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Biologic agents

  • Biologic agents differ in their effectiveness for controlling specific rheumatic diseases depending on which cytokine is driving the patient’s inflammation.

  • Tumor necrosis factor inhibitors are more effective when combined with methotrexate.

  • Interleukin-1 inhibitors are most effective for Still’s disease and the cryopyrinopathies.

  • Risk of hepatitis B reactivation and mycobacterial infections are increased in patients on biologics.

  • Live vaccines should not be given to patients on biologic agents.

Nomenclature

-cept: receptor drug which prevents a ligand from binding to its receptor (e.g., etanercept, abatacept, rilonacept)

-ximab: chimeric monoclonal antibody (e.g., infliximab, rituximab).

-omab: murine antibody (e.g., Tositumomab)

-zumab: humanized monoclonal antibody (e.g., certilizumab, tocilizumab, eculizumab).

-mumab: fully human monoclonal antibody (e.g., adalimumab, golimumab, belimumab, ustekinumab).

-ra: receptor antagonist (e.g., anakinra).

-tinib: inhibitor (e.g., tofacitinib).

Precautions that should be done before starting any biologic agents:

--> Establish and record disease activity.

--> Screen for comorbidities: infection risk, HIV risk factors, hepatitis B/C risk factors, history of malignancy (lymphoma, melanoma, others), history of demyelinating disease, history of tuberculosis (TB), history of fungal exposure, hyperlipidemia, liver disease, pregnancy, medications.

--> Vaccination status: patients should receive inactivated influenza vaccine (seasonal) and age-appropriate pneumococcal, meningococcal, and Haemophilus influenzae B (Hib). Give herpes zoster vaccine (live) at least 2 to 4 weeks before biologic use.

--> Tests before use: complete blood count (CBC), creatinine, hepatic enzymes, lipids, C-reactive protein, hepatitis B and hepatitis C serologies, purified protein derivative (PPD) (or interferon gamma release assay), chest X-ray, HIV (if risk factors).


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