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Tocilizumab and hepatotoxicity
Medicines Safety Update
Health professionals are advised that serious drug-induced liver injury, including acute liver failure, hepatitis and jaundice, have been observed with the administration of tocilizumab. The frequency of serious hepatotoxicity is considered rare, but in some cases treatment has required liver transplant.
Tocilizumab, which is marketed in Australia under the brand name Actemra, is indicated for treatment of:
- rheumatoid arthritis
- giant cell arteritis in adults
- polyarticular juvenile idiopathic arthritis in patients 2 years of age and older
- systemic juvenile idiopathic arthritis in patients 2 years of age and older
- chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome in adults and paediatric patients 2 years of age and older.
Patients treated with tocilizumab should be closely monitored for liver adverse events and advised to seek immediate medical advice if they have signs or symptoms of hepatotoxicity such as jaundice, dark urine, itch, loss of appetite, nausea or vomiting. Patients presenting with signs or symptoms of hepatotoxicity should be promptly investigated.
The current Product Information (PI) for tocilizumab does not recommend treatment in patients with elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) above five times the upper limit of normal (ULN). Caution should continue to be exercised when considering initiation of tocilizumab treatment in patients with ALT or AST above 1.5 times ULN.
For recommended dose modifications (reduction, interruption or discontinuation) of tocilizumab due to liver enzyme abnormalities, refer to the PI.
Tocilizumab is known to cause transient or intermittent mild to moderate elevation of hepatic transaminases.
The TGA is currently reviewing the data on the nature and incidence of hepatotoxicity with tocilizumab, and may recommend changes to the PI.
What to report? You don't need to be certain, just suspicious!
The TGA encourages the reporting of all suspected adverse reactions to medicines, including vaccines, over-the-counter medicines, herbal, traditional or alternative remedies.
We particularly request reports of:
- all suspected reactions to new medicines
- all suspected medicines interactions
- suspected reactions causing death, admission to hospital or prolongation of hospitalisation, increased investigations or treatment, or birth defects.
Reports may be submitted:
Medicines Safety Update is aimed at health professionals. It is intended to provide practical information to health professionals on medicine safety, including emerging safety issues. The information in Medicines Safety Update is necessarily general and is not intended to be a substitute for a health professional's judgment in each case, taking into account the individual circumstances of their patients. Reasonable care has been taken to ensure that the information is accurate and complete at the time of publication. The Australian Government gives no warranty that the information in this document is accurate or complete, and shall not be liable for any loss whatsoever due to negligence or otherwise arising from the use of or reliance on this document.
© Commonwealth of Australia 2019
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For correspondence or further information about Medicines Safety Update, contact the TGA's Pharmacovigilance and Special Access Branch at ADR.Reports@tga.gov.au.
Medicines Safety Update is written by staff from the Pharmacovigilance and Special Access Branch.
Acting Editor: Dr Grant Pegg
Deputy Editor: Mr Michael Pittman
Contributors include: Dr Richard Hill