your autoinjectors and syringes can be stored outside the fridge for up to two weeks below 86 F, but they must always be kept in their original cartons to protect the medicine from light and moisture. Don’t expose Actemra to extremely hot or cold temperatures, such as by freezing it or leaving it in your car on a hot day.

If you'll be doing your own subcutaneous injection, you will likely get a sharps container sent to you from your specialty pharmacy along with Actemra. If not, call the specialty pharmacy or ask your local pharmacist about getting a sharps container so that you don’t have loose needles or medicine in your household garbage.

If you’re traveling by plane, keep Actemra in your carry-on luggage if your checked baggage goes missing.

What Are the Side Effects of Actemra?

This is not a complete list of side effects, and others may occur. A healthcare provider can advise you on side effects. If you experience other effects, contact your pharmacist or a healthcare provider. You may report side effects to the FDA at fda.gov/medwatch or 1-800-FDA-1088.

Common Side Effects

These are the most common side effects of Actemra. If you experience these side effects and think they are severe or do not go away, you should notify your healthcare provider:

• Injection site reactions if using subcutaneous Actemra, such as mild pain, itching, or redness in the area where you received your injection
• Upper respiratory bacterial and viral infections, such as sinusitis (sinus infections), pharyngitis (a sore throat), or influenza
• Headache
• Hypertension, or increased blood pressure
• Dizziness
  

Severe Side Effects

Call your healthcare provider right away if you have serious side effects. Call 911 if your symptoms feel life-threatening or if you think you’re having a medical emergency. Potential severe side effects can include:

• Infections: Since IL-6 blockers like Actemra work by affecting your immune system, you may be more vulnerable to various types of infections while you’re on the medicine. This may be especially true if you have a suppressed immune system, or are a carrier of some viruses like hepatitis B or tuberculosis. Your healthcare provider should check for these infections before starting you on Actemra.
• Gastrointestinal perforation is rare but may occur. This is when a hole is formed in the lining of your intestine. Most people who developed these perforations in clinical trials were also taking nonsteroidal anti-inflammatory medications (NSAIDs), corticosteroids, or methotrexate, but how much these medications versus Actemra contributed to perforations is unknown.
• Hypersensitivity reactions, including anaphylaxis, are infrequent but do require stopping Actemra. These reactions during clinical trials were generally seen during the second to fourth infusion.
• Lab abnormalities were seen during clinical trials in a small percentage of people receiving Actemra. Neutropenia is a decrease in neutrophil count, which may lower your ability to fight infections and may slow your healing time. Thrombocytopenia is a lowered platelet count, which may make you more prone to bleeding and increase the time it takes for your blood to clot. Transaminitis, or elevated liver enzymes, may indicate some liver damage or hepatotoxicity. In most cases, adjusting Actemra dosing helped normalize liver enzymes during clinical trials.
  

Dosage: How Much Actemra Should I Take?

Modifications

Your dosage or treatment of Actemra may need to be adjusted in certain cases.

Pregnancy

There is not enough data regarding the use of Actemra in pregnant people to make a recommendation on the risk of birth defects, miscarriage, or adverse outcomes. The medicine does get transferred from the pregnant person to the fetus in small amounts via the placenta, which can potentially harm the fetus, but the effect is not well established. Speak with your healthcare provider about whether to use Actemra if you’re planning to become pregnant.

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

Breastfeeding

It’s unknown whether Actemra is present in human milk. A breastfed baby may absorb a small amount of the drug. The effects this may have are unknown due to a lack of data. As in pregnancy, the clinical benefit of Actemra for pregnant people should be weighed against any risk the drug and the pregnant person’s autoimmune condition may pose to a newborn.

Children

Actemra is approved to treat several conditions in children 2 years and older, including SJIA, pJIA, and CRS. However, it hasn’t been studied in children younger than 2, and its safety and effectiveness in that population are unknown.

Adults Over 65

The frequency of serious infections during clinical trials for Actemra was higher among individuals older than 65 versus younger than 65. Since older people are generally more prone to infections, caution should be used when treating people older than 65 with Actemra.

Missed Dose

You will most likely be receiving Actemra once every one to four weeks. Ensure you understand how often you’re supposed to get an injection or infusion. It can help to set phone or calendar reminders to give yourself doses. Whenever you receive your Actemra infusion, schedule your next infusion appointment.

If you inject your own Actemra and forget to give a dose, do not give yourself two injections to make up for a missed one. If you realize you’ve missed a dose and it’s been less than seven days since you missed one, you can give yourself the missed dose. Beyond that point, contact your healthcare provider for advice on giving the missed dose and setting a new schedule for injections.

