Monitoring of lipids in patients on tocilizumab
Dr Katarzyna Nowak, Dr James Burns, Debbie Collins, Dr Claire Masih, Dr Gary Meenagh, Dr Esme Whitehead
Department of Rheumatology, Antrim Area Hospital, Northern Ireland
Tocilizumab is a humanised monoclonal antibody that inhibits cytokine interleukin-6. It is licensed in treatment of rheumatoid arthritis. The British Society for Rheumatology recommends lipid monitoring in patients receiving tocilizumab1– fasting lipids should be done at baseline and at 3 months into treatment. Cholesterol lowering treatment should be instituted based on the results.
Tocilizumab can potentially cause significant hypercholesterolaemia. Our aim is to look at lipid monitoring in patients on tocilizumab and the institution of treatment where necessary.
We obtained a list of patients who were currently on tocilizumab from rheumatology nurse specialist in Antrim. Thirty-five patients were identified with one excluded from analysis due to missing data. A retrospective data collection from medical charts was performed. Data were analysed using Microsoft Excel.
The patient cohort included 24 females and 10 males with an average age of 57 years.
Fasting lipids were checked at baseline in 85% of patients and 59% of those patients had high cholesterol levels. Lipids were then re-checked at 2-3 months into therapy in 91% of patients and 74% had high cholesterol identified.
In summary, a total of 21 patients had high cholesterol levels (either on initial or repeat check or both) and were not on cholesterol-lowering therapy prior to tocilizumab treatment. Only 10 of those patients were commenced on statin.
Poor compliance with guidelines on lipid management was revealed and as a result the biologic review document has been modified in order to highlight the importance of lipid check. (Image 1)
During a re-audit we looked at 6 patients newly commenced on tocilizumab over 5-month period. 100% had baseline lipids checked; however only 50% had them repeated at 2-3 months. 3 patients were identified to have high cholesterol but only 1 had been commenced on statin.
The number of patients having their baseline cholesterol checked increased from 85% to 100%. However, still not all patients are having their lipids checked at 2-3 months and even if they are checked not all results are acted upon. Furthermore, in many charts there was still the ‘old’ biologic pathway used which lacks the reminder to check lipids in patients on tocilizumab. Potential reasons for the lack of improvement include shortage of staff amongst nurse specialist team and inadequate dissemination of results amongst the consultant medical team due to junior staff changeover. Therefore further recommendations are to replace the ‘old’ biologic pathway with the ‘new’ version and formally present these results at a fully attended audit meeting. Re-audit is planned in the future.
1. Malaviya AP., Ledingham J. et al. “The 2013 BSR and BHPR guideline for the use of intravenous tocilizumab in the treatment of adult patients with rheumatoid arthritis”. Rheumatology 2014; 53:1344-1346