Analysis of data from a German registry of patients with rheumatoid arthritis (RA; n = 13,310) identifies tocilizumab use as a risk factor associated with lower intestinal perforation (LIP), which has been reported as a rare but serious complication in clinical trials of this drug. The incidence of LIP was significantly higher in patients receiving toclilizumab (2.7 events per 1,000 person-years) than in those receiving conventional or biologic DMARDs (0.2–0.6 events per 1,000 person-years). Some patients with tocilizumab-induced LIP displayed only minor symptoms and most did not show elevation of C-reactive protein levels. Notably, the 30-day mortality rate among patients with LIP was 46%, emphasizing the importance of closely monitoring patients receiving tocilizumab for gastrointestinal events.