Consumer medicine information

Actemra Infusion

Tocilizumab

BRAND INFORMATION

Brand name

Actemra

Active ingredient

Tocilizumab

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Actemra Infusion.

What is in this leaflet

This leaflet answers some common questions about Actemra infusion.

It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking Actemra against the benefits they expect it will have for you.

If you have any concerns about taking this medicine, ask your doctor or pharmacist.

Keep this leaflet with the medicine. You may need to read it again.

What Actemra is used for

Actemra contains the active ingredient tocilizumab.

Actemra belongs to a group of medicines called anti-rheumatic agents. There are many different classes of anti-rheumatic agents. Actemra belongs to a class called monoclonal antibodies.

Monoclonal antibodies are proteins which specifically recognise and bind to other unique proteins in the body.

Actemra is used to treat active moderate to severe rheumatoid arthritis (RA).

Actemra is used to treat adults and children 2 years of age and older with severe or life-threatening cytokine release syndrome (CRS), a side-effect in patients treated with chimeric antigen receptor (CAR) T-cell therapies used to treat certain types of cancer.

Actemra is also used to treat active systemic juvenile idiopathic arthritis (sJIA) and active moderate to severe polyarticular juvenile idiopathic arthritis (pJIA) in children over 2 years of age. Some of the signs and symptoms of RA, pJIA and sJIA are caused by the actions of a protein called interleukin-6 receptor (IL-6R).

Actemra works by binding and blocking IL-6R thereby helping to relieve some of the signs and symptoms of RA, pJIA, sJIA and CRS. For RA, Actemra can also prevent damage occurring to your joints.

There are many different types of medicines used to treat RA, pJIA and sJIA. Your doctor, however, may have prescribed Actemra for another purpose.

Ask your doctor if you have any questions about why Actemra has been prescribed for you.

Actemra is not addictive.

This medicine is available only with a doctor's prescription. For pJIA and sJIA Actemra should be prescribed by a doctor experienced in the management of these conditions.

Before you are given Actemra

When you must not be given Actemra

Do not use Actemra if:

  1. you have had an allergic reaction to Actemra or any ingredients listed at the end of this leaflet
Some of the symptoms of an allergic reaction may include:
  • chest tightness, wheezing or difficulty breathing
  • severe dizziness or light-headedness
  • swelling of the face, lips, tongue, throat or other parts of the body with difficulty breathing
  • rash, itching or hives on the skin
  1. you have had an allergic reaction to any other recombinant human or humanised antibodies or proteins that are of hamster origin
  2. you have an active, severe infection
  3. the package is torn or shows signs of tampering
  4. the expiry date (EXP) printed on the pack has passed.
If you take this medicine after the expiry date has passed, it may not work as well.

If you are not sure if you should be given Actemra, talk to your doctor.

Before you are given Actemra

Tell your doctor if:

  1. you have or develop any kind of infection
Actemra can reduce your body's ability to respond to infections and may make an existing infection worse or increase the chance of getting a new infection. This may be important if you have diabetes or diverticulitis (which increase your risk of infection).
Your doctor will perform blood tests before you are given Actemra to determine if you have low white blood cell or platelet counts, or high liver enzymes.
  1. you have any other health problems, especially the following:
  • liver disease such as viral hepatitis or other liver problems
    Your doctor will monitor your liver function closely before and during your treatment with Actemra.
  • HIV or AIDs
  • tuberculosis
  • diverticulitis or intestinal ulcers
  • a low white blood cell count or a low platelet count
  • diabetes
  • cancer
  • heart problems
  • raised blood pressure
  • high cholesterol or triglycerides
  • kidney disease
  • nerve disease such as neuropathy
  1. you have a history of macrophage activation syndrome (MAS)
MAS is a complication of sJIA. If you have a history of MAS your doctor will decide if you can still be given Actemra.
  1. you are planning to have a vaccination or have recently had a vaccination
Certain types of vaccines should not be given while receiving Actemra. It is particularly recommended that sJIA patients receive all necessary vaccinations prior to receiving Actemra.
  1. you are pregnant or plan to become pregnant
Tell your doctor if you are pregnant or plan to become pregnant. Women of childbearing potential should be advised to use adequate contraception during and for several months after treatment with Actemra. Actemra should not be used during pregnancy. However if there is a need to take Actemra when you are pregnant your doctor will discuss the risks and benefits to you and the unborn baby.
  1. you are breast-feeding or plan to breast-feed
It is not known whether Actemra passes into breast milk. It is recommended that you discontinue breast-feeding while you are treated with Actemra.
  1. you are on a controlled sodium diet
Actemra contains a small amount of sodium.
  1. you are allergic to any other medicines, foods, dyes or preservatives

If you have not told your doctor about any of the above, tell him or her before you start taking Actemra.

Use in Children

Actemra given as an intravenous injection in patients below 18 years of age with conditions other than pJIA, sJIA and CRS has not been studied. There is only limited data available for Actemra use in children with pJIA who are under 4 years of age. The use of Actemra in children under the age of 2 has not been studied.

Taking other medicines

Tell your doctor if you are taking any other medicines, including any that you have bought from a pharmacy, supermarket or health food shop.

Do not use Actemra with other biological medicines including infliximab, adalimumab, etanercept, anakinra, abatacept, rituximab, certolizumab pegol and golimumab. It is unknown how Actemra interacts with these medicines.

Actemra may interfere with some medicines. These include:

  • warfarin, a medicine used to prevent blood clots
  • cyclosporin, a medicine used after organ transplants
  • some vaccines
  • atorvastatin and simvastatin, medicines used to reduce cholesterol levels
  • calcium channel blockers, such as amlodipine, which are used to treat raised blood pressure
  • theophylline, a medicine used to treat asthma
  • phenytoin, a medicine used to treat convulsions
  • benzodiazepines, such as diazepam, which are used to treat anxiety

These medicines may be affected by Actemra, or may affect how well the medicine works. You may need to use different amounts of your medicine, or you may need to take different medicines. Your doctor will advise you.

Your doctor or pharmacist has more information on medicines to be careful with or avoid while taking Actemra.

Ask your doctor or pharmacist if you are not sure about this list of medicines.

How Actemra is given

How Actemra is given

Actemra is given by infusion into a vein (intravenous infusion) by a health care professional.

The infusion usually takes one hour. For pJIA, sJIA and CRS Actemra should be given in a hospital setting.

For RA and pJIA Actemra is usually given in combination with methotrexate (MTX). However you may receive Actemra on its own if your doctor determines that initial treatment with MTX is inappropriate or unsuccessful.

For sJIA Actemra can be given on its own or in combination with MTX.

For CRS Actemra can be given alone or in combination with corticosteroids.

How much is given

For RA the normal dose of Actemra is 8 mg per kilogram (kg) of your body weight. Your doctor will prescribe an amount of Actemra that is right for you.

For pJIA the normal dose of Actemra is 8 mg per kg of your body weight if you weigh 30 kg or more, or 10 mg per kg of your body weight if you weigh less than 30 kg. Your doctor will prescribe amount of Actemra that is right for you.

For sJIA the normal dose of Actemra is 8 mg per kg of your body weight if you weigh 30 kg or more, or 12 mg per kg of your body weight if you weigh less than 30 kg. Your doctor will prescribe an amount of Actemra that is right for you.

For CRS the normal dose of Actemra is 8 mg per kg of your body weight if you weigh 30 kg or more, or 12 mg per kg of your body weight if you weigh less than 30 kg. Your doctor will prescribe an amount of Actemra that is right for you.

How long is Actemra given

For RA and pJIA you will be treated with Actemra once every 4 weeks.

For sJIA you will be treated with Actemra once every 2 weeks.

For CRS you will receive a single dose of Actemra, and if needed additional doses.

The number of infusions you will receive depends on how you are responding to treatment. Your doctor will discuss this with you.

Continue receiving Actemra until your doctor tells you to stop.

If you miss a dose

As Actemra is given to you under the supervision of your doctor, you are unlikely to miss a dose. However, if you do then your doctor will decide when you should be given your next dose of Actemra.

Overdose

As Actemra is given to you under the supervision of your doctor it is unlikely that you will be given too much. However, if you experience any side effects after being given Actemra, tell your doctor immediately.

While you are receiving Actemra

Things you must do

When using Actemra, there is a risk of serious allergic reaction which needs immediate medical attention. Tell your doctor immediately or go to Accident and Emergency at your nearest hospital if you experience symptoms of a serious allergic reaction during or after receiving Actemra such as;

  • chest tightness, wheezing or difficulty breathing
  • severe dizziness or light-headedness
  • swelling of the face, lips, tongue, throat or other parts of the body with difficulty breathing
  • rash, itching or hives on the skin.

Tell your doctor immediately if you develop an infection or have symptoms of an infection while you are being treated with Actemra. Signs of an infection, with or without fever include:

  • sweating or chills,
  • feeling very tired
  • cough
  • shortness of breath
  • muscle aches
  • weight loss
  • warm, red, or painful skin or sores on your body
  • blood in phlegm
  • diarrohea or stomach ache
  • persistent headaches
  • burning when you urinate or urinating more often than normal.

Tell your doctor immediately if you develop severe blisters and bleeding in the lips, eyes, mouth, nose and genitals while you are being treated with Actemra.

When using immunosuppressive medication (lowers resistance to disease): such as Actemra, there is an increased risk of developing skin cancer (melanoma and nonmelanoma). Regular skin examination is recommended if you are at increased risk for skin cancer. Exposure to sunlight and UV light should be limited by wearing protective clothing and using sunscreen with a high protection factor.

Tell all doctors, dentists and pharmacists who are treating you that you are receiving Actemra.

Tell your doctor if you become pregnant while taking Actemra.

Tell your doctor if you are breast-feeding while being treated with Actemra.

Tell your doctor if you feel Actemra is not helping your condition.

Be sure to keep all of your appointments with your doctor so that your progress can be checked.

Your doctor will perform blood tests at regular intervals during your treatment to determine if you have low white blood cell or platelet counts, or high liver enzymes or cholesterol.

For pJIA your doctor will check your cholesterol at 3 monthly intervals.

Things you must not do

You should not breast-feed your infant during treatment with Actemra. It is not known whether Actemra crosses into human milk.

Do not take any other medicines whether they require a prescription or not without first telling your doctor or consulting a pharmacist.

Things to be careful of

Be careful driving or operating machinery until you know how Actemra affects you. Actemra has not been shown to impair the ability to drive or operate machinery. However if you experience dizziness, a reported side effect, then you should not drive or operate machinery until it has resolved.

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are receiving Actemra.

Actemra helps many patients with RA, pJIA, sJIA and CRS but it may have unwanted side effects.

All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor immediately or go to Accident and Emergency at your nearest hospital if you notice any of the following:

  • chest tightness, wheezing or difficulty breathing,
  • severe dizziness or light-headedness
  • swelling of the face, lips, tongue, throat or other parts of your body with difficulty breathing
  • rash, itching or hives on the skin
  • signs of an infection, with or without fever
  • signs of tears (perforation) of the stomach or intestines such as fever and pain in the stomach area that does not go away, vomiting blood or material that looks like coffee grounds, bleeding from your rectum, and a change in your bowel habits
  • severe blisters and bleeding in the lips, eyes, mouth, nose and genitals.
  • signs of liver disease, hepatitis and/or jaundice including: nausea, vomiting, loss of appetite, feeling generally unwell, fever, itching, yellowing of the skin and eyes, light coloured bowel motions, dark coloured urine.

These are serious side effects. You may need urgent medical attention. Serious side effects are rare.

Tell your doctor if you notice any of the following and they worry you:

  • high blood pressure (symptoms may include headache, dizziness, ringing in the ears)
  • headache
  • upper respiratory tract infection such as a common cold or sinus infection (cough, blocked or runny nose, sore throat)
  • dizziness
  • nausea or indigestion
  • stomach pain
  • constipation
  • diarrhoea
  • back pain
  • cold sores
  • mouth or skin blisters
  • mouth ulcers
  • skin infection (redness, pain and/or swelling)
  • low white blood cell and platelet counts shown by blood tests
  • raised blood fat (cholesterol) levels

These are the more common side effects of Actemra. Mostly these are mild.

This is not a complete list of all possible side effects. Others may occur in some people and there may be some side effects not yet known.

Tell your doctor if you notice anything else that is making you feel unwell, even if it is not on this list.

Ask your doctor or pharmacist if you don't understand anything in this list.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

After receiving Actemra

Storage

Actemra should be stored in the pharmacy or on the hospital ward.

The concentrated solution for infusion should be kept in a refrigerator at 2°C to 8°C. It should not be frozen.

Actemra should be stored away from light.

Product description

Availability

Actemra is available as 80 mg/4 mL, 200 mg/10 mL and 400 mg/20 mL single dose vials

Actemra comes in packs of 1 vial for each of the 80 mg, 200 mg or 400 mg presentations.

Actemra is also available as a solution for subcutaneous injection.

What Actemra looks like

Actemra is a clear to opalescent, colourless to pale yellow liquid for intravenous infusion.

Ingredients

Active ingredient - tocilizumab (rch)

Inactive ingredients

  • polysorbate 80
  • sucrose
  • dibasic sodium phosphate dodecahydrate
  • monobasic sodium phosphate dihydrate
  • water for injections

Distributor

Actemra is distributed in Australia by:

Roche Products Pty Limited
ABN 70 000 132 865
Level 8, 30-34 Hickson Road
Sydney NSW Australia
Medical enquiries: 1800 233 950

Please check with your pharmacist for the latest Consumer Medicine Information.

Australian Registration Numbers

  • 80 mg/4 mL AUST R 149403
  • 200 mg/10 mL AUST R 149404
  • 400 mg/20 mL AUST R 149402

This leaflet was prepared on 1 April 2020.

Published by MIMS May 2020

BRAND INFORMATION

Brand name

Actemra

Active ingredient

Tocilizumab

Schedule

S4

 

1 Name of Medicine

Tocilizumab.

6.7 Physicochemical Properties

Chemical structure.


Tocilizumab is a recombinant humanised monoclonal antibody of the immunoglobulin (Ig) IgG1 subclass which binds to human interleukin 6 (IL-6) receptors. It is composed of two heterodimers, each of which consists of a heavy and a light polypeptide chain. The light chain contains of 214 amino acids and the heavy chain 448 amino acids. The four polypeptide chains are linked intra- and inter-molecularly by disulfide bonds. Tocilizumab has a molecular weight of approximately 148,000 Daltons. Tocilizumab binds to both soluble and membrane-bound IL-6 receptors (sIL-6R and mIL-6R).

CAS number.

375823-41-9.

2 Qualitative and Quantitative Composition

Actemra 80 mg/4 mL concentrate solution for intravenous infusion vial contains 80 mg tocilizumab.
Actemra 200 mg/10 mL concentrate solution for intravenous infusion vial contains 200 mg tocilizumab.
Actemra 400 mg/20 mL concentrate solution for intravenous infusion vial contains 400 mg tocilizumab.
Actemra SC 162 mg/0.9 mL solution for subcutaneous (SC) injection contains 162 mg tocilizumab.

Excipients with known effect.

Actemra concentrated solution for intravenous infusion contains sodium.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Concentrated solution for intravenous infusion.

Actemra concentrated solution for intravenous (IV) infusion is a clear to opalescent, colourless to pale yellow sterile solution.

Solution for subcutaneous injection.

Actemra solution for subcutaneous (SC) injection is a clear to strongly opalescent, colourless to slightly yellowish sterile solution.

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Pharmacotherapeutic group: Immunosuppressants, Interleukin inhibitors, ATC code: L04AC07.

Mechanism of action.

Tocilizumab is a recombinant humanised monoclonal antibody of the immunoglobulin (Ig) IgG1 subclass. Tocilizumab binds to both soluble and membrane-bound IL-6 receptors, and has been shown to inhibit sIL-6R and mIL-6R-mediated signaling. IL-6 is a multi-functional cytokine, produced by a variety of cell types involved in local paracrine function as well as regulation of systemic physiological and pathological processes such as induction of immunoglobulin secretion, T-cell activation, induction of hepatic acute phase proteins and stimulation of haematopoiesis. IL-6 has been implicated in the pathogenesis of inflammatory diseases, including rheumatoid arthritis (RA).
The possibility exists for tocilizumab to affect host defences against infections and malignancies. The role of IL-6 receptor inhibition in the development of malignancies is not known.

Pharmacodynamic effect.