Overdose: What Happens If I Take Too Much Actemra?

Since Actemra is an injection that you will either go to a clinic to receive or give yourself every one to four weeks, it would be difficult to overdose on this medication. Contact your healthcare provider if you accidentally give yourself too much Actemra and are worried. If you have symptoms and are concerned about an overdose, go to the emergency room.

Precautions

What Are Reasons I Shouldn't Take Actemra?

You should not take Actemra, or it may not be the best choice for you, if you have any of the following.

• An allergy to Actemra or any of its ingredients.
• A current active infection. Let your healthcare provider know if you have an active, chronic, or recurrent infection of any organ or if you think you're displaying signs of an infection, such as sweating or chills, muscle aches, shortness of breath, or feeling very tired. The infection should be treated and resolved before starting Actemra.
• Liver problems such as hepatitis or if you recently received lab results with high liver enzymes.
• Abdominal pain or if you’ve been diagnosed with diverticulitis or ulcers, as Actemra may increase the risk for gastrointestinal perforation.
• Neurological disorders. Central or peripheral nervous system demyelinating disorders, such as multiple sclerosis, optic neuritis, Guillain-Barré syndrome, and peripheral neuropathies, may be worsened by Actemra.
  

What Other Medications Interact With Actemra?

Avoid live vaccines while you’re taking Actemra. Live vaccines include:

• Chickenpox (varicella)
• FluMist (flu vaccine nasal spray)
• MMR (measles, mumps, rubella)
• Yellow fever vaccine

Let anyone who may be giving you a vaccine know that you take Actemra. Non-live or inactivated vaccinations, such as the seasonal flu shot, are fine to receive.

Other notable interactions involve drugs that are metabolized (or cleared) by certain proteins called cytochromes. Taking Actemra may cause these proteins to be more active, processing drugs and potentially clearing them from your body more quickly, causing them not to work as well. This means that some dose adjustments may need to be made for some drugs, including:

• Prilosec (omeprazole)
• Some statin drugs such as Zocor (simvastatin), Altoprev (lovastatin), and Lipitor (atorvastatin)
• Oral contraceptives, also called birth control pills
• Jantoven (warfarin)
• Gengraf, Neoral, Sandimmune (cyclosporine)
  

What Medications Are Similar?

There are many other biologic medications like Actemra. They all have slightly different mechanisms, but work similarly in that they mimic or improve a certain part of the function of your immune system.

• Kevzara (sarilumab) is another IL-6 blocker like Actemra. It was approved in 2017 and is also used for rheumatoid arthritis.
• Enbrel (etanercept) is a biologic drug called a tumor necrosis factor (TNF) inhibitor that is very expensive and injected subcutaneously. It is also used for rheumatoid arthritis and other autoimmune diseases.
• Humira (adalimumab) is another biologic drug that is also a TNF inhibitor. It is used to treat two forms of inflammatory bowel disorder (IBD), Crohn’s disease and ulcerative colitis, both autoimmune diseases affecting the digestive system.
• Remicade (infliximab) is given intravenously rather than subcutaneously, every eight weeks in an infusion clinic. Biosimilars for Remicade (highly similar products that are usually cheaper to manufacture and purchase) include Avsola (infliximab-axxq), Inflectra (infliximab-dyyb), Ixifi (infliximab-qbtx) and Renflexis (infliximab-abda).
• Cimzia (certolizumab pegol) is another biologic used to treat many autoimmune conditions.
• Simponi (golimumab) is a monoclonal antibody that is injected subcutaneously. It’s also available as Simponi Aria, which is given intravenously at an infusion clinic.

This is a list of drugs also prescribed for immune-mediated conditions such as arthritis, digestive issues, or skin conditions. It is NOT a list of drugs recommended to take with Actemra. In fact, you should not take these drugs together. Talk to your pharmacist or a healthcare provider if you have questions.

How Can I Stay Healthy While Taking Actemra?

Conditions caused by an overactive immune system, known as autoimmune diseases, are difficult to understand because our immune systems are so complicated. Uncontrolled arthritis can be very frustrating because every type of arthritis can profoundly impact everyday life in both children and adults.

While it may seem scary to be prescribed a medicine that has to be injected, subcutaneous injections are very easy, quick, and cause little to no pain—many people even self-inject subcutaneous drugs. Plus, medications like Actemra help relieve joint pain and stiffness and can improve your quality of life. You should also talk to your healthcare provider about additional ways to relieve symptoms, such as through diet or exercise changes.

Being patient and sticking to your dosing schedule while continuing to use other medicines you have been prescribed will all help you fight arthritis and give you the best shot at reducing your symptoms.