Biologics in rheumatology

 

What are biologics

• Biologics are any medication synthesised or derived from biological sources
• In rheumatology, biologics are a subtype of disease-modifying antirheumatological drug (DMARD)
• They interfere with autoimmune processes by any of these:
  • Interfering with cytokine function
  • Inhibiting the second signal required for cytokine function
  • Depleting B-cells
• They are usually given once other DMARDS have been shown to be insufficient and require close monitoring

 

Examples of biologics (with how often they are given and brand names)

• Anti-TNF
  • Infliximab (IV 6-8/52, ‘Remicade’)
  • Etanercept (SC 1/52, ‘Enbrel’)
  • Adalimumab (SC 2/52, ‘Humira’)
  • Golimumab (SC 1/12, ‘Simponi’)
  • Certolizumab (SC 2/52, ‘Cimzia’)
• Anti B cell
  • Rituximab (IV 6-12/12, ‘Rituxan, MabThera’)
  • Belimumab (IV 1/12, ‘Benlysta’)
• Anti- IL-1
  • Anakinra (SC OD, ‘Kineret’)
• Anti-IL6
  • Tocilizumab (IV 1/12, ‘Actemra’)
• Anti-CTLA4
  • Abatacept (SC 1/12, ‘Orencia’)

 

How to start biologics

• Pre-treatment requirements
  • Screen for TB (CXR, Elispot)
  • Check Hep B, Hep C, HIV, VZV if history of chickenpox uncertain
  • Flu & pneumococcal vaccination
  • Consider varicella vaccine in those with negative VZV
  • Check immunoglobulins for rituximab

 

Risks and cautions with biologics

• Contraindications to biologic therapy
  • Presence of serious active infection
  • Hep B/C & HIV relative contra-indications
  • Anti-TNF not recommended in malignancy
  • Anti-TNF not recommended in multiple sclerosis
  • NYHA stage III or IV heart failure
• Side effects and risks with biologics
  • Infection
  • Malignancy
    • Skin cancer, lymphoma
  • Lupus
    • With anti-TNF, rare, mostly commonly manifests as rash
  • Demyelinating disease
  • Psoriasis may develop with anti-TNF
• Biologics in pregnancy
  • There is increasing use of biologics in pregnancy
  • Uncertainty about increased infection risk in early neonatal life
• Biologics and surgery
  • May need stopping e.g. two weeks prior to surgery but risks of flare must be weighed up

 

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