In clinical studies with tocilizumab in RA, rapid decreases in C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and serum amyloid A and fibrinogen were observed. Rapid increases in haemoglobin levels (within the first 2 weeks) were also observed, through tocilizumab decreasing the IL-6 driven effects on hepcidin production to increase iron availability.
In patients with giant cell arteritis (GCA), similar rapid decreases in CRP and ESR were observed along with slight increases in mean corpuscular haemoglobin concentration.
In healthy subjects administered tocilizumab in doses from 2 to 28 mg/kg, absolute neutrophil counts (ANC) decreased to their lowest levels 3 to 5 days following administration. Thereafter, neutrophils recovered towards baseline in a dose dependent manner. Patients with RA and GCA demonstrated a similar pattern of absolute neutrophil counts following tocilizumab administration (see Section 4.4 Special Warnings and Precautions for Use, Haematological abnormalities).

Clinical trials.

Rheumatoid arthritis.

The efficacy of intravenous Actemra in alleviating the signs and symptoms of RA was assessed in five randomised, double-blind, multicentre studies (Studies I - V). The efficacy of subcutaneous Actemra was assessed in two randomised, double-blind studies (Studies VI and VII). In addition, the efficacy of intravenous Actemra has been evaluated in patients with MTX-naïve, early RA (Study VIII) and as a monotherapy versus adalimumab monotherapy (Study IX).
Studies I-V required patients ≥ age 18 with active RA diagnosed according to American College of Rheumatology (ACR) criteria who had at least 8 tender and 6 swollen joints at baseline.
Actemra was administered intravenously every 4 weeks as monotherapy (Study I), in combination with methotrexate (MTX) (Studies II, III, V) or with other disease-modifying anti-rheumatic drugs (DMARDs) (Study IV).
Study I (AMBITION) evaluated 673 patients who had not been treated with MTX within 6 months prior to randomisation, and who had not discontinued previous MTX treatment as a result of clinically important toxic effects or lack of response. The majority (67%) of patients were MTX naïve. Doses of 8 mg/kg of Actemra were given every 4 weeks as monotherapy. The comparator group was weekly MTX (dose titrated from 7.5 to a maximum of 20 mg weekly over an 8 week period). The primary endpoint was the proportion of patients who achieved an ACR20 response at week 24.
Study II (LITHE), a 2 year study, evaluated 1196 patients who had an inadequate clinical response to MTX. Doses of 4 or 8 mg/kg of Actemra or placebo were given every 4 weeks as blinded therapy for 52 weeks, in combination with stable MTX (10-25 mg weekly). The primary endpoint at week 24 was the proportion of patients who achieved ACR20 response criteria. At week 52 the co-primary endpoints were prevention of joint damage and improvement in physical function.
Study III (OPTION) evaluated 623 patients who had an inadequate clinical response to MTX. Doses of 4 or 8 mg/kg of Actemra or placebo were given every 4 weeks, in combination with stable MTX (10-25 mg weekly). The primary endpoint was the proportion of patients who achieved an ACR20 response at week 24.
Study IV (TOWARD) evaluated 1220 patients who had an inadequate response to their existing rheumatologic therapy, including one or more DMARDs. Doses of 8 mg/kg Actemra or placebo were given every 4 weeks, in combination with the stable DMARD. The primary endpoint was the proportion of patients who achieved an ACR20 response at week 24.
Study V (RADIATE) evaluated 499 patients who had an inadequate clinical response or were intolerant to one or more antitumour necrosis factor (TNF) therapies. The anti-TNF agent was discontinued prior to randomisation. Doses of 4 or 8 mg/kg of Actemra or placebo were given every 4 weeks, in combination with stable MTX (10-25 mg weekly). The primary endpoint was the proportion of patients who achieved an ACR20 response at week 24.
The efficacy and safety of subcutaneously administered Actemra was assessed in two double-blind, controlled, multicentre studies in patients with active RA.
Study VI (SUMMACTA) was a non-inferiority study that compared the efficacy and safety of subcutaneous Actemra 162 mg administered every week to intravenous Actemra 8 mg/kg every 4 weeks. In SUMMACTA, 1262 patients were randomised 1:1 to receive subcutaneous Actemra 162 mg every week or intravenous Actemra 8 mg/kg every 4 weeks in combination with DMARD(s).
Study VII (BREVACTA) was a placebo-controlled superiority study that evaluated the safety and efficacy of subcutaneous Actemra 162 mg administered every other week to placebo. In BREVACTA, 656 patients were randomised 2:1 to subcutaneous Actemra 162 mg every other week or placebo, in combination with DMARD(s).
The primary endpoint in both studies was the proportion of patients who achieved an ACR20 response at Week 24. Both SUMMACTA and BREVACTA required patients to be ≥ 18 years of age with moderate to severe active RA diagnosed according to ACR criteria. Patients had at least 4 tender and 4 swollen joints at baseline (SUMMACTA) or at least 8 tender and 6 swollen joints at baseline (BREVACTA), and an inadequate response to their existing DMARD therapy. Approximately 20% also had a history of inadequate response to at least one TNF inhibitor. All patients in both SC studies received background non-biological DMARD(s).
The percent of patients achieving ACR 20, 50 and 70 responses in Studies I to V are shown in Table 5.
In studies I to V, 8 mg/kg Actemra-treated patients had statistically significant higher ACR20, 50, 70 response rates at 6 months compared to placebo. The treatment effect was similar in patients independent of rheumatoid factor status, age, gender, race, number of prior treatments or disease status. Time to onset was rapid (as early as week 2) and the magnitude of response continued to improve with duration of treatment. Continued durable responses were seen for over 3 years in the ongoing open label extension studies of studies I-V.
In the 8 mg/kg Actemra-treated patients significant improvements were noted on all individual components of the ACR response: tender and swollen joint counts; pain assessment and CRP normalisation; disability index scores; patients and physician global assessment, compared to patients receiving placebo + MTX/DMARDS in all studies. Actemra 8 mg/kg treated patients had a statistically significant greater reduction in disease activity score (DAS28) than patients treated with placebo + DMARD. The rate of remission (defined as DAS < 2.6) for patients treated with Actemra ranged from 27.5% to 33.6%. Actemra treated patients had a statistically significant greater rate of remission than patients treated with placebo + DMARD. A good to moderate EULAR response was achieved by significantly more Actemra treated patients compared to patients treated with placebo + DMARD (Table 6).
The clinical response to 24 weeks of subcutaneous Actemra therapy is shown in Table 7. In SUMMACTA, the primary outcome measure was ACR20 at Week 24. The pre-specified non-inferiority margin was a treatment difference of 12%. The study demonstrated non-inferiority of Actemra with respect to ACR20 at Week 24; ACR50, ACR70 and DAS28 responses are also shown in Table 7. The efficacy and safety of subcutaneous Actemra used as a monotherapy is supported by SUMMACTA which demonstrates, in combination with DMARD(s), the noninferiority of Actemra 162 mg SC every week to 8 mg/kg IV every 4 weeks. However, the efficacy of subcutaneous Actemra administered every week as a monotherapy was not directly established in this study.
In SUMMACTA, ACR 20, 50 and 70 response rates were comparable between the subcutaneous and intravenous Actemra study arms across the three body weight categories (< 60 kg, 60-100 kg, ≥ 100 kg). ACR 20, 50 and 70 response rates in the heaviest weight category (≥ 100 kg) were lower compared to the other weight categories in the subcutaneous and intravenous Actemra study arms. The same phenomenon of lower response rates in heavier patients (≥ 100 kg) compared to other weight categories was seen in patients receiving the subcutaneous Actemra every other week regimen in BREVACTA.

Major clinical response.

After 2 years of treatment with intravenous Actemra + MTX, 14% of patients achieved a major clinical response (maintenance of an ACR70 response for 24 weeks or more).

Radiographic response.

In study II (LITHE), in patients with an inadequate response to MTX, inhibition of structural joint damage was assessed radiographically and expressed as change in modified Sharp score and its components, the erosion score and joint space narrowing (JSN) score. Missing week 52 radiographic data was imputed using linear extrapolation. This was performed for any patient who had a baseline assessment and at least one post-baseline radiographic assessment. The change from baseline was then calculated using the extrapolated score. Inhibition of structural joint damage was shown with significantly less radiographic progression in patients receiving Actemra compared to control (Table 8).
In the open-label extension of study II further improvement in the inhibition of progression of structural damage in Actemra + MTX-treated patients were observed in the second year of treatment. Study II did not investigate the effect of Actemra monotherapy on radiographic endpoints.
Following 1 year of treatment with Actemra + MTX, 83% of patients had no progression of structural damage, as defined by a change in the Total Sharp Score of zero or less, compared with 67% of placebo + MTX-treated patients. This remained consistent following 2 years of treatment (83%). Ninety three percent (93%) of patients had no progression between week 52 and week 104.
In Study VII (BREVACTA), inhibition of structural joint damage was assessed radiographically and expressed as a change from baseline in the van der Heijde modified mean Total Sharp Score (mTSS). At week 24, inhibition of structural damage was shown, with significantly less radiographic progression in patients receiving subcutaneous Actemra compared with placebo; mean change from baseline in mTSS of 0.62 vs. 1.23 (p = 0.0149; van Elteren) with an adjusted mean difference of -0.60 (-1.1, -0.1). These results are consistent with those observed in patients treated with intravenous Actemra.

Quality of life outcomes.

Clinically significant improvements in disability index (HAQ-DI, Health Assessment Questionnaire Disability Index), fatigue (FACIT-F, Functional Assessment of Chronic Illness Therapy Fatigue) and improvement in both the physical (PCS, Physical Component Summary) and mental health (MCS, Mental Component Summary) domains of the SF-36 (Short Form 36) were observed in patients treated with 8 mg/kg Actemra (monotherapy or combination with DMARDs) compared to patients treated with MTX/DMARDs.
At week 24, the proportion of 8 mg/kg Actemra treated patients showing a clinically relevant improvement in HAQ-DI (defined as an individual total score decrease of > 0.25), was significantly higher than among patients receiving placebo + MTX/DMARDs in all studies (Studies I to V). During the open-label period of study II the improvement in physical function has been maintained for up to 2 years.
At week 52, the mean change in HAQ-DI was -0.58 in the Actemra 8 mg/kg + MTX group compared with -0.39 in the placebo + MTX group. The mean change in HAQ-DI was maintained at week 104 in the Actemra 8 mg/kg + MTX group (-0.61). The percentage of Actemra-treated patients showing a clinically relevant improvement in HAQ-DI (≥ 0.3 units) at weeks 52 and 104 were 63% and 62%, respectively.
In Study VI (SUMMACTA), the mean decrease in HAQ-DI from baseline to week 24 was 0.6 for both subcutaneous Actemra 162 mg weekly and intravenous Actemra 8 mg/kg every 4 weeks. The proportion of patients achieving a clinically relevant improvement in HAQ-DI at week 24 (change from baseline of ≥ 0.3 units) was comparable in the subcutaneous Actemra every week group (65.2%) versus the intravenous Actemra 8 mg/kg group (67.4%), with a weighted difference in proportions of -2.3% (95% CI -8.1, 3.4). The SF-36 summary was split into mental and physical components. The mental component scores were similar between the groups, with a mean change from baseline at week 24 of 6.22 for the SC group and 6.54 for the IV group. The physical component scores were also similar between the groups, with mean change from baseline at week 24 of 9.49 for the SC group and 9.65 for the IV group. In Study VII (BREVACTA), the mean decrease in HAQ-DI from baseline to week 24 was 0.4 and 0.3, and the proportion of patients who achieved a clinically relevant improvement in HAQ-DI was 58% and 47%, for the subcutaneous Actemra 162 mg every other week, and placebo treatment groups, respectively.

Laboratory evaluations.

Treatment with 8 mg/kg Actemra in combination with DMARD/MTX or as monotherapy resulted in a statistically significant improvement in haemoglobin levels compared with placebo + MTX/DMARD (p < 0.0001) at week 24. The greatest improvement was observed in patients with chronic anaemia associated with RA; mean haemoglobin levels increased by week 2 and remained within normal range through week 24.
A marked decrease in mean levels of acute phase reactants, CRP, ESR, and serum amyloid A occurred rapidly after Actemra administration. Consistent with the effect on acute phase reactants, treatment with Actemra was associated with reduction in platelet count within the normal range.

MTX naive, early RA.

Study VIII (FUNCTION), a 2 year study with the planned primary analysis at week 52 evaluated 1162 MTX-naïve adult patients with moderate to severe, active early RA (mean disease duration ≤ 6 months) and one or more indicators of poor prognosis, such as elevated inflammatory markers (e.g. ESR and/or CRP), the presence of RF and/or anti-CCP, and/or the presence of bony erosions attributable to RA. This study evaluated the efficacy of intravenous Actemra 4 or 8 mg/kg every 4 weeks in combination with MTX, Actemra 8 mg/kg monotherapy and MTX monotherapy in reducing the signs and symptoms and rate of progression of joint damage for 104 weeks. The primary endpoint was the proportion of patients achieving DAS28 remission (DAS28 < 2.6) at week 24. A significantly higher proportion of patients in the Actemra 8 mg/kg + MTX and Actemra monotherapy groups met the primary endpoint compared with MTX alone. The Actemra 8 mg/kg + MTX group also showed statistically significant results across the key secondary endpoints. Numerically greater responses compared with MTX alone were observed in the Actemra 8 mg/kg monotherapy group in all secondary endpoints, including radiographic endpoints (although the differences between Actemra 8 mg/kg monotherapy and MTX were not statistically significant). The results from study VIII are shown in Table 9.

Actemra versus adalimumab in monotherapy.

Study IX (ADACTA) evaluated 326 patients with RA who were intolerant of MTX or in whom continued treatment with MTX was considered inappropriate, which included patients considered to be MTX inadequate responders. Patients in the Actemra arm received an intravenous (IV) infusion of Actemra (8 mg/kg) every 4 weeks (q4w) and a subcutaneous (SC) placebo injection every 2 weeks (q2w). Patients in the adalimumab arm received an adalimumab SC injection (40 mg) q2w plus an IV placebo infusion q4w.
A statistically significant superior treatment effect was seen in favour of Actemra over adalimumab in control of disease activity from baseline to week 24 for the primary endpoint of change in DAS28 and for all secondary endpoints (Table 10).

Cardiovascular outcomes.

Study WA25204 was a randomised, open-label (sponsor-blinded), 2-arm parallel-group, multi centre, non-inferiority, cardiovascular (CV) outcomes trial in patients with a diagnosis of moderate to severe RA. This CV safety study was designed to exclude a moderate increase in CV risk in patients treated with tocilizumab compared with a TNF inhibitor standard of care (etanercept).
The study included 3,080 seropositive RA patients with active disease and an inadequate response to non-biologic disease-modifying anti-rheumatic drugs, who were aged ≥ 50 years with at least one additional CV risk factor beyond RA. Patients were randomised 1:1 to IV tocilizumab 8 mg/kg every four weeks (q4w) or SC etanercept 50 mg every week (qw) and followed for an average of 3.2 years. The primary endpoint was the comparison of the time-to-first occurrence of any component of a composite of major adverse CV events (MACE; non-fatal myocardial infarction, non-fatal stroke, or CV death), with the final intent-to-treat analysis based on a total of 161 confirmed CV events reviewed by an independent and blinded adjudication committee.
Non-inferiority of tocilizumab to etanercept for cardiovascular risk was determined by excluding a > 80% relative increase in the risk of MACE. The primary endpoint was met with a hazard ratio [HR] comparing tocilizumab to etanercept = 1.05; 95% CI = 0.77, 1.43.

Giant cell arteritis (GCA).

Study X (GiACTA) was a randomised, multicentre, double-blind, placebo-controlled Phase III superiority study conducted to assess the efficacy and safety of Actemra in patients with GCA.
Two hundred and fifty one (251) patients with new-onset or relapsing GCA were enrolled and assigned to one of four treatment arms. The study consisted of a 52-week blinded period (Part 1), followed by a 104-week open-label extension (Part 2). The purpose of Part 2 is to describe the long term safety and maintenance of efficacy after 52 weeks of Actemra therapy, to explore the rate of relapse and the requirement for Actemra therapy beyond 52 weeks, and to gain insight into the potential long-term steroid-sparing effect of Actemra.
Two subcutaneous (SC) doses of Actemra (162 mg every week and 162 mg every other week) were compared to two different placebo control groups randomised 2:1:1:1. All patients received background glucocorticoid (prednisone) therapy. Each of the Actemra-treated groups and one of the placebo-treated groups followed a pre-specified prednisone-taper regimen over 26 weeks, while the second placebo-treated group followed a pre-specified prednisone-taper regimen over 52 weeks.
The study included adult patients with new-onset or relapsing active GCA, where active GCA was defined as the presence of clinical signs and symptoms of GCA (cranial or polymyalgia rheumatica) and ESR ≥ 30 mm/hour or CRP ≥ 1 mg/dL within 6 weeks prior to the baseline visit. New-onset disease was defined as GCA diagnosed within 6 weeks of baseline, and relapsing disease was defined as GCA diagnosed > 6 weeks before baseline and previous treatment with ≥ 40 mg/day prednisone for ≥ 2 consecutive weeks. The majority of the enrolled population were Caucasian (96.8%) and a majority were female (74.9%). The mean age of patients was 69 years. Relapsing disease patients comprised 53% of the study population with 47% of patients presenting with new-onset disease. The most common clinical manifestations of GCA at diagnosis were headache and polymyalgia rheumatica (in 67% and 62% patients, respectively). Jaw claudication and scalp tenderness were reported in approximately one third of patients. Temporal artery tenderness was observed in 29%, decreased temporal artery pulsation in 12%, and ischemia-related vision loss in 10% of patients.
The primary efficacy endpoint, assessed by the proportion of patients achieving steroid-free sustained remission at Week 52 on Actemra plus 26 weeks prednisone taper compared with placebo plus 26 weeks prednisone taper, was met (Table 11).

