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

Click here for medical student OSCE and PACES questions about Biologics in rheumatology

Common Biologics in rheumatology exam questions for medical students, finals, OSCEs and MRCP PACES

Click here to download free teaching notes on biologics in rheumatology: Biologics in rheumatology

Perfect revision for medical students, finals, OSCEs and MRCP PACES