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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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