Secondary endpoints.

The key secondary efficacy endpoint, also based on the proportion of patients achieving sustained remission at Week 52, comparing Actemra plus 26 weeks prednisone taper with the longer placebo plus 52 weeks prednisone taper, was also met (Table 11). A statistically significant superior treatment effect was seen in favour of Actemra over placebo in achieving steroid-free sustained remission at Week 52 on Actemra plus 26 weeks prednisone taper compared with placebo plus 26 weeks prednisone taper and with placebo plus 52 weeks prednisone taper. The percentage of patients achieving sustained remission at week 52 are shown in Table 11.
The assessment of the time to first GCA flare showed a significantly lower risk of flare for the Actemra weekly group compared to placebo plus 26 weeks prednisone and placebo plus 52 weeks prednisone taper groups and for the Actemra every other week group compared to placebo plus 26 weeks prednisone (when compared at a 0.01 significance level). Actemra weekly dose also showed a clinically meaningful decrease in the risk for flare compared to placebo plus 26 weeks prednisone in patients who entered the trial with relapsing GCA as well as those with new-onset disease (Table 11).
The median cumulative prednisone dose at Week 52 was significantly lower in the two Actemra dose groups compared to the two placebo groups (Table 11). In a separate analysis of the patients who received escape prednisone to treat GCA flare during the first 52 weeks, the cumulative prednisone dose varied greatly. The median doses for escape patients in the Actemra weekly and every other week groups were 3129.75 mg and 3847 mg, respectively - both considerably lower than in the placebo plus 26 weeks and the placebo plus 52 weeks prednisone taper groups, 4023.5 mg and 5389.5 mg respectively. A lower proportion of patients stopped the protocol defined prednisone taper and moved onto treatment with escape prednisone in the Actemra weekly (23.0%) and Actemra every-other-week (32.7%) groups compared with patients in the placebo plus 52 weeks prednisone taper (54.9%) and placebo plus 26 weeks prednisone taper (74.0%) groups. Median prednisone starting dose for the escape patient population was 30.0 mg in each of the Actemra weekly, Actemra every-other-week and placebo plus 26 weeks prednisone taper groups and 37.5 mg in the placebo plus 52 weeks prednisone taper group. There was no consistent pattern to the time of initiation of escape therapy.

Quality of life outcomes.

In Study X, the SF-36 results were separated into the physical and mental component summary scores (PCS and MCS, respectively). The PCS mean change from baseline to week 52 was higher (showing more improvement) in the Actemra weekly and every other week dose groups [4.10, 2.76, respectively] than in the two placebo groups [placebo plus 26 weeks; -0.28, placebo plus 52 weeks; -1.49], although only the comparison between Actemra weekly plus 26 weeks prednisone taper group and placebo plus 52 weeks prednisone taper group (5.59, 99% CI: 0.86 10.32) showed a statistically significant difference (p = 0.0024). For MCS, the mean change from baseline to week 52 for both Actemra weekly and every other week dose groups [7.28, 6.12, respectively] were higher than the placebo plus 52 weeks prednisone taper group [2.84] (although the differences were not statistically significant [p = 0.0252 for weekly, p = 0.1468 for every other week]) and similar to the placebo plus 26 weeks prednisone taper group [6.67].
The Patient's Global Assessment of disease activity was assessed on a 0-100 mm Visual Analogue Scale (VAS). The mean change in Patient's global VAS from baseline at week 52 was lower (showing greater improvement) in the Actemra weekly and every other week dose groups [-19.0, -25.3, respectively] than in both placebo groups [placebo plus 26 weeks; -3.4, placebo plus 52 weeks; -7.2], although only the Actemra every other week plus 26 weeks prednisone taper group showed a statistically significance difference compared to placebo [placebo plus 26 weeks taper p = 0.0059, and placebo plus 52 week taper p = 0.0081].
FACIT-Fatigue change from baseline to Week 52 scores were calculated for all groups. The mean [SD] change scores were as follows: Actemra weekly 5.61 [10.115], Actemra every other week 1.81 [8.836], PBO plus 26 weeks 0.26 [10.702], and PBO plus 52 weeks -1.63 [6.753].
Change in EQ5D scores from baseline to week 52 were Actemra weekly 0.10 [0.198], Actemra every other week 0.05 [0.215], placebo 0.07 [0.293], and placebo plus 52 weeks -0.02 [0.159].
Higher scores signal improvement in both FACIT-Fatigue and EQ5D.

Polyarticular juvenile idiopathic arthritis.

Intravenous administration.

The efficacy of intravenous Actemra was assessed in a three-part study including an open-label extension in children with moderately to severely active pJIA, who had an inadequate response to methotrexate (MTX) or inability to tolerate MTX (Study XI, CHERISH). Patients had at least 6 months of active disease (mean disease duration of 4.2 ± 3.7 years), with at least 5 joints with active arthritis (swollen or limitation of movement accompanied by pain and/or tenderness) and/or at least 3 active joints having limitation of motion (mean, 20 ± 14 active joints). The patients treated had subtypes of JIA that at disease onset included rheumatoid factor positive or negative polyarticular JIA, or extended oligoarticular JIA. Treatment with a stable dose of MTX was permitted but was not required during the study. Concurrent use of DMARDs other than MTX, or other biologics (e.g. TNF antagonists or T-cell costimulation modulator) were not permitted in the study. Ten patients who participated in the study were less than 4 years of age.
Part I consisted of a 16 week active Actemra treatment lead in period (n=188) followed by Part II, a 24 week randomised, double-blind, placebo-controlled withdrawal period (ITT n=163), followed by Part III, a 64 week open-label period. Eligible patients ≥ 30 kg received Actemra at 8 mg/kg for 4 doses. Patients < 30 kg were randomised 1:1 to receive either Actemra 8 mg/kg or 10 mg/kg IV every 4 weeks for 4 doses. Patients who completed Part I of the study and achieved at least a JIA ACR30 response at week 16 compared to baseline entered the blinded withdrawal period (Part II) of the study. In Part II, patients were randomised to Actemra (same dose received in Part I) or placebo in a 1:1 ratio, stratified by concurrent MTX use and concurrent corticosteroid use. Each patient continued in Part II of the study until Week 40 or until the patient satisfied JIA ACR30 flare criteria (relative to Week 16) and qualified for escape.
The primary endpoint was the proportion of patients with a JIA ACR30 flare at week 40 relative to week 16. JIA ACR 30 flare was defined as 3 or more of the 6 core outcome variables worsening by at least 30% with no more than 1 of the remaining variables improving by more than 30% relative to Week 16. Forty eight percent (48.1%, 39/81) of the patients treated with placebo flared compared with 25.6% (21/82) of Actemra-treated patients. These proportions were statistically significantly different (p=0.0024).
At the conclusion of Part I, JIA ACR 30/50/70/90 responses were 89.4%, 83.0%, 62.2%, and 26.1%, respectively.
During the withdrawal phase (Part II), the percentages of patients achieving JIA ACR 30, 50, and 70 responses at Week 40 relative to baseline are shown in Table 12.
A difference in the incidence of JIA ACR30 flare during Week 16 to 40 was observed between those patients who were and were not taking concurrent MTX, and those patients who had previously been exposed to a biologic DMARD or not. Irrespective of concurrent MTX or previous biologic DMARD use JIA ACR30 flare was lower for patients receiving Actemra compared to placebo (see Table 13).
In Part III maintenance of efficacy through week 104 was demonstrated for each of the JIA responses rates and were similar between the continuous Actemra-treated subgroup and the placebo-treated patients in Part II who recommenced Actemra. For the continuous Actemra group the JIA ACR30/50/70/90 response rates at Week 104 were 95.1%, 90.2%, 86.6% and 70.7%, respectively. For placebo-treated patients in Part II who recommenced Actemra JIA ACR30/50/70/90 response rates at Week 104 were 95.1%, 95.1%, 91.4%, and 66.7%, respectively. Improvement in JIA ACR core components observed at Week 40 was maintained.

Subcutaneous administration.

A 52-week, open-label, multi-centre, PK-PD and safety study (Study XI, JIGSAW) was conducted in paediatric patients with pJIA, aged 1 to 17 years old.
Eligible patients received Actemra dosed according to body weight, with patients weighing ≥ 30 kg (n = 25) dosed with 162 mg of Actemra every 2 weeks (Q2W) and patients weighing below 30 kg (n = 27) dosed with 162 mg of Actemra every 3 weeks (Q3W) for 52 weeks. Of these 52 patients, 37 (71%) were naive to Actemra and 15 (29%) had been receiving IV Actemra and switched to SC Actemra at baseline.
The SC Actemra regimens of 162 mg Q3W for patients weighing below 30 kg and of 162 mg Q2W for patients weighing ≥ 30 kg, respectively provided PK exposure and PD responses to support efficacy and safety outcomes similar to those achieved with the approved IV Actemra regimens for pJIA.
Exploratory efficacy results showed that SC Actemra improved median Juvenile Arthritis Disease Activity Score (JADAS)-71 for Actemra naïve patients and maintained the median JADAS-71 for patients who switched from IV to SC Actemra treatment over the entire course of the study for patients in both body weight groups (below 30 kg and ≥ 30 kg).

Systemic juvenile idiopathic arthritis.

Intravenous administration.

The efficacy of intravenous Actemra for the treatment of active sJIA was assessed in a 12-week randomised, double blind, placebo-controlled, parallel group, 2-arm study (Study XII, TENDER). Patients (treated with or without MTX) were randomised (Actemra: placebo = 2:1) to one of two treatment groups. 75 patients received Actemra infusions every two weeks either 8 mg/kg for patients ≥ 30 kg or 12 mg/kg for patients < 30 kg and 37 patients were assigned to receiving placebo infusions every two weeks. Corticosteroid tapering could occur from week 6 for patients who achieved a JIA ACR70 response. After 12 weeks or at the time of escape, due to disease worsening, patients were treated in the open-label extension phase at weight appropriate dosing.
The demographic characteristics at baseline were similar between the placebo and Actemra groups. Patients were evenly split between male and female, with a median age of 9 and 10 for the placebo and Actemra groups, respectively. 27 patients in the study were aged between 2-5 years, 48 patients between 6-12 years and 37 patients between 13-18 years. Baseline disease characteristics studied included fever and rash status, previous use of DMARDs, previous use of biologics, CRP, and articular and extra-articular damage. All were similar between the placebo and Actemra groups except for a higher proportion of patients with rash in the placebo group (48.6%) compared with the Actemra group (29.3%). In addition, baseline CRP was lower in the placebo group in comparison with the Actemra group.
The primary endpoint was the proportion of patients with at least 30% improvement in JIA ACR core set (JIA ACR30 response) at Week 12 and absence of fever (no temperature recording ≥ 37.5°C in the preceding 7 days). Eighty five percent (64/75) of the patients treated with Actemra and 24.3% (9/37) of placebo patients achieved this endpoint. These proportions were highly significantly different (p < 0.0001).
The percent of patients achieving JIA ACR 30, 50, 70 and 90 responses are shown in Table 14.
Secondary endpoints of the study included the proportion of patients with fever due to sJIA at baseline who were free of fever at week 12, corticosteroid tapering, quality of life improvements as measured by CHAQ-DI and changes in laboratory parameters.

Systemic features.

In those patients treated with Actemra, 85% who had fever due to sJIA at baseline were free of fever (no temperature recording ≥ 37.5°C in the preceding 14 days) at week 12 versus only 21% of placebo patients (p < 0.0001), and 64% of Actemra-treated patients with rash characteristic of sJIA at baseline were free of rash at week 12 versus 11% of placebo patients (p=0.0008).
There was a highly statistically significant reduction in pain for Actemra-treated patients at week 12 in comparison to placebo patients. The adjusted mean change in the pain VAS after 12 weeks of Actemra treatment was a reduction of 41 points on a scale of 0-100 compared to a reduction of 1 for placebo patients (p < 0.0001).

Corticosteroid tapering.

Of the 31 placebo and 70 Actemra patients receiving oral corticosteroids at baseline, 8 placebo and 48 Actemra patients achieved a JIA ACR70 response at week 6 or 8 enabling corticosteroid dose reduction. Seventeen (24%) Actemra patients versus 1 (3%) placebo patient were able to reduce the dose of corticosteroid by at least 20% without experiencing a subsequent JIA ACR30 flare or occurrence of systemic symptoms to week 12 (p=0.028).

Quality of life.

At week 12, the proportion of Actemra-treated patients showing a minimally clinically important improvement in CHAQ-DI (defined as an individual total score decrease of ≥ 0.13) was significantly higher than in patients receiving placebo, 77% versus 19% (p < 0.0001).

Laboratory parameters.

Fifty out of 75 (67%) patients treated with Actemra had a haemoglobin < LLN at baseline. Forty (80%) of these patients with decreased haemoglobin had an increase in their haemoglobin to within the normal range at week 12, in comparison to only 2 out of 29 (7%) of placebo patients with haemoglobin < LLN at baseline (p < 0.0001). Forty-four (88%) Actemra patients with decreased haemoglobin at baseline had an increase in their haemoglobin by ≥ 10 g/L at week 6 versus 1 (3%) placebo patient (p < 0.0001).
The proportion of Actemra-treated patients with thrombocytosis at baseline who had a normal platelet count at week 12 was significantly higher than in the placebo patients, 90% versus 4%, (p < 0.0001).
A marked decrease in mean levels of acute phase reactants, CRP, ESR, and serum amyloid A occurred rapidly after Actemra administration.

Subcutaneous administration.

A 52-week, open-label, multi-centre, PK/PD and safety study (WA28118) was conducted in paediatric patients with sJIA, aged 1 to 17 years, to determine the appropriate SC dose of Actemra that achieved comparable PK/PD and safety profiles to the IV regimen.
Eligible patients received Actemra dosed according to body weight (BW), with patients weighing ≥ 30 kg (n = 26) dosed with 162 mg of Actemra every week (QW) and patients weighing below 30 kg (n = 25) dosed with 162 mg of Actemra every 10 days (Q10D; n = 8) or every 2 weeks (Q2W; n = 17) for 52 weeks. Of these 51 patients, 26 (51%) were naive to Actemra and 25 (49%) had been receiving IV Actemra and switched to SC Actemra at baseline.
Exploratory efficacy results showed that SC Actemra improved all exploratory efficacy parameters including Juvenile Arthritis Disease Activity Score (JADAS)-71, for Actemra naïve patients and maintained all exploratory efficacy parameters for patients who switched from IV to SC Actemra treatment over the entire course of the study for patients in both body weight groups (below 30 kg and ≥ 30 kg).

Cytokine release syndrome (CRS).

The efficacy of Actemra for the treatment of CRS was assessed in a retrospective analysis of data from clinical trials of CAR T-cell therapies (tisagenlecleucel and axicabtagene ciloleucel) for haematological malignancies. Evaluable patients had been treated with tocilizumab 8 mg/kg (12 mg/kg for patients < 30 kg) with or without additional high-dose corticosteroids for severe or life-threatening CRS; only the first episode of CRS was included in the analysis.
The efficacy population for the tisagenlecleucel cohort included 28 males and 23 females (total 51 patients) of median age 17 years (range, 3-68 years). The median time from start of CRS to first dose of tocilizumab was 3 days (range, 0-18 days). Resolution of CRS was defined as lack of fever and off vasopressors for at least 24 hours. Patients were considered responders if CRS resolved within 14 days of the first dose of tocilizumab, if no more than 2 doses of Actemra were needed, and no drugs other than Actemra and corticosteroids were used for treatment. Thirty-nine patients (76.5%; 95% CI: 62.5%-87.2%) achieved a response. In an independent cohort of 15 patients (range: 9-75 years old) with axicabtagene ciloleucel-induced CRS, 53% responded.

5.2 Pharmacokinetic Properties

Rheumatoid arthritis.

Intravenous administration.

