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Friday, 20 October 2017

Rheumatology Medications

A number of types of drugs are used to treat arthritis and connective tissue disease. These generally fall into the following groups:

Rheumatology Medications FAQs

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Biologic therapy

In recent years new drug treatments known as 'biologics' have been developed for people with rheumatoid arthritis, psoriatic arthritis and some other conditions. These have proved effective in controlling symptoms and preventing further joint damage in people with more active disease which is not adequately controlled by more conventional disease-modifying treatment (DMARDs). These drugs include 'anti-TNF drugs such as infliximab (Remicade), etanercept (Enbrel) and adalimumab (Humira) and B-cell inhibitors such as rituximab (MabThera). In people with rheumatoid arthritis (and some other inflammatory joint diseases) the body produces excessive amounts of a protein called TNF, This is present in the blood and the joints where it increases inflammation. Anti-TNF drugs block the action of TNF, thus reducing inflammation and relieving symptoms of pain and swelling.

Anti-TNF drugs are extremely costly and will only be prescribed if you have active arthritis and have already tried, but failed to tolerate or respond to methotrexate and at least one other DMARD. These drugs can only be prescribed by a consultant rheumatologist and strict criteria must be fulfilled in order to qualify for treatment. Biologics are not suitable for women who are pregnant or breastfeeding or people with chronic or acute infection. Anti-TNF treatment is not usually appropriate if you have multiple sclerosis (MS) or have previously had tuberculosis (TB), cancer (with the exception of some skin cancers), blood disorders or other recurrent infections

Baseline blood tests and a chest X-ray will be required before starting biologic therapy, and further blood tests monitored regularly whilst you remain on the treatment to check for side effects and ensure the treatment is working. You will also be reviewed by one of the rheumatology team approximately every three months in order to formally assess your disease activity. At each appointment your joints will be examined for pain and swelling and your blood tests reviewed.

Infliximab, Etanercept and Adalimumab
Infliximab (trade name Remicade) can be prescribed for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and Crohn's disease (a bowel condition). Etanercept (trade name Enbrel) can be prescribed for rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis (JIA) and ankylosing spondylitis. Adalimumab can be prescribed for rheumatoid arthritis, psoriatic arthritis and some other types of arthritis.

Infliximab is given by intravenous infusion (drip) into a vein in your hand or arm and is administered by staff in our Day Unit. The dose is calculated according to your weight and infusions are usually repeated at two weeks, six weeks and every eight weeks thereafter.

Etanercept is given by subcutaneous (under the skin) injection once or twice weekly; Adalimumab is given once weekly or once a fortnight. You may be able to do this yourself after instruction, or your partner or another family member or friend can be taught how to give you the injections. If this is not possible your practice nurse or district nurse can usually give the injections, or you can come to the monitoring clinic here in the rheumatology department.

Those who respond to these drugs usually begin to feel better in 2-12 weeks.

As with all drugs, infliximab, etanercept and adalimumab can cause side effects. The most common side effects are a blocked or runny nose, headache, dizziness, flushing, rash, abdominal pain or indigestion. They may cause a decrease in certain types of blood cells which are important to fight infection and control bleeding. It is therefore very important that you inform the rheumatology department immediately if you develop a fever, sore throat or other infection, or if you suddenly bruise or bleed easily or become very pale. With Etanercept and Adalimumab you may also have inflammation around the site of the injection, which should be reported if it is severe. All these drugs can cause an allergic reaction, in which case they will have to be stopped. Very occasionally infliximab can cause a condition known as 'drug-induced lupus'. This is usually mild but may cause symptoms such as a rash, fever and increased joint pain, which usually disappear upon stopping treatment. A blood test can check for this, if suspected. The long-term side effects of these drugs are as yet unknown since they are relatively new drugs.

The effects of these drugs on an unborn child are unknown so women of child-bearing age must use contraception whilst on biologic therapy. You should not receive infliximab, etanercept or adalimumab if you are pregnant, planning a pregnancy or if you are not using reliable contraception. Both men and women should wait for at least 6 months after their last dose of biologic therapy before trying for a baby. You should not breast feed whilst on biologic therapy as the drug could pass into your breast milk and harm your baby.

'Live' vaccinations such as polio, rubella (German measles) and yellow fever should be avoided whilst on biologic therapy. An inactivated polio vaccine may be given instead if indicated; this should also be used for household members and other close contacts. You should avoid close contact with children or other who have received the 'live' polio vaccine for 4-6 weeks after vaccination. Annual flu and pneumonia vaccines are both safe and recommended.

Further information about infliximab is available from the Arthritis Research Campaign.

Further information about etanercept is available from the Arthritis Research Campaign.

Further information about adalimumab is available from the Arthritis Research Campaign.

Rituximab
Rituximab (trade name MabThera) is a new type of drug which works in a different way to the anti-TNF drugs, by removing certain types of cells from the blood called B-cells. These B-cells produce antibodies, a type of protein which fights off germs, viruses or other substances that the body considers 'foreign' or potentially dangerous. In people with rheumatoid arthritis some B-cells produce harmful 'auto antibodies' such as rheumatoid factors. Rituximab removes these B-cells, as well as some B-cells which make useful antibodies, but these return after some months. Rituxumab can be prescribed for people with rheumatoid arthritis and some other autoimmune diseases such as lupus.

Rituximab is given by intravenous infusion or a 'drip' into a vein in your hand or arm and is administered by a staff nurse in our day unit. Two doses are given, a fortnight apart, and you will require blood tests at intervals thereafter to check the level of B-cells in your blood.

Further information about rituximab is available from the Arthritis Research Campaign.

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