The pharmacokinetics of tocilizumab were determined using a population pharmacokinetic analysis on a database composed of 1793 RA patients treated with a one hour infusion of 4 and 8 mg/kg every 4 weeks for 24 weeks.
The pharmacokinetic parameters of tocilizumab did not change with time. A more than dose-proportional increase in area under the curve (AUC) and trough concentration (Cmin) was observed for doses of 4 and 8 mg/kg every 4 weeks. Maximum concentration (Cmax) increased dose-proportionally. At steady-state, predicted AUC and Cmin were 2.7 and 6.5 fold higher at 8 mg/kg as compared to 4 mg/kg, respectively.
The following parameters are valid for a dose of 8 mg/kg tocilizumab given every 4 weeks. Predicted mean (± SD) steady-state AUC, Cmin and Cmax of tocilizumab were 35,000 ± 15,500 microgram.h/mL, 9.74 ± 10.5 microgram/mL, and 183 ± 85.6 microgram/mL, respectively. The accumulation ratios for AUC and Cmax were small; 1.22 and 1.06, respectively. The accumulation ratio was higher for Cmin (2.35), which was expected based on the nonlinear clearance contribution at lower concentrations. Steady-state was reached following the first administration and after 8 and 20 weeks for Cmax, AUC, and Cmin, respectively. Tocilizumab AUC, Cmin and Cmax increased with increase of body weight. At body weight ≥ 100 kg, the predicted mean (± SD) steady-state AUC, Cmin and Cmax of tocilizumab were 55,500 ± 14,100 microgram.h/mL, 19.0 ± 12.0 microgram/mL, and 269 ± 57 microgram/mL, respectively, which are higher than mean exposure values for the patient population. Therefore, tocilizumab doses exceeding 800 mg per infusion are not recommended in patients ≥ 100 kg (see Section 4.2 Dose and Method of Administration).
The following parameters are valid for a dose of 4 mg/kg tocilizumab given every 4 weeks. Predicted mean (± SD) steady-state AUC, Cmin and Cmax of tocilizumab were 13,000 ± 5800 microgram.h/mL, 1.49 ± 2.13 microgram/mL, and 88.3 ± 41.4 microgram/mL, respectively. The accumulation ratios for AUC and Cmax were small; 1.11 and 1.02, respectively. The accumulation ratio was higher for Cmin (1.96). Steady-state was reached following the first administration for both Cmax and AUC and from 16 weeks for Cmin.

Subcutaneous administration.

The pharmacokinetics of tocilizumab were determined using a population pharmacokinetic analysis on a database composed of 1759 RA patients treated with 162 mg SC every week, 162 mg SC every other week, and 8 mg/kg every 4 weeks for 24 weeks.
The pharmacokinetic parameters of tocilizumab did not change with time. For the 162 mg SC every week dose, the predicted mean (± SD) steady-state AUC1week, Cmin and Cmax of tocilizumab were 8200 ± 3600 microgram.h/mL, 44.6 ± 20.6 microgram/mL, and 50.9 ± 21.8 microgram/mL, respectively. The accumulation ratios for AUC, Cmin, and Cmax were 6.83, 6.37, and 5.47, respectively. Steady-state was reached after 12 weeks for AUC, Cmin, and Cmax.
For the 162 mg SC every other week dose, the predicted mean (± SD) steady-state AUC2week, Cmin, and Cmax of tocilizumab were 3200 ± 2700 microgram.h/mL, 5.6 ± 7.0 microgram/mL, and 12.3 ± 8.7 microgram/mL, respectively. The accumulation ratios for AUC, Cmin, and Cmax were 2.67, 5.6, and 2.12, respectively. Steady-state was reached after 12 weeks for AUC and Cmin, and after 10 weeks for Cmax.

Giant cell arteritis (GCA).

The pharmacokinetics of tocilizumab in GCA patients were determined using a population pharmacokinetic model from an analysis dataset composed of 149 GCA patients treated with 162 mg SC every week or with 162 mg SC every other week. The developed model had the same structure as the population PK model developed earlier based on data from RA patients (see Table 15).
The steady-state profile following the Actemra weekly dose was almost flat, with very little fluctuations between trough and peak values, while there were substantial fluctuations for the tocilizumab every other week dose. Approximately 90% of the steady-state (AUCτ) was reached by Week 14 in the every other week and Week 17 in the weekly dose groups.

Polyarticular juvenile idiopathic arthritis.

The pharmacokinetics of tocilizumab in polyarticular juvenile idiopathic arthritis (pJIA) patients were characterised using a population pharmacokinetic analysis which included 237 patients who were treated with 8 mg/kg IV every 4 weeks (patients weighing ≥ 30 kg), 10 mg/kg IV every 4 weeks (patients weighing below 30 kg), 162 mg SC every 2 weeks (patients weighing ≥ 30 kg), or 162 mg SC every 3 weeks (patients weighing below 30 kg). See Table 16.
After IV dosing, approximately 90% of the steady-state was reached by Week 12 for the 10 mg/kg (body weight < 30 kg), and by Week 16 for the 8 mg/kg (body weight ≥ 30 kg) dose. After SC dosing, approximately 90% of the steady-state was reached by Week 12 for both the 162 mg SC q2w and q3w regimens.
Caution is advised with interpretation of the model-derived PK results as the model under predicted Ctrough.ss after SC dosing in the body weight < 30 kg group by greater than 30%.

Systemic juvenile idiopathic arthritis.

The pharmacokinetics of tocilizumab in sJIA patients was characterised by a population pharmacokinetic analysis which included 140 patients who were treated with 8 mg/kg IV every 2 weeks (patients weighing ≥ 30 kg), 12 mg/kg IV every 2 weeks (patients weighing below 30 kg), 162 mg SC every week (patients weighing ≥ 30 kg), 162 mg SC every 10 days or every 2 weeks (patients weighing below 30 kg). Limited data are available regarding exposures following subcutaneous administration of Actemra in sJIA patients below 2 years of age and in sJIA patients who weigh less than 10 kg. Three patients aged 1-2 were included in study WA28118.
Patients with sJIA must have a minimum body weight of 10 kg when receiving Actemra subcutaneously (see Section 4.2 Dose and Method of Administration). (See Table 17.)
After IV dosing, approximately 90% of the steady-state was reached by Week 8 for both the 12 mg/kg and 8 mg/kg Q2W regimens. After SC dosing, approximately 90% of the steady-state was reached by Week 12 for both the 162 mg QW and Q2W regimens.

Absorption.

Following SC dosing in RA and GCA patients, the absorption half-life was around 4 days. The bioavailability for the SC formulation was 80%.
In GCA patients, the median values of Tmax were 3 days after the tocilizumab weekly dose and 4.5 days after the tocilizumab every other week dose.
Following SC dosing in pJIA patients, the absorption half-life was around 2 days, and the bioavailability for the SC formulation in pJIA patients was 96%.
Following SC dosing in sJIA patients, the absorption half-life was around 2 days, and the bioavailability for the SC formulation in sJIA patients was 95%.

Distribution.

Following IV dosing, tocilizumab undergoes biphasic elimination from the circulation. In RA patients the central volume of distribution was 3.5 L and the peripheral volume of distribution was 2.9 L, resulting in a volume of distribution at steady-state of 6.4 L.
In GCA patients, the central volume of distribution was 4.09 L, the peripheral volume of distribution was 3.37 L resulting in a volume of distribution at steady-state of 7.46 L.
In paediatric patients with pJIA, the central volume of distribution was 1.98 L, the peripheral volume of distribution was 2.1 L, resulting in a volume of distribution at steady-state of 4.08 L.
In paediatric patients with sJIA, the central volume of distribution was 1.87 L and the peripheral volume of distribution was 2.14 L resulting in a volume of distribution at steady-state of 4.01 L.

Metabolism.

Not applicable.

Excretion.

The total clearance of tocilizumab was concentration-dependent and is the sum of the linear clearance and the nonlinear clearance. The linear clearance was estimated as a parameter in the population pharmacokinetic analysis and was 12.5 mL/h in RA patients, 6.7 mL/h in GCA patients, 5.8 mL/h in paediatric patients with pJIA and 5.7 mL/h in paediatric patients with sJIA. The concentration-dependent nonlinear clearance plays a major role at low tocilizumab concentrations. Once the nonlinear clearance pathway is saturated, at higher tocilizumab concentrations, clearance is mainly determined by the linear clearance. Due to dependence of total clearance on tocilizumab serum concentrations, t1/2 of tocilizumab is also concentration-dependent and can only be calculated at a given serum concentration level.
In RA patients, for intravenous administration, the concentration-dependent apparent t1/2 is up to 11 days for 4 mg/kg and 13 days for 8 mg/kg every 4 weeks in patients with RA at steady-state. For subcutaneous administration, the concentration-dependent apparent t1/2 is up to 13 days for 162 mg every week and 5 days for 162 mg every other week in patients with RA at steady-state. At high serum concentrations, when total clearance of tocilizumab is dominated by linear clearance, a terminal t1/2 of approximately 21.5 days was derived from the population parameter estimates.
In GCA patients, at steady-state, the effective t1/2 of tocilizumab varied between 18.3 and 18.9 days for 162 mg weekly regimen, and between 4.2 and 7.9 days for 162 mg every other week regimen. At high serum concentrations, when total clearance of tocilizumab is dominated by linear clearance, an effective t1/2 of approximately 32 days was derived from the population parameter estimates.
In children with pJIA, the effective t1/2 of tocilizumab in children with pJIA is up to 17 days for the two body weight categories (8 mg/kg for body weight ≥ 30 kg or 10 mg/kg for body weight < 30 kg) during a dosing interval at steady-state. After subcutaneous administration, the estimated effective t1/2 of tocilizumab in pJIA patients is up to 10 days for the two body weight categories (Q2W regimen for body weight ≥ 30 kg or Q3W regimen for body weight below 30 kg) during a dosing interval at steady-state.
In children with sJIA, the effective t1/2 of IV tocilizumab is up to 16 days for both the 12 mg/kg and 8 mg/kg Q2W regimens during a dosing interval at steady-state. Following subcutaneous administration, the effective t1/2 of tocilizumab in sJIA patients is up to 14 days for both the 162 mg QW and Q2W regimens during a dosing interval at steady-state.

Pharmacokinetics in special populations.

Hepatic impairment.

No formal study of the effect of hepatic impairment on the pharmacokinetics of Actemra was conducted.

Renal impairment.

No formal study of the effect of renal impairment on the pharmacokinetics of Actemra was conducted.
Most of the patients in the RA and GCA studies in the population pharmacokinetic analysis had normal renal function or mild renal impairment. Mild renal impairment (estimated creatinine clearance based on Cockcroft-Gault formula) did not impact the pharmacokinetics of Actemra. Actemra has not been studied in patients with moderate to severe renal impairment. (See Section 5.1 Pharmacodynamic Properties, Clinical trials; Section 4.2 Dose and Method of Administration.)
Approximately one-third of the patients in the Study X (GiACTA) had moderate renal impairment at baseline (estimated creatinine clearance of 30-59 mL/min). No impact on tocilizumab exposure was noted in these patients.
No dose adjustment is required in patients with mild or moderate renal impairment.

Other special populations.

Population pharmacokinetics in adult RA and GCA patients showed that age, sex and race did not affect the pharmacokinetics of Actemra. No dose adjustment is necessary for these demographic factors.

5.3 Preclinical Safety Data

Genotoxicity.

Standard genotoxicity studies with tocilizumab in both prokaryotic and eukaryotic cells were negative.

Carcinogenicity.

A carcinogenicity study of Actemra has not been conducted. Proliferating lesions were not observed in a chronic cynomolgus monkey 6-month toxicity study.

4 Clinical Particulars

4.1 Therapeutic Indications

Rheumatoid arthritis (IV and SC formulations).

Actemra is indicated for the treatment of moderate to severe active rheumatoid arthritis (RA) in adult patients in combination with methotrexate (MTX) or other non-biological disease-modifying anti-rheumatic drugs (DMARDs) in case of either an inadequate response or intolerance to previous therapy with one or more DMARDs.
Actemra is indicated for the treatment of moderate to severe active rheumatoid arthritis in adult patients with poor prognostic factors (see Section 5.1 Pharmacodynamic Properties, Clinical trials) in combination with MTX in those not previously treated with MTX.
In the two groups of patients above, Actemra can be given as monotherapy in case of intolerance to MTX or where continued treatment with MTX is inappropriate.
Actemra has been shown to inhibit the progression of joint damage in adults, as measured by X-ray, when given in combination with methotrexate.

Giant cell arteritis (SC formulation only).

Actemra is indicated for the treatment of giant cell arteritis (GCA) in adult patients.

Polyarticular juvenile idiopathic arthritis (IV and SC formulations).

Actemra is indicated for the treatment of moderate to severe active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older who have had an inadequate response to or intolerance to methotrexate (MTX). Actemra can be given alone or in combination with MTX.

Systemic juvenile idiopathic arthritis (IV and SC formulations).

Intravenous formulation.

Actemra is indicated for the treatment of active systemic juvenile idiopathic arthritis in patients 2 years of age and older.

Subcutaneous formulation.

Actemra is indicated for the treatment of active systemic juvenile idiopathic arthritis in patients 1 year of age and older.
Actemra IV and SC can be given alone or in combination with methotrexate (MTX).

Cytokine release syndrome (CRS) (IV formulation only).

Actemra is indicated for the treatment of chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome (CRS) in adults and paediatric patients 2 years of age and older.

4.3 Contraindications

Actemra is contraindicated in patients with:
known hypersensitivity to any component of the product or with a history of any reaction consistent with hypersensitivity to any component of the product, Chinese hamster ovary cell products or other recombinant human or humanised antibodies;
active, severe infections (see Section 4.4 Special Warnings and Precautions for Use).

4.4 Special Warnings and Precautions for Use

In order to improve the traceability of biological medicinal products, the tradename and batch number of the administered product should be clearly recorded in the patient medical record.
Substitution by any other biological medicinal product requires the consent of the prescribing physician.

All indications.

Infections.

Serious and sometimes fatal infections have been reported in patients receiving immunosuppressive agents including Actemra (see Section 4.8 Adverse Effects (Undesirable Effects)). Actemra treatment should not be initiated in patients with active infections (see Section 4.3 Contraindications). If a patient develops a serious infection, administration of Actemra should be interrupted until the infection is controlled. Physicians should exercise caution when considering the use of Actemra in patients with a history of recurring or chronic infection, or with underlying conditions (e.g. diverticulitis, diabetes) which may predispose patients to infections.
Vigilance for the timely detection of serious infection is recommended for patients receiving immunosuppressive agents, such as Actemra, as signs and symptoms of acute inflammation may be lessened, due to suppression of the acute phase reaction. The effects of Actemra on C-reactive protein (CRP), neutrophils and signs and symptoms of infection should be considered when evaluating a patient for a potential infection. Patients (which include younger children who may be less able to communicate their symptoms) and parents/ guardians of minors should be instructed to contact a physician immediately when any symptoms suggesting infection appear, in order to assure rapid evaluation and appropriate treatment.
The use of Actemra is not recommended in patients with HIV, positive core antibody for hepatitis B, prior HCV infection, or symptomatic EBV infection. Viral reactivation (e.g. hepatitis B) has been reported with biologic therapies for RA. In clinical studies with Actemra, patients who screened positive for hepatitis were excluded.
In the RA long term exposure population, the overall rate of serious infections (bacterial, viral and fungal) was 4.7 events per 100 patient years. Reported serious infections, some with fatal outcome, included active tuberculosis, which may present with intrapulmonary or extrapulmonary disease, invasive pulmonary infections, including candidiasis, aspergillosis, coccidioidomycosis and Pneumocystis jirovecii, pneumonia, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and bacterial arthritis. Cases of opportunistic infections have been reported.

Gastrointestinal perforation - complications of diverticulitis.

Events of diverticular perforation as complications of diverticulitis have been reported in patients treated with Actemra. Actemra should be used with caution in patients with previous history of intestinal ulceration or diverticulitis. Patients presenting with symptoms potentially indicative of complicated diverticulitis, such as abdominal pain, should be evaluated promptly for early identification of gastrointestinal perforation.

Tuberculosis.

As recommended for other biological treatments all patients should be screened for latent tuberculosis (TB) infection prior to starting Actemra therapy. Patients with latent TB should be treated with standard anti-mycobacterial therapy before initiating Actemra. Physicians are reminded of the risk of false negative tuberculin skin and interferon-gamma TB blood test results, especially in patients who are severely ill or immunocompromised.
Patients should be instructed to seek medical advice if signs or symptoms suggestive of a TB infection (e.g. persistent cough, wasting/ weight loss, low grade fever) occur during or after therapy with Actemra.

Vaccinations.

Live and live attenuated vaccines should not be given concurrently with Actemra as clinical safety has not been established.
No data are available on the secondary transmission of infection from persons receiving live vaccines to patients receiving Actemra.
In a small, randomised open-label study, adult RA patients treated with Actemra plus MTX had a response to both the 23-valent pneumococcal polysaccharide (PPV) and tetanus toxoid (TTV) vaccines comparable to the response seen in patients receiving MTX only (60% vs 71% for PPV; 42% vs 39% for TTV, respectively). Because of the small number of patients in the study no firm conclusions can be drawn about the absolute differences in antibody responses between the two groups.
It is recommended that all patients, particularly paediatric or elderly patients be brought up to date with all immunisations in agreement with current immunisation guidelines prior to initiating Actemra therapy. The interval between live vaccinations and initiation of Actemra therapy should be in accordance with current vaccination guidelines regarding immunosuppressive agents.

Hypersensitivity reactions, including anaphylaxis.

Serious hypersensitivity reactions, including anaphylaxis, have been reported in association with Actemra (see Section 4.8 Adverse Effects (Undesirable Effects)) and anaphylactic events with a fatal outcome have been reported with intravenous infusions of Actemra. In the post-marketing setting, events of serious hypersensitivity and anaphylaxis, have occurred in patients treated with a range of doses of Actemra, including intravenous and subcutaneous administration of Actemra, with or without concomitant therapies, premedication and/or a previous hypersensitivity reaction.
In the post marketing setting, cases with a fatal outcome have been reported with intravenous Actemra. These events have occurred as early as the first infusion of Actemra (see Section 4.3 Contraindications; Section 4.8 Adverse Effects (Undesirable Effects)). Appropriate treatment should be available for immediate use in the event of an anaphylactic reaction during infusion with Actemra.
The treating healthcare professional should consider the risks of potential hypersensitivity reactions when assessing a patient's suitability for home use with subcutaneous Actemra. Healthcare professionals should ensure training in the subcutaneous injection technique is provided to patients. Serious hypersensitivity reactions have occurred with subcutaneous Actemra and anaphylaxis has occurred in the post-marketing setting. Hypersensitivity reactions, including anaphylaxis, may occur even after multiple injections of subcutaneous Actemra. Inform patients that some patients who have been treated with Actemra have developed serious allergic reactions, including anaphylaxis. Instruct patients to inform a healthcare professional if they experience symptoms of allergic reaction before administering the next dose. Patients should seek immediate medical attention if developing symptoms of serious allergic reactions (see Section 4.2 Dose and Method of Administration).
If an anaphylactic reaction or other serious hypersensitivity reaction occurs, administration of Actemra should be stopped immediately and Actemra should be permanently discontinued.
Patients with a history of any reaction consistent with hypersensitivity (e.g. urticaria, bronchospasm, angioedema) to Actemra or any component of the product must not be re-challenged with Actemra (see Section 4.3 Contraindications).

Viral reactivation.

Viral reactivation (e.g. hepatitis B virus) has been reported with biologic therapies for RA. In clinical studies with Actemra, patients who screened positive for hepatitis were excluded.

Active hepatic disease and hepatic impairment.

Treatment with Actemra particularly when administered concomitantly with MTX, may be associated with elevations in hepatic transaminases, therefore caution should be exercised. Treatment with Actemra is not recommended in patients with active hepatic disease or hepatic impairment (see Section 4.8 Adverse Effects (Undesirable Effects); Section 4.2 Dose and Method of Administration).
Viral reactivation (e.g. hepatitis B) has been reported with biologic therapies for RA. In clinical studies with Actemra, patients who screened positive for hepatitis were excluded.

Hepatotoxicity.

Mild and moderate elevations of hepatic transaminases and bilirubin have been reported with Actemra treatment (see Section 4.8 Adverse Effects (Undesirable Effects)). An increased frequency of these elevations was observed when potentially hepatotoxic drugs (e.g. MTX) were used in combination with Actemra. There is a potential risk of hepatotoxicity with use of Actemra.
Serious drug-induced liver injury, including acute liver failure, hepatitis and jaundice, have been observed with tocilizumab (see Section 4.8 Adverse Effects (Undesirable Effects), Post-marketing experience). Serious hepatic injury occurred between 2 weeks to more than 5 years after initiation of Actemra. Some of these cases have resulted in liver transplant or death. While most cases presented with marked elevations of transaminases (> 5 times ULN), some cases presented with signs or symptoms of liver dysfunction and only mildly elevated transaminases.
It is not recommended to initiate tocilizumab treatment in patients with elevated transaminases ALT or AST greater than 1.5x ULN, except in cases of CRS (see Section 4.2 Dose and Method of Administration). In patients who develop elevated ALT or AST greater than 5x ULN, discontinue Actemra.
In RA and GCA, the ALT/AST should be monitored every 4 to 8 weeks for the first 6 months of treatment followed by every 12 weeks thereafter. For recommended modifications including Actemra discontinuation based on transaminases levels, see Section 4.2 Dose and Method of Administration. For ALT or AST elevations > 3 to 5 x ULN, confirmed by repeat testing, Actemra treatment should be interrupted. Once the patient's hepatic transaminases are below 3 x ULN, treatment with Actemra may recommence at 4 or 8 mg/kg for the IV formulation or every other week or weekly injection for the SC formulation.
In pJIA and sJIA, ALT and AST should be monitored at the time of the second administration and thereafter every 4 to 8 weeks for pJIA and every 2 to 4 weeks for sJIA (see Section 4.2 Dose and Method of Administration).

Haematological abnormalities.

Decreases in neutrophil and platelet counts have occurred following treatment with Actemra 8 mg/kg in combination with MTX (see Section 4.8 Adverse Effects (Undesirable Effects)). There may be an increased risk of neutropenia in patients who have previously been treated with a TNF antagonist.
In patients not previously treated with Actemra, initiation is not recommended in patients with an absolute neutrophil count (ANC) below 2 x 109/L. Caution should be exercised when considering initiation of Actemra treatment in patients with a low platelet count (i.e. platelet count below 100 x 109/L). In patients with an ANC below 0.5 x 109/L or a platelet count < 50 x 109/L treatment is not recommended (see Section 4.4 Special Warnings and Precautions for Use).
Severe neutropenia may be associated with an increased risk of serious infections, although there has been no clear association between decreases in neutrophils and the occurrence of serious infections in clinical trials with Actemra to date.
In RA and GCA, neutrophils and platelets should be monitored 4 to 8 weeks after start of therapy and thereafter according to standard clinical practice. For recommended dose modifications based on ANC and platelet counts, see Section 4.2 Dose and Method of Administration.
In pJIA and sJIA, neutrophils and platelets should be monitored at the time of the second administration and thereafter every 4 to 8 weeks for pJIA and every 2 to 4 weeks for sJIA (see Section 4.2 Dose and Method of Administration).

Lipid parameters.

Elevations in lipid parameters including total cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides were observed in patients treated with Actemra (see Section 4.8 Adverse Effects (Undesirable Effects)). In the majority of patients, there was no increase in atherogenic indices, and elevations in total cholesterol responded to treatment with lipid lowering agents.
Assessment of lipid parameters should be performed in patients 4 to 8 weeks following initiation of Actemra therapy. RA and sJIA patients should then be managed according to local clinical guidelines for management of hyperlipidaemia. For pJIA patients, assessment of lipid parameters should be performed at 3 monthly intervals during Actemra treatment until it is clear the risk of development of significant changes in lipid parameters has diminished.

Demyelinating disorders.

Physicians should be vigilant for symptoms potentially indicative of new-onset central demyelinating disorders. The potential for central demyelination with Actemra is currently unknown. Multiple sclerosis and chronic inflammatory demyelinating polyneuropathy were reported rarely in RA clinical studies.

Malignancy.

The risk of malignancy is increased in patients with RA. Immunomodulatory medicinal products may increase the risk of malignancy.
Patients receiving immunosuppressive therapy are at an increased risk of developing skin cancer (melanoma and non-melanoma). The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent. Periodic skin examination is recommended for all patients who are at increased risk for skin cancer and exposure to sunlight and UV light should be limited by wearing protective clothing and using a sunscreen with a high protection factor.

Intravenous infusion reactions.

Infusion reactions have been observed during and within 24 hours of treatment with Actemra (see Section 4.8 Adverse Effects (Undesirable Effects)).

Cardiovascular risk.

RA patients have an increased risk for cardiovascular disorders and should have risk factors (e.g. hypertension, hyperlipidaemia) managed as part of usual standard of care (see Section 4.4 Special Warnings and Precautions for Use, Lipid parameters). Elevations in LDL and HDL lipids have been observed, with no clinical consequences identified. No data are available concerning cardiovascular outcomes with long-term use of Actemra.

Combination with TNF antagonists and/or other biological therapies.

There is no experience with the use of Actemra with TNF antagonists or other biological treatments for RA. Actemra is not recommended for use with other biological agents including TNF antagonists, anakinra, rituximab and abatacept.

Sodium.

Intravenous Actemra contains 1.17 mmol (26.55 mg) of sodium per maximum dose of 1200 mg. This should be taken into consideration by patients on a controlled sodium diet. Doses below 1025 mg of Actemra contain less than 1 mmol of sodium (23 mg) and can essentially be considered 'sodium free'.
The subcutaneous Actemra formulation does not contain sodium.

Systemic juvenile idiopathic arthritis.

Macrophage activation syndrome (MAS).

MAS is a serious life threatening disorder that may develop in patients with sJIA. In clinical trials, Actemra has not been studied in patients during an episode of active MAS (see Section 4.8 Adverse Effects (Undesirable Effects)).

Use in the elderly.

Population analyses evaluated the potential effects of demographic characteristics on the pharmacokinetics of Actemra in adult RA patients. Results of these analyses showed that no adjustment of the dose is necessary for age, gender, or race.
No dose adjustment is required in elderly patients.

Paediatric use.

The safety and efficacy of intravenous Actemra in children below 18 years of age with conditions other than pJIA, sJIA or CRS have not been established. Ten patients who participated in the pivotal study for pJIA were less than 4 years of age. The use of Actemra IV in children under the age of two have not been studied.
Available data only support use of intravenous Actemra in children with pJIA who have had an inadequate response to or intolerance to MTX. Long-term safety data for intravenous Actemra use in children with pJIA are currently limited to 2 years, and at present no comparison with the safety profile of other biological DMARDs approved for use in this indication has been made.
Treatment with a murine analogue did not exert toxicity in juvenile mice. In particular, there was no impairment of skeletal growth, immune function and sexual maturation.
The safety and efficacy of subcutaneous Actemra in children from birth to less than 1 year has not been established. No data are available. Data in patients with sJIA aged 1 year is limited (see Section 5.2 Pharmacokinetic Properties). Three patients aged 1-2 were included in tudy WA28118. The safety and efficacy of Actemra SC has not been established for patients with CRS or children below 2 years of age with pJIA. The pre-filled pen (ACTPen) should not be used to treat children and adolescent patients ˂ 12 years of age since there is a potential risk of intramuscular injection due to a thinner subcutaneous tissue layer.

Effects on laboratory tests.

Caution should be exercised when considering initiation of Actemra treatment in patients with a low neutrophil count. Decreases in neutrophil counts below 1 x 109/L occurred in 3.4%, with counts < 0.5 x 109/L occurring in 0.3%, of patients on Actemra 8 mg/kg + DMARD without clear association with serious infection (see Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)). In patients with an absolute neutrophil count < 0.5 x 109/L treatment is not recommended.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Population pharmacokinetic analyses did not detect any effect of MTX, nonsteroidal anti-inflammatory drugs or corticosteroids on tocilizumab clearance in RA patients. In GCA patients, no effect of cumulative corticosteroid dose on tocilizumab exposure was observed.
Concomitant administration of a single dose of 10 mg/kg tocilizumab with 10-25 mg MTX once weekly had no clinically significant effect on MTX exposure.
Actemra has not been studied in combination with other biological DMARDs.
The expression of hepatic CYP450 enzymes is suppressed by cytokines that stimulate chronic inflammation, such as IL-6. Thus suppression of CYP450 expression may be reversed when potent cytokine inhibitory therapy, such as tocilizumab, is introduced.
In vitro studies with cultured human hepatocytes demonstrated that IL-6 caused a reduction in CYP3A4 and to a lesser extent CYP1A2, CYP2C9 and CYP2C19 enzyme messenger RNA (mRNA) expression. Tocilizumab was shown to normalise expression of the mRNA for these enzymes.
This is clinically relevant for CYP450 substrates with a narrow therapeutic index, and/or where the dose is individually adjusted.
In a study in RA patients, levels of simvastatin and its acid metabolite (CYP3A4 substrates) were decreased by 57% and 39%, respectively, one week following a single dose of tocilizumab, to a level similar or slightly higher than those observed (in other studies) in healthy subjects.
When starting or stopping therapy with Actemra, patients taking medicinal products which are individually adjusted and are metabolised via CYP450 3A4, 1A2, 2C9 or 2C19 (e.g. atorvastatin, calcium channel blockers, theophylline, warfarin, phenytoin, cyclosporin or benzodiazepines) should be monitored as doses may need to be adjusted to maintain therapeutic effect. The degree of dose up titration upon initiation of therapy or dose down titration when stopping therapy with Actemra should be based on the therapeutic response and/or adverse effects of the patient to the individual medicine. Given a relatively long elimination half-life (t1/2), the effect of tocilizumab on CYP450 enzyme activity may persist for several weeks after stopping therapy.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Preclinical data do not suggest an effect on fertility under treatment with a murine analogue of tocilizumab. Effects on endocrine active organs or on organs of the reproductive system were not seen in a chronic cynomolgus monkey toxicity study, nor was reproductive performance affected in IL-6 deficient male and female mice.
(Category C)
Actemra should not be used during pregnancy unless clearly necessary. There are no adequate data from the use of Actemra in pregnant women. The potential risk for humans is unknown. Women of childbearing potential should be advised to use adequate contraception during and for several months after therapy with Actemra.
In an embryofoetal toxicity study conducted in cynomolgus monkeys, a slight increase of abortion/ embryofoetal death was observed with high systemic cumulative exposure in the 10 mg/kg/day mid dose group (> 35 times human exposure) and in the 50 mg/kg/day high dose group (> 100 times human exposure) compared to vehicle control and low dose groups. It cannot be excluded that this finding is related to Actemra treatment. Placental transfer of both tocilizumab and anti-tocilizumab antibodies to the foetus was seen in cynomolgus monkeys.
It is unknown whether tocilizumab is excreted in human breast milk and its efficacy and safety in lactating women has not been established. However, it is known that endogenous immunoglobulins of the IgG isotype are excreted into human milk. A decision on whether to continue/ discontinue breastfeeding or to continue/ discontinue therapy with Actemra should be made taking into account the benefit of breastfeeding to the child and the benefit of Actemra therapy to the woman.
Transfer of a murine analogue of tocilizumab into the milk of lactating mice has been observed.

4.8 Adverse Effects (Undesirable Effects)

Rheumatoid arthritis.

Patients treated with intravenous Actemra.

The safety of Actemra has been studied in 5 phase III, double-blind controlled trials and their extension periods.
The all control population includes all patients who received at least one dose of Actemra in the double-blind controlled period of the 5 studies. The control period in 4 of the studies was 6 months and in 1 study was up to 2 years. In the double-blind controlled studies 774 patients received Actemra 4 mg/kg in combination with MTX, 1870 patients received Actemra 8 mg/kg in combination with MTX/ other DMARDs and 288 patients received Actemra 8 mg/kg monotherapy.
The all exposure population includes all patients who received at least one dose of Actemra either in the double-blind control period or open label extension phase in studies. Of the 4009 patients in this population, 3577 received treatment for at least 6 months, 3296 for at least one year; 2806 received treatment for at least 2 years and 1222 for 3 years. The mean duration of exposure to Actemra in the all exposure population was 2.14 years.
The most commonly reported AEs in controlled studies up to 2 years (occurring in ≥ 5% of patients treated with Actemra monotherapy or in combination with DMARDs) were upper respiratory tract infections, nasopharyngitis, headache, hypertension, increased ALT and bronchitis. In study II the rate of AEs (including deaths, serious AEs and AEs leading to treatment withdrawal or dose modification) after 2 years, calculated as a function of exposure (i.e. events per 100 patient years), had not increased in comparison with the AE profile observed after 1 year of study II. See Table 3.
Other infrequent and medically relevant adverse events occurring at an incidence of less than 2% in RA patients treated with Actemra in controlled trials were:

Infections and infestations.

Cellulitis, oral herpes simplex, herpes zoster, diverticulitis.

Gastrointestinal disorders.

Stomatitis, gastric ulcer.

Skin and subcutaneous tissue disorders.

Pruritus, urticaria.

Investigations.

Weight increased, total bilirubin increased.

Blood and lymphatic system disorders.

Leucopenia, neutropenia.

Metabolism and nutrition disorders.

Hypercholesterolaemia, hypertriglyceridaemia.

General disorders and administration site conditions.

Hypersensitivity reaction.

Respiratory, thoracic and mediastinal disorders.

Dyspnoea.

Eye disorders.

Conjunctivitis.

Renal disorders.

Nephrolithiasis.

Endocrine disorders.

Hypothyroidism.

Infections.

In the 6 month controlled clinical trials, the rate of all infections reported with Actemra 8 mg/kg + DMARD treatment was 127 events per 100 patient (pt) years compared to 112 events per 100 pt years in the placebo + DMARD group. In the all exposure population the overall rate of infections with Actemra was 108 events per 100 pt years exposure.
In the 6 month controlled clinical trials, the rate of serious infections (bacterial, viral and fungal) with Actemra 8 mg/kg + DMARD was 5.3 events per 100 pt years exposure compared to 3.9 events per 100 pt years exposure in the placebo + DMARD group. In the monotherapy study the rate of serious infections was 3.6 events per 100 pt years of exposure in the Actemra group and 1.5 events per 100 pt years of exposure in the MTX group.
In the all exposure population the overall rate of serious infections was 4.7 events per 100 pt years. Reported serious infections, some with fatal outcome, included active tuberculosis, which may present with intrapulmonary or extrapulmonary disease, invasive pulmonary infections, including candidiasis, aspergillosis, coccidioidomycosis and Pneumocystis jirovecii, pneumonia, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and bacterial arthritis. Cases of opportunistic infections have also been reported.

Gastrointestinal perforation.

During the 6 month controlled clinical trials, the overall rate of gastrointestinal (GI) perforation was 0.26 events per 100 pt years with Actemra therapy. In the all exposure population the overall rate of gastrointestinal perforation was 0.28 events per 100 pt years. Reports of gastrointestinal perforation were primarily reported as complications of diverticulitis including generalised purulent peritonitis, lower GI perforation, fistulae and abscess.

Infusion reactions.

In the 6 month controlled trials, adverse events associated with infusion (selected events occurring during or within 24 hours of infusion) were reported by 6.9% of patients in the Actemra 8 mg/kg + DMARD and 5.1% of patients in the placebo + DMARD group. Events reported during the infusion were primarily episodes of hypertension. Events reported within 24 hours of finishing an infusion were headache and skin reactions (rash, urticaria). These events were not treatment limiting.
The rate of anaphylactic reactions (occurring in a total of 8/4009 patients, 0.2%) was several fold higher with the 4 mg/kg dose, compared to the 8 mg/kg dose.
Clinically significant hypersensitivity reactions associated with Actemra and requiring treatment discontinuation, were reported in a total of 56 out of 4009 patients (1.4%) treated with Actemra during the controlled and open label clinical trials. These reactions were generally observed during the second to fifth infusions of Actemra.

Immunogenicity.

A total of 2876 patients have been tested for anti-tocilizumab antibodies in the 6 month controlled clinical trials. Forty-six patients (1.6%) developed positive anti-tocilizumab antibodies of whom 5 had an associated medically significant hypersensitivity reaction leading to withdrawal. Thirty patients (1.1%) developed neutralising antibodies.

Early rheumatoid arthritis.

Study VIII (FUNCTION) evaluated 1162 patients with early, moderate to severe RA who were naïve to treatment with both MTX and a biologic agent. The overall safety profile observed in the Actemra treatment groups was consistent with the known safety profile of Actemra (Table 3).
The overall rate of serious adverse events (SAEs) per 100 patient years (PY) was numerically higher for the Actemra arms (13.2 SAEs per 100 PY) than the placebo + MTX arm (10.6 SAEs per 100 PY). These were reported under 'infections and infestations', 'neoplasms benign, malignant and unspecified', 'respiratory, thoracic and mediastinal disorders' and 'injury, poisoning and procedural complications'.
The rate of discontinuation due to an adverse event was approximately twice as high in the Actemra arms, as in the placebo + MTX arm (16.1 and 8.2 events per 100 PY respectively). In all 3 Actemra treatment arms, the most common reason for treatment discontinuation was attributed to 'investigations' events, in particular events related to liver enzyme elevations. In the study there were 14 patient deaths reported, 12 in Actemra-treated patients and 2 in placebo + MTX-treated patients.

Actemra vs adalimumab in monotherapy.

In a 24-week double-blinded, parallel study (monotherapy with Actemra 8 mg/kg IV q4w (n=162) compared to adalimumab 40 mg SC q2w (n=162)), the overall clinical adverse event profile was similar between Actemra and adalimumab. The proportion of patients with serious adverse events was balanced between the treatment groups (Actemra 11.7% vs. adalimumab 9.9%) with the most common event being infections (3.1% each). There was a sudden death in the Actemra arm of a patient who died 10 days after the last dose. The cause of death was unknown. The patient had a history of peripheral vascular disease, hypertension, smoking and interstitial lung disease. Both study treatments induced the same pattern of changes in laboratory safety parameters (decreases in neutrophil and platelet counts, increases in ALT, AST and lipids), however, the magnitude of change and the frequency of marked abnormalities was higher with Actemra compared with adalimumab. Four (2.5%) patients in the Actemra arm and two (1.2%) patients in the adalimumab arm experienced CTC grade 3 or 4 neutrophil count decreases. Eleven (6.8%) patients in the Actemra arm and 5 (3.1%) patients in the adalimumab arm experienced ALT increases of CTC grade 2 or higher. For patients not receiving lipid lowering agents the mean increase in LDL from baseline to week 24 was 0.64 mmol/L (25 mg/dL) for patients in the Actemra arm and 0.19 mmol/L (7 mg/dL) for patients in the adalimumab arm. The safety observed in the Actemra arm was consistent with the known safety profile of Actemra and no new or unexpected adverse drug reactions were observed.

Patients treated with subcutaneous Actemra.

The safety of subcutaneous Actemra includes data from Study VI (SUMMACTA) and Study VII (BREVACTA). SUMMACTA compared the efficacy and safety of subcutaneous Actemra 162 mg administered every week versus intravenous Actemra 8 mg/kg every 4 weeks in 1262 subjects with adult RA. BREVACTA was a placebo-controlled superiority study that evaluated the safety and efficacy of subcutaneous Actemra 162 mg administered every other week or placebo in 656 patients. All patients in both studies received background non-biological DMARD(s).
The safety and immunogenicity observed for subcutaneous Actemra was consistent with the known safety profile of intravenous Actemra and no new or unexpected adverse drug reactions were observed (see Table 3). A higher frequency of injection site reactions was observed in patients who received subcutaneous Actemra compared with those who received subcutaneous placebo injections (in the IV arms of the studies).

Injection site reactions.

During the 6-month controlled period in SUMMACTA, the frequency of injection site reactions was 10.1% (64/631) and 2.4% (15/631) for the subcutaneous Actemra and the subcutaneous placebo (in the IV arm of the study) weekly injections, respectively. In BREVACTA, the frequency of injection site reactions was 7.1% (31/437) and 4.1% (9/218) for the subcutaneous Actemra and placebo every other week, respectively. These injection site reactions (including erythema, pruritus, pain and haematoma) were mild to moderate in severity. The majority was resolved without any treatment and none necessitated drug discontinuation.

Immunogenicity.

In SUMMACTA, a total of 625 patients treated with Actemra 162 mg weekly were tested for anti-tocilizumab antibodies in the 6 month controlled period. Five patients (0.8%) developed positive anti-tocilizumab antibodies; of these, all developed neutralising anti-tocilizumab antibodies. In BREVACTA, a total of 434 patients treated with Actemra 162 mg every other week were tested for anti-tocilizumab antibodies. Seven patients (1.6%) in the subcutaneous Actemra arm developed anti-tocilizumab antibodies; of these 6 (1.4%) in the subcutaneous Actemra arm developed neutralising antibodies.
A total of 1454 subcutaneous Actemra all exposure patients have been tested for anti-tocilizumab antibodies, 13 patients (0.9%) developed positive anti-tocilizumab antibodies, and of these 12 patients (0.8%) developed neutralising anti-tocilizumab antibodies.
No correlation of antibody development to clinical response or adverse events was observed.

Hypersensitivity and anaphylaxis.

In the subcutaneous Actemra development program clinically significant hypersensitivity reactions were defined as any adverse event during or within 24 hours of an injection (excluding injection site reactions), related to treatment and leading to study withdrawal. Clinically significant hypersensitivity reactions were experienced in 0.7% (8 out of 1068) of patients in the subcutaneous 6-month controlled RA trials and 0.7% (10 out of 1465) of patients in the subcutaneous all-exposure population. The events included, but were not limited to hypersensitivity (5 events) and urticaria (1 event).
There were no cases of anaphylaxis in the subcutaneous Actemra pivotal studies SUMMACTA and BREVACTA, however anaphylaxis has been reported in the post-market setting.

Giant cell arteritis.

The safety of subcutaneous Actemra was studied in 251 GCA patients in a Phase III study (Study X, GiACTA). The total patient years duration in the Actemra all exposure population was 138.5 patient years during the 12-month double blind, placebo-controlled phase of the study. The overall safety profile observed in the Actemra treatment groups was consistent with the known safety profile of Actemra (see Table 15).

Infections.

The rate of infection/serious infection events was 200.2/9.7 events per 100 patient years in the Actemra weekly group and 160.2/4.4 events per 100 patient years in the Actemra every other week group compared to 156.0/4.2 events per 100 patient years in the placebo plus 26 week prednisone taper 210.2/12.5 events per 100 patient years in the placebo plus 52 weeks taper groups.

Injection site reactions.

In the Actemra weekly group and the every other week group, 6% (6/100) of patients and 14% (7/49) of patients, reported an adverse reaction occurring at the site of a subcutaneous injection, respectively. No injection site reaction was reported as a serious adverse event or required treatment discontinuation.

Immunogenicity.

In the Actemra weekly group and the every other week group, 1 patient (1.1%, 1/95) and 3 patients (6.5%, 3/46), developed positive neutralising anti-tocilizumab antibodies, respectively. These were not of the IgE isotype. These patients did not develop hypersensitivity reactions or injection site reactions.

Hypersensitivity and anaphylaxis.

In the Actemra weekly group, no patients experienced a clinically significant hypersensitivity reaction or anaphylaxis. Two patients in the Actemra every other week group had clinically significant hypersensitivity reactions. One patient in the Actemra every other week group experienced events constituting an anaphylactic reaction. These were not considered to be clinically significant upon medical review.

Polyarticular juvenile idiopathic arthritis.

The safety profile of tocilizumab was studied in 240 paediatric patients with pJIA. In the CHERISH study, 188 patients (2 to 17 years of age) were treated with IV Actemra and in the JIGSAW study, 52 patients (1 to 17 years of age) were treated with SC Actemra. The total patient exposure to Actemra in the pJIA all exposure population was 184.4 patient years for IV Actemra and 50.4 patient years for SC Actemra. In general, the safety profile observed in patients with pJIA was consistent with the known safety profile of Actemra with the exception of injection site reactions (see Table 3). A higher frequency of injection site reactions was experienced by pJIA patients following SC Actemra injections compared to adult RA patients (see Section 4.8 Adverse Effects (Undesirable Effects)).

Infections.

Infections are the most commonly observed events in pJIA. The rate of infections in the pJIA IV Actemra all exposure population was 163.7 per 100 pt years. The most common events observed were nasopharyngitis and upper respiratory tract infections. The rate of serious infections was 4.9 per 100 pt years. The rate of serious infections was numerically higher in patients weighing below 30 kg treated with 10 mg/kg Actemra (12.2 per 100 pt years) compared to patients weighing ≥ 30 kg, treated with 8 mg/kg Actemra (4.0 per 100 pt years). The incidence of infections leading to dose interruptions was also numerically higher in patients weighing below 30 kg treated with 10 mg/kg Actemra (21%) compared to patients weighing ≥ 30 kg, treated with 8 mg/kg Actemra (8%). The rate of infection in pJIA patients treated with SC Actemra was comparable with pJIA patients treated with IV Actemra.

Infusion reactions.

In pJIA patients, infusion related reactions are defined as all events occurring during or within 24 hours of an infusion with IV Actemra. In the Actemra all exposure population, 11 patients (5.9%) experienced infusion reactions during the infusion, and 38 patients (20.2%) experienced an event within 24 hours of an infusion. The most common events occurring during infusion were headache, nausea and hypotension and within 24 hours of infusion were dizziness and hypotension. In general, the ADRs observed during or within 24 hours of an infusion were similar in nature to those seen in RA and sJIA patients.
No clinically significant hypersensitivity reactions were reported.

Injection site reactions.

A total of 28.8% (15/52) pJIA patients experienced injection site reactions to SC Actemra. These injection site reactions occurred in 44% of patients greater than 30 kg compared to 14.8% of patients below 30 kg. The most common injection site reactions were injection site erythema, swelling, hematoma, pain and pruritus. All injection site reactions reported were non-serious Grade 1 events, and none of the injection site reactions required patient withdrawal from treatment or dose interruption.

Immunogenicity.

Across the two studies in pJIA patients, only four patients developed neutralising antitocilizumab (Nab) antibodies. Of the four patients (0.5% [1/188] in the IV Study WA19977 and 5.8% [3/52] in the SC Study WA28117) that developed positive neutralising antitocilizumab antibodies, none developed a serious or clinically significant hypersensitivity reaction. Of these 4 patients, 2 subsequently withdrew from the study. No correlation between antibody development and clinical response or adverse events was observed.

Systemic juvenile idiopathic arthritis.

The safety profile of Actemra in sJIA was studied in 163 paediatric patients. In study WA18221 (12-week trial and long term extension) 112 patients (2 to 17 years of age) were treated with IV Actemra and in study WA28118 (52-week trial), 51 patients (1 to 17 years of age) were treated with SC Actemra.
In general, the ADRs in patients with sJIA were similar in type to those seen in RA and pJIA patients (see Section 4.8 Adverse Effects (Undesirable Effects)).

Infections.

In the 12 week controlled trial (study WA18221) the rate of all infections in the IV Actemra group was 344.7 per 100 patient years and 287.0 per 100 patient years in the placebo group. In the on-going open label extension study (Part II) the overall rate of infections remained similar at 306.6 per 100 patient years.
In the 12 week controlled trial (study WA18221) the rate of serious infections in the IV Actemra group was 11.5 per 100 patient years. In the open label extension study the overall rate of serious infections remained stable at 11.3 per 100 patient years. Reported serious infections were similar to those seen in RA patients with the addition of varicella and otitis media.
The rate of infection in sJIA patients treated with SC Actemra was comparable to sJIA patients treated with IV Actemra.
In Australia, a case of fatal sepsis occurred in a 6-year old who had been treated with Actemra for approximately 2 years for sJIA. Methotrexate was given concomitantly. The patient had symptoms of gastroenteritis on the day preceding his death, and the last dose of Actemra was administered 10 days prior to the event. The death was assessed as related to septicemia.

Macrophage activation syndrome.

In the 12 week controlled study (study WA18221), no patient in any treatment group experienced macrophage activation syndrome (MAS) while on assigned treatment. Three per 112 (3%) developed MAS during open-label treatment with IV Actemra. One patient in the placebo group escaped to IV Actemra 12 mg per kg at Week 2 due to severe disease activity, and ultimately developed MAS at Day 70. Two additional patients developed MAS during the long-term extension. All 3 patients had Actemra dose interrupted (2 patients) or discontinued (1 patient) for the MAS event, received treatment, and the MAS resolved without sequelae. Based on a limited number of cases, the incidence of MAS does not appear to be elevated in the Actemra sJIA clinical development experience, however no definitive conclusions can be made.
A case of MAS with a fatal outcome was reported in a patient enrolled in a clinical study of Actemra in sJIA. The patient had interrupted Actemra treatment 4 weeks prior to the onset of MAS because of a rotavirus infection. The patient also experienced a worsening of sJIA prior to the diagnosis of MAS.

Infusion reactions.

For sJIA patients, infusion related reactions are defined as all events occurring during or within 24 hours of an infusion with IV Actemra. In the 12 week controlled trial (study WA18221), 4.0% of patients from the Actemra group experienced events occurring during infusion, one event (angioedema) was considered serious and life-threatening, and the patient was discontinued from study treatment.
In the 12 week controlled trial experience, 16% of patients in the IV Actemra group and 5.4% of patients in the placebo group experienced an event within 24 hours of infusion. In the Actemra group, the events included, but not limited to rash, urticaria, diarrhoea, epigastric discomfort, arthralgia and headache. One of these events (urticaria) was considered serious.
Clinically significant hypersensitivity reactions associated with IV Actemra and requiring treatment discontinuation were reported in 1 out of 112 patients (< 1%) treated with IV Actemra during the controlled and open-label parts of the clinical trial. In an open-label, single arm study over 12 weeks in paediatric sJIA patients (N=11) under 2 years of age, the safety and immunogenicity of tocilizumab was assessed descriptively. SAEs, AEs leading to discontinuation, and infectious AEs were reported by 27.3%, 36.4%, and 81.8% of patients. Six patients (54.5%) experienced hypersensitivity reactions, defined as all adverse events occurring during or within 24 hours after an infusion considered related to Actemra. Three of these patients experienced serious hypersensitivity reactions and were withdrawn from the study. Three patients with hypersensitivity reactions (two with serious hypersensitivity reactions) developed treatment induced anti-tocilizumab antibodies after the event. There were no cases of MAS based on the protocol-specified criteria, but 2 cases of suspected MAS based on Ravelli criteria. Reports of anaphylaxis, anaphylactoid reactions, and hypersensitivity reactions in patients under 18 years of age have been reported in the post-marketing setting.
Injection site reactions (ISRs).In the study WA28118, a total of 41.2% (21/51) sJIA patients experienced ISRs to SC Actemra. The most common ISRs were erythema, pruritus, pain, and swelling at the injection site. The majority of ISRs reported were Grade 1 events and all ISRs reported were non-serious and none of the ISRs required patient withdrawal from treatment or dose interruption.

Immunogenicity.

In study WA18221, all 112 patients were tested for anti-tocilizumab antibodies at baseline. Two patients developed positive anti-tocilizumab antibodies with one of these patients having a hypersensitivity reaction leading to withdrawal. In study WA28118, 46 of the 51 (90.2%) patients tested for anti-tocilizumab antibodies at baseline had at least one postbaseline screening assay result. No patient developed positive anti-tocilizumab antibodies postbaseline.

Cytokine release syndrome.

The safety of tocilizumab in CRS has been evaluated in a retrospective analysis of data from clinical trials, where 51 patients were treated with intravenous tocilizumab 8 mg/kg (12 mg/kg for patients less than 30 kg) with or without additional high-dose corticosteroids for severe or life-threatening CAR T-cell-induced CRS. A median of 1 dose of tocilizumab (range, 1-4 doses) was administered.

Laboratory abnormalities. Haematology abnormalities.

Rheumatoid arthritis.

Neutrophils - intravenous administration.

In the 6 month controlled trials decreases in neutrophil counts below 1 x 109/L occurred in 3.4% of patients on Actemra 8 mg/kg + DMARD compared to < 0.1% of patients on placebo + DMARD. Approximately half of the patients who developed an ANC < 1 x 109/L did so within 8 weeks after starting therapy. Decreases below 0.5 x 109/L were reported in 0.3% patients receiving Actemra 8 mg/kg + DMARD (see Section 4.4 Special Warnings and Precautions for Use).
There was no clear relationship between decreases in neutrophils below 1 x 109/L and the occurrence of serious infections.
In the all control and all exposure population, the pattern and incidence of decreases in neutrophil counts remained consistent with what was seen in the 6 month controlled clinical trials.

Neutrophils - subcutaneous administration.

During routine laboratory monitoring in the Actemra 6 month controlled period of SUMMACTA and BREVACTA, a decrease in neutrophil count below 1 x 109/L occurred in 2.9% and 2.3% of patients on Actemra 162 mg SC weekly and every other week, respectively.
There was no clear relationship between decreases in neutrophils below 1 x 109/L and the occurrence of serious infections.

Platelets - intravenous administration.

In the 6 month controlled trials, decreases in platelet counts below 100 x 109/L occurred in 1.7% of patients on Actemra 8 mg/kg + DMARDs compared to < 1% on placebo + DMARDs. These decreases occurred without associated bleeding events. (See Section 4.2 Dose and Method of Administration; Section 4.4 Special Warnings and Precautions for Use.)
In the all control and all exposure population, the pattern and incidence of decreases in platelet counts remained consistent with what was seen in the 6 month controlled clinical trials.

Platelets - subcutaneous administration.

During routine laboratory monitoring in the 6-month controlled period of SUMMACTA and BREVACTA, 1.6% and 1.4% of patients experienced a decrease in platelet count to < 100 x 109/L on Actemra 162 mg SC weekly and every other week, respectively.

Giant cell arteritis.

Neutrophils.

During routine laboratory monitoring in the Actemra 12-month double blind, placebo-controlled phase of Study X (GiACTA), a decrease in neutrophil count below 1 x 109/L occurred in 4% of patients in the Actemra weekly group. This was not observed in either of the placebo plus prednisone taper groups. There was no clear relationship between decreases in neutrophils below 1 x 109/L and the occurrence of serious infections.

Platelets.

During routine laboratory monitoring in the Actemra 12-month double blind, placebo-controlled phase of Study X (GiACTA), one patient (1%, 1/100) in the Actemra weekly group had a single transient occurrence of decreased platelet count below 100 x 109/L without associated bleeding events. A decrease in platelet count below 100 x 109/L was not observed in either of the placebo plus prednisone taper groups.

Polyarticular juvenile idiopathic arthritis.

Neutrophils.

During routine laboratory monitoring in the Actemra all exposure population, a decrease in neutrophil count below 1 x 109/L occurred in 3.7% of patients. There was no clear relationship between decreases in neutrophils below 1 x 109/L and the occurrence of serious infections.

Platelets.

During routine laboratory monitoring in the Actemra all exposure population, a decrease in platelet count to ≤ 50 x 103/microL occurred in 1% of patients treated with IV Actemra without associated bleeding events and in no patients treated with SC Actemra.

Systemic juvenile idiopathic arthritis.

Neutrophils.

During routine laboratory monitoring in the 12 week controlled trial (study WA18221), a decrease in neutrophil counts below 1 x 109/L occurred in 7% of patients in the Actemra group, and in none in the placebo group. In the open label extension study (study WA18221) decreases in neutrophil counts below 1 x 109/L occurred in 15% of patients in the IV Actemra group.
There was no clear relationship between decreases in neutrophils below 1 x 109/L and the occurrence of serious infections.
In the 52-week open-label trial (study WA28118), neutrophil count decreases below 1 x 109/L occurred in 23.5% of patients treated with SC Actemra.

Platelets.

During routine laboratory monitoring in the 12 week controlled trial (study WA18221), 3% of patients in the placebo group and 1% in the IV Actemra group had a decrease in platelet count to ≤ 100 x 103/microL. In the open label extension study (WA18221) decreases in platelet counts below 100 x 103/microL occurred in 3% of patients in the IV Actemra group, without associated bleeding events.
In the 52-week open-label trial (Study WA28118), decreases in platelet counts below 100 x 103/microL occurred in 2% of patients treated with SC Actemra.

Liver enzyme elevations.

Rheumatoid arthritis.

Intravenous administration.

During the 6 month controlled trials transient elevations in ALT (alanine transaminase)/AST (aspartate transaminase) > 3 x ULN (Upper Limit of Normal) were observed in 2.1% of patients on Actemra 8 mg/kg compared to 4.9% of patients on MTX, and in 6.5% of patients who received Actemra 8 mg/kg + DMARD compared to 1.5% of patients on placebo + DMARD. The addition of potentially hepatotoxic drugs (for example MTX) to Actemra monotherapy resulted in increased frequency of these elevations. Elevations of ALT/AST > 5 x ULN were observed in 0.7% of Actemra monotherapy patients and 1.4% of Actemra + DMARD patients, the majority of whom were discontinued from Actemra treatment. During routine laboratory monitoring, the incidence of indirect bilirubin > ULN is 6.2% in patients treated with 8 mg/kg Actemra + DMARD in the all control population.
In the all control and all exposure population, the pattern and incidence of elevations in ALT/AST remained consistent with what was seen in the 6 month controlled clinical trials. In Study VIII (FUNCTION), MTX-naïve adult patients with moderate to severe, active early RA (mean disease duration ≤ 6 months) experienced more transient elevations in ALT > 3 x ULN compared with the all control population. Transient elevations in ALT > 3 to 5 x ULN were observed in 6.6% of patients on Actemra 4 mg/kg + MTX, 9.7% of patients on Actemra 8 mg/kg + MTX compared to 3.4% of patients on Actemra 8 mg/kg + placebo and 3.9% of patients on MTX + placebo.
In Study WA25204 (ENTRACTE), of the 1538 patients with moderate to severe RA (see Section 5.1, Clinical trials) and treated with Actemra, elevations in ALT or AST > 3 x ULN occurred in 5.3% and 2.2% patients, respectively. One serious event of drug induced hepatitis with hyperbilirubinemia was reported in association with Actemra treatment (see Section 4.4 Special Warnings and Precautions for Use).

Subcutaneous administration.

During routine laboratory monitoring in the Actemra 6-month controlled period of SUMMACTA, elevation in ALT or AST ≥ 3 x ULN occurred in 6.5% and 1.4% of patients, respectively on the SC weekly dose. In the 6-month controlled period of BREVACTA, elevation in ALT or AST ≥ 3 x ULN occurred in 3.4% and 0.7% of patients, respectively on the SC every other week dose.

Giant cell arteritis.

During routine laboratory monitoring in the Actemra 12-month double blind, placebo-controlled phase of Study X (GiACTA), elevation in ALT ≥ 3 x ULN occurred in 3% of patients in the Actemra weekly group compared to 2% in the placebo plus 52 week prednisone taper group and none in the placebo plus 26 weeks prednisone taper group. An elevation in AST > 3 x ULN occurred in 1% of patients in the Actemra weekly group, compared to no patients in either of the placebo plus prednisone taper groups.

Polyarticular juvenile idiopathic arthritis.

During routine laboratory monitoring in the Actemra all exposure population, elevation in ALT or AST ≥ 3 x ULN occurred in 3.7% and < 1% of patients treated with IV Actemra and in 9.6% and 3.8% patients treated with SC Actemra, respectively.

Systemic juvenile idiopathic arthritis.

During routine laboratory monitoring in the 12 week controlled trial (study WA18221), elevation in ALT or AST ≥ 3 x ULN occurred in 5% and 3% of patients, respectively, in the IV Actemra group, and in 0% of placebo patients.
In the open label extension study (WA28118), elevation in ALT or AST ≥ 3 x ULN occurred in 12% and 4% of patients, respectively, in the IV Actemra group.
In the 52-week open-label trial (study WA28118), elevation in ALT or AST ≥ 3 x ULN occurred in 9.8% and 4.0% patients treated with SC Actemra, respectively.

Elevations in lipid parameters.

Rheumatoid arthritis.

Intravenous administration.

During routine laboratory monitoring in the 6 month controlled clinical trials, increases of lipid parameters such as total cholesterol, triglycerides, LDL cholesterol, and/or HDL cholesterol have been reported commonly. Approximately 24% of patients receiving Actemra in clinical trials experienced sustained elevations in total cholesterol > 6.2 mmol/L (240 mg/dL), with 15% experiencing a sustained increase in LDL to ≥ 4.1 mmol/L (160 mg/dL). Elevations in lipid parameters responded to treatment with lipid-lowering agents.
In the all control and all exposure population, the pattern and incidence of elevations in lipid parameters remained consistent with what was seen in the 6-month controlled clinical trials.

Subcutaneous administration.

During routine laboratory monitoring in the 6-month controlled periods of SUMMACTA and BREVACTA, 19% of patients on the SC weekly dose and 20% of patients dosed every other week experienced sustained elevations in total cholesterol above 6.2 mmol/L (240 mg/dL), with 9% and 10% experiencing a sustained increase in LDL to ≥ 4.1 mmol/L (160 mg/dL) on the SC weekly dose and every other week dose.

Giant cell arteritis.

During routine laboratory monitoring in the Actemra 12-month double blind, placebo-controlled phase of Study X (GiACTA), 25% of patients experienced elevations in total cholesterol above 6.2 mmol/L (240 mg/dL), with 47% experiencing an increase in LDL to ≥ 4.1 mmol/L (160 mg/dL) in the Actemra weekly group.

Polyarticular juvenile idiopathic arthritis.

During routine laboratory monitoring in the IV Actemra Study, 3.4% and 10.4% of patients experienced a post-baseline elevation of their LDL-cholesterol value to ≥ 3.4 mmol/L (130 mg/dL) and total cholesterol value to ≥ 5.2 mmol/L (200 mg/dL) at any time during the study treatment, respectively. Of 185 patients assessed 19 patients experienced consecutive sustained elevation of their total cholesterol value ≥ 4.4 mmol/L (170 mg/dL) at any time during study treatment.
In the SC Actemra study, 14.3% and 12.8% of patients experienced a post-baseline elevation of their LDL-cholesterol value to ≥ 3.4 mmol/L (130 mg/dL) and total cholesterol value to ≥ 5.2 mmol/L (200 mg/dL) at any time during study treatment, respectively.

Systemic juvenile idiopathic arthritis.

During routine laboratory monitoring in the 12 week controlled trial (study WA18221), 13.4% and 33.3% of patients experienced a post-baseline elevation of their LDL-cholesterol value to ≥ 3.4 mmol/L (130 mg/dL) and total cholesterol value to ≥ 5.2 mmol/L (200 mg/dL), respectively.
In the open-label extension study (WA18221), 13.2% and 27.7% of patients experienced a post-baseline elevation of their LDL-cholesterol value to ≥ 3.4 mmol/L (130 mg/dL) and total cholesterol value to ≥ 5.2 mmol/L (200 mg/dL), respectively. Of 107 patients assessed 22 experienced consecutive sustained elevation of their total cholesterol value ≥ 4.4 mmol/L (170 mg/dL) at any time during study treatment.
In the 52-week open-label trial (study WA28118), 23.4% and 35.4% of patients experienced a post-baseline elevation of their LDL-cholesterol value to ≥ 3.4 mmol/L (130 mg/dL) and total cholesterol value to ≥ 5.2 mmol/L (200 mg/dL), respectively.

Malignancies.

The clinical data are insufficient to assess the potential incidence of malignancy following exposure to Actemra. Long-term safety evaluations are ongoing.

Neoplasms benign, malignant, and unspecified (including cysts and polyps).

Melanoma and non-melanoma skin cancer (NMSC) have been reported in patients treated with tocilizumab.

Post-marketing experience.

The following adverse drug reactions have been identified from clinical trials and/or post marketing experience with tocilizumab (Table 4) based on spontaneous case reports, literature cases and cases from non-interventional study programs. Adverse drug reactions are listed according to system organ classes in MedDRA and the corresponding frequency category estimation for each adverse drug reaction is based on the following convention: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000).

Respiratory, thoracic and mediastinal disorders.

There have been reports of interstitial lung disease (including pneumonitis and pulmonary fibrosis), some of which had fatal outcomes.

Blood and lymphatic system disorders.

Very rare reports of pancytopenia have occurred.

Reporting of suspected adverse reactions.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.

4.2 Dose and Method of Administration

Dose.

Treatment should be initiated by healthcare professionals experienced not only in the diagnosis and treatment of RA, GCA, pJIA, sJIA or CRS but also in the use of biological therapies for these conditions. For pJIA and sJIA treatment should be prescribed by medical practitioners experienced in the management of these conditions.
For adult patients with RA and children with pJIA and sJIA, Actemra may be administered as an IV infusion or an SC injection.
For adult patients with GCA, Actemra is administered as a SC injection.
For paediatric and adult patients with CRS, Actemra is administered as an IV infusion.
Actemra IV formulation is not intended for SC administration.
Actemra SC formulation is not intended for IV administration.
For the treatment of patients with pJIA, sJIA and CRS, Actemra administration as an IV infusion should be administered in a hospital setting with immediate access to the necessary medical personnel and full resuscitation facilities (see Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)).

Subcutaneous administration.

Subcutaneous Actemra is indicated in the treatment of patients with adult RA, GCA, pJIA and sJIA.
For patients receiving Actemra as an SC injection, at least the first injection must be performed under the supervision of a qualified healthcare professional, in a healthcare facility with the necessary medical treatment available (including resuscitation equipment, protocols and appropriately trained personnel) in case of the need to initiate management of serious hypersensitivity reactions, including anaphylaxis. The patient must be closely monitored during the injection and afterwards for any signs and symptoms of a hypersensitivity reaction.
Patients transitioning from IV Actemra therapy to SC administration should administer the first SC dose at the time of the next scheduled IV dose under the supervision of a qualified healthcare professional.
Subcutaneous Actemra is intended for use under the guidance and supervision of the patient's treating physician. After proper training in injection technique, patients or parent/guardian may inject with Actemra only if their treating physician determines that it is appropriate and is satisfied that the patient or parent/guardian can safely inject in the home environment and with medical follow-up as necessary.
Assess suitability of patient or parent/guardian for SC home use and instruct patients or parent/guardian to inform a healthcare professional if they experience symptoms of allergic reaction before administering the next dose. Patients should seek immediate medical attention if developing symptoms of serious allergic reactions (see Section 4.4 Special Warnings and Precautions for Use). Treating healthcare professionals must ensure that the patient or parent/guardian is aware of the signs of hypersensitivity and the risk of anaphylaxis, and is capable of seeking assistance should early features of a serious hypersensitivity reaction occur.
The pre-filled syringe with needle safety device can be used to treat paediatric patients of all approved ages. The pre-filled pen (ACTPen) should not be used to treat children and adolescent patients ˂ 12 years of age.

Rheumatoid arthritis in adults (IV or SC formulation).

Intravenous dosing regimen.

The recommended dose of Actemra for adult patients is 8 mg/kg given once every 4 weeks as an IV infusion.
For individuals whose body weight is more than 100 kg, doses exceeding 800 mg per infusion are not recommended (see Section 5.2 Pharmacokinetic Properties).
Actemra can be used alone or in combination with MTX and/or other nonbiological DMARDs.
Actemra IV formulation should be diluted by a healthcare professional with sterile 0.9% w/v sodium chloride solution using aseptic technique (see Method of administration). The recommended duration of IV infusion is 1 hour.
During IV infusion, and for 30 minutes' post-infusion with Actemra, the patient must be closely monitored at all times for any signs or symptoms of a hypersensitivity reaction. Should any such reaction occur then appropriate urgent responses and treatments are to be initiated. The necessary equipment, treatments and protocols sufficient to initiate the management of acute anaphylaxis are to be in place along with the availability of appropriately trained personnel. There must be continued education and training of the health care professionals who administer the infusions. As part of the informed consent process patients should be made aware of the risk of anaphylaxis and the equipment, treatments and protocols in place to manage this risk.

Subcutaneous dosing regimen.

The recommended dose of Actemra for adult patients is 162 mg given once every week as a subcutaneous injection.
Actemra can be used alone or in combination with MTX and/or other non-biological DMARDs.
At least the first injection must be performed under the supervision of a qualified healthcare professional, in a healthcare facility with the necessary medical treatment available (including resuscitation equipment, protocols and appropriately trained personnel) in case of the need to initiate management of serious hypersensitivity reactions, including anaphylaxis (see Section 4.2 Dose and Method of Administration, Subcutaneous administration for information about requirements for patients who may be suitable for SC home use).

Dose modification recommendations for RA.

See Table 1.

Giant cell arteritis (SC formulation only).

The recommended dose of Actemra for adult patients with GCA is 162 mg given once every week as a subcutaneous injection, in combination with a tapering course of glucocorticoids. A dose of 162 mg given once every other week as a subcutaneous injection, in combination with a tapering course of glucocorticoids, may be prescribed based on clinical considerations.
Actemra can be used alone following discontinuation of glucocorticoids.
Data on use of Actemra beyond 52 weeks is limited. Treatment beyond 52 weeks should be guided by disease activity, physician assessments, patient choice and emerging data.
In the event of patients experiencing a relapse of GCA during the course of Actemra therapy, the treating physician should consider re-introducing and/or escalating the dose of concomitant glucocorticoids (or restarting glucocorticoid therapy if it has been discontinued) according to best medical judgement/treatment guidelines.
Actemra SC formulation is not intended for IV administration.
At least the first injection must be performed under the supervision of a qualified healthcare professional, in a healthcare facility with the necessary medical treatment available (including resuscitation equipment, protocols and appropriately trained personnel) in case of the need to initiate management of serious hypersensitivity reactions, including anaphylaxis. The patient must be closely monitored during the injection and afterwards for any signs and symptoms of a hypersensitivity reaction.
Subcutaneous Actemra is intended for use under the guidance and supervision of the patient's treating physician. After proper training in injection technique, patients may self-inject with Actemra only if their treating physician determines that it is appropriate and is satisfied that the patient can safely self-inject in the home environment and with medical follow-up as necessary.
Assess suitability of patient for SC home use and instruct patients to inform a healthcare professional if they experience symptoms of allergic reaction before administering the next dose. Patients should seek immediate medical attention if developing symptoms of serious allergic reactions (see Section 4.4 Special Warnings and Precautions for Use). Treating healthcare professionals must ensure that the patient is aware of the signs of hypersensitivity and the risk of anaphylaxis, and is capable of seeking assistance should early features of a serious hypersensitivity reaction occur.

Dose modification recommendations for GCA.

See Table 2.

Missed dose (GCA/RA).

If a patient misses a weekly injection of Actemra within 7 days of the scheduled dose, they should be instructed to take the missed dose on the next scheduled day. If a patient misses a fortnightly (i.e. every other week) injection of Actemra within 7 days of the scheduled dose, they should be instructed to take the missed dose immediately and the next dose on the next scheduled day.

Cytokine release syndrome (CRS) (adults and paediatrics).

The recommended dose for treatment of CRS is 8 mg/kg in patients weighing greater than or equal to 30 kg or 12 mg/kg in patients weighing less than 30 kg given as a 60-minute intravenous infusion.
Actemra can be given alone or in combination with corticosteroids.
If no clinical improvement in the signs and symptoms of CRS occurs after the first dose, up to 3 additional doses of Actemra may be administered. The interval between consecutive doses should be at least 8 hours. Doses exceeding 800 mg per infusion are not recommended in CRS patients.
Patients with severe or life-threatening CRS frequently have cytopenias or elevated ALT or AST due to the underlying malignancy, preceding lymphodepleting chemotherapy or the CRS.

Polyarticular juvenile idiopathic arthritis (pJIA) (IV and SC formulations).

A change in dose should only be based on a consistent change in the patient's body weight over time. Actemra can be used alone or in combination with MTX.

Intravenous dosing regimen.

The recommended dose of IV Actemra for patients with pJIA is:
10 mg/kg for patients below 30 kg;
8 mg/kg for patients ≥ 30 kg, given once every four weeks as an IV infusion.
The recommended duration of IV infusion is 1 hour.

Subcutaneous dosing regimen.

The recommended dose of SC Actemra for patients with pJIA is:
162 mg once every three weeks for patients below 30 kg;
162 mg once every two weeks for patients ≥ 30 kg.
The pre-filled syringe with needle safety device can be used to treat paediatric patients of all approved ages. The pre-filled pen (ACTPen) should not be used to treat children and adolescent patients ˂ 12 years of age.
At least the first injection must be performed under the supervision of a qualified healthcare professional, in a healthcare facility with the necessary medical treatment available (including resuscitation equipment, protocols and appropriately trained personnel) in case of the need to initiate management of serious hypersensitivity reactions, including anaphylaxis (see Section 4.2 Dose and Method of Administration, Subcutaneous administration for information about requirements for patients who may be suitable for SC home use).

Missed dose (pJIA).

If a pJIA patient misses a subcutaneous injection of Actemra within 7 days of the scheduled dose, they should inject the missed dose as soon as they remember and give the next dose at the regular scheduled time. If a patient misses a subcutaneous injection of Actemra by more than 7 days of the scheduled dose or is unsure when to inject the next dose, they should contact their Healthcare professional.

Systemic juvenile idiopathic arthritis (sJIA) (IV and SC formulations).

A change in dose should only be based on a consistent change in the patient's body weight over time. Actemra can be used alone or in combination with MTX.

Intravenous dosing regimen.

The recommended dose of IV Actemra for patients with sJIA is:
12 mg/kg for patients below 30 kg, 8 mg/kg for patients ≥ 30 kg, given once every two weeks as an IV infusion.
The recommended duration of IV infusion is 1 hour.

Subcutaneous dosing regimen.

The recommended dose of SC Actemra for patients with sJIA is:
162 mg once every two weeks for patients below 30 kg, 162 mg once every week for patients ≥ 30 kg.
Patients must have a minimum body weight of 10 kg when receiving Actemra subcutaneously. The pre-filled syringe with needle safety device can be used to treat paediatric patients of all approved ages. The pre-filled pen (ACTPen) should not be used to treat children and adolescent patients ˂ 12 years of age.

Missed dose (sJIA).

If a patient misses a weekly injection of Actemra within 7 days of the scheduled dose, they should be instructed to take the missed dose on the next scheduled day. If a patient misses a fortnightly (i.e. every other week) injection of Actemra within 7 days of the scheduled dose, they should be instructed to take the missed dose immediately and the next dose on the next scheduled day.

Dose modification recommendations for pJIA and sJIA.

Dose reduction of Actemra has not been studied in the pJIA or sJIA population. Dose interruptions of Actemra for laboratory abnormalities are recommended in patients with pJIA or sJIA at levels similar to what is outlined above for patients with RA (see Section 4.4 Special Warnings and Precautions for Use). If appropriate, concomitant MTX and/or other medications should be dose modified or stopped and Actemra dosing interrupted until the clinical situation has been evaluated. In pJIA or sJIA the decision to discontinue Actemra for a laboratory abnormality should be based upon the medical assessment of the individual patient.

Special populations.

Children.

The safety and efficacy of Actemra in children below 18 years of age with conditions other than pJIA, sJIA or CRS have not been established. The safety and efficacy in patients aged less than 2 years with pJIA and CRS have not been established. The safety and efficacy in patients aged less than 2 years with IV Actemra in sJIA or less than 1 year with SC Actemra in sJIA have not been established. Actemra subcutaneous formulation is not intended to be given to children with sJIA weighing less than 10 kg.

Elderly.

No dose adjustment is required in elderly patients aged 65 years and older.

Renal impairment.

No dose adjustment is required in patients with mild to moderate renal impairment (see Section 5.2 Pharmacokinetic Properties). Actemra has not been studied in patients with severe renal impairment.

Hepatic impairment.

The safety and efficacy of Actemra has not been studied in patients with hepatic impairment (see Section 4.4 Special Warnings and Precautions for Use) and therefore no dose recommendations can be made.

Method of administration.

Concentrated solution for intravenous infusion.

Parenteral medications should be inspected visually for particulate matter or discolouration prior to administration.
Only solutions which are clear to opalescent, colourless to pale yellow and free of visible particles must be infused.

Rheumatoid arthritis and CRS patients (≥ 30 kg).

From a 100 mL infusion bag, withdraw a volume of 0.9% sodium chloride solution equal to the volume of the Actemra solution required for the patient's dose, and discard. Withdraw the required amount of Actemra (0.4 mL per kg of the patient's body weight) under aseptic conditions and add to the infusion bag. To mix the solution, gently invert the bag to avoid foaming.

Use in paediatric patients.

pJIA, sJIA and CRS patients ≥ 30 kg.

From a 100 mL infusion bag, withdraw a volume of 0.9% sodium chloride solution equal to the volume of the Actemra solution required for the patient's dose. Withdraw the required amount of Actemra (0.4 mL per kg of the patient's body weight) under aseptic conditions and dilute in a 100 mL infusion bag containing sterile, non-pyrogenic 0.9% sodium chloride solution. To mix the solution, gently invert the bag to avoid foaming.

pJIA patients below 30 kg.

From a 50 mL infusion bag, withdraw a volume of 0.9% sodium chloride solution equal to 0.5 mL/kg of the patient's body weight and discard. This volume should be replaced in the saline bag with an equal volume of Actemra under aseptic conditions. To mix the solution, gently invert the bag to avoid foaming.

sJIA and CRS patients below 30 kg.

From a 50 mL infusion bag, withdraw a volume of 0.9% sodium chloride solution equal to 0.6 mL/kg of the patient's body weight and discard. This volume should be replaced in the saline bag with an equal volume of Actemra under aseptic conditions. To mix the solution, gently invert the bag to avoid foaming.

Solution for subcutaneous injection.

Actemra SC formulation is administered with a single-use pre-filled syringe or pen. The pre-filled pen (ACTPen) should not be used to treat children and adolescent patients ˂ 12 years of age since there is a potential risk of intramuscular injection due to a thinner subcutaneous tissue layer.
The recommended injection sites (abdomen, thigh and upper arm) should be rotated and injections should never be given into moles, scars, or areas where the skin is tender, bruised, red, hard, or not intact. Administration in the thigh may result in slightly increased absorption compared to the other recommended injection sites but this is not considered clinically relevant.
Do not use if the medicine is cloudy or contains particles, is any colour besides colourless to slightly yellowish, or any part of the pre-filled syringe appears to be damaged.
Actemra should not be shaken.
After removing the pre-filled syringe from the refrigerator, it should be allowed to reach room temperature by waiting for 25 to 30 minutes, before injecting. After removing the cap the injection should be started within 5 minutes.
After removing the pre-filled pen from the refrigerator, it should be allowed to reach room temperature by waiting 45 minutes, before injecting. After removing the cap the injection should be started within 3 minutes.

4.7 Effects on Ability to Drive and Use Machines

No studies on the effects on the ability to drive and use machines have been performed and there is no evidence from the available data that Actemra treatment affects the ability to drive and use machines. However, given that dizziness has been reported, patients who experience this adverse reaction should be advised not to drive or use machines until it has resolved.

4.9 Overdose

There are limited data available on overdose with Actemra. One case of accidental overdose was reported in which a patient with multiple myeloma received a single dose of 40 mg/kg IV. No adverse drug reactions were observed. No serious adverse drug reactions were observed in healthy volunteers who received a single dose up to 28 mg/kg IV, although dose-limiting neutropenia was observed.
Treatment of overdose should consist of general supportive measures.
For information on the management of overdose, contact the Poisons Information Centre on 131126 (Australia).

7 Medicine Schedule (Poisons Standard)

S4.

6 Pharmaceutical Particulars

6.1 List of Excipients

Concentrated solution for intravenous infusion.

Polysorbate 80, sucrose, dibasic sodium phosphate dodecahydrate, monobasic sodium phosphate dihydrate, water for injections.

Solution for subcutaneous injection.

Histidine, histidine hydrochloride, polysorbate 80, arginine, arginine hydrochloride, methionine, water for injections.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.
The medicine should not be used after the expiry date (EXP) shown on the vial or vial carton or the pre-filled syringe or the pre-filled pen and the carton.

6.4 Special Precautions for Storage

Concentrated solution for intravenous infusion.

Store vials at 2°C to 8°C. (Refrigerate. Do not freeze.)
Keep the container in the outer carton in order to protect from light.
Actemra does not contain any antimicrobial agent; therefore, care must be taken to ensure the sterility of the prepared solution. Product is for single use in one patient only. Discard any residue.
The prepared infusion solution of Actemra is physically and chemically stable in 0.9% w/v sodium chloride solution at 30°C for 24 hours. To reduce microbiological hazard, the prepared infusion should be used immediately. If storage is necessary, hold at 2°C to 8°C for not more than 24 hours.

Solution for subcutaneous injection.

Store the pre-filled syringe or pen at 2°C to 8°C. (Refrigerate. Do not freeze.) Keep in carton to protect from light and keep dry.
Once removed from the refrigerator, Actemra must be administered within 8 hours and should not be kept above 30°C.
Actemra does not contain any antimicrobial agent. Product is for single use in one patient only. Discard any residue.

6.5 Nature and Contents of Container

Concentrated solution for intravenous infusion.

Actemra is supplied in preservative-free, non-pyrogenic single-use, clear glass vials.
Single use vial containing 80 mg of Actemra in 4 mL (20 mg/mL). Packs of 1 and 4 vials.
Single use vial containing 200 mg of Actemra in 10 mL (20 mg/mL). Packs of 1 and 4 vials.
Single use vial containing 400 mg of Actemra in 20 mL (20 mg/mL). Packs of 1 and 4 vials.

Solution for subcutaneous injection.

Actemra is supplied as a preservative-free, non-pyrogenic solution presented in a ready-to-use, single-use pre-filled syringe and pre-filled pen (ACTPen) with needle safety device.
Single-use pre-filled syringe with needle safety device. Each syringe contains 162 mg of Actemra in 0.9 mL. Packs of 1 and 4 syringes.
Single-use pre-filled pen (ACTPen) with needle safety device. Each pen contains 162 mg of Actemra in 0.9 mL. Available in packs of 1 and 4 pens.
Some pack sizes are not marketed.

6.6 Special Precautions for Disposal

The release of medicines into the environment should be minimised. Medicines should not be disposed of via wastewater and disposal through household waste should be avoided. Unused or expired medicine should be returned to a pharmacy for disposal.

Disposal of syringes/pens/sharps.

The following points should be strictly adhered to regarding the use and disposal of the pre-filled syringe and pre-filled pen:
Syringes and pens should never be reused.
Place all used syringes and pens into a sharps container (puncture-proof disposable container).
Keep this container out of the reach of children.
Placing used sharps containers in the household waste should be avoided.
Dispose of the full container according to local requirements or as instructed by your healthcare provider.
For home use, patients should procure a puncture resistant container for the disposal of used syringes and pens.

Summary Table of Changes