Biologic medications

Tumor necrosis factor alpha (TNF-alpha) is a protein that primarily causes inflammation in rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and several other diseases. Etanercept (Enbrel®), Infliximab (Remicade®) and Adalimumab (Humira®) are medications that bind to the joints and help eliminate high levels of TNF.

Enbrel is given at a dose of 50 mg once a week. Common injection sites are the thigh and abdomen. An area of skin is pinched, quickly entered at a 45-degree angle, then injected. There generally is minimal discomfort. Our nurses also are skilled at this technique and can teach you the proper way to inject.

For more information, visit enebrel.com.

Remicade is taken intravenously, often at an infusion center. The medication dose usually is started at three to five mg/kg. For example, if you weigh 160 pounds (72 kg), the starting dose of Remicade would be 216 mg. Often, the dose is rounded to the nearest 10 mg increment. Traditionally, Remicade is given with infusions at zero, two and six weeks, then every eight weeks. Sometimes the dose needs to be increased or the interval between infusions shortened to obtain maximum benefit. Remicade is an antibody. In the manufacturing process, a small amount of mouse protein is inserted into the antibody. As a result, some people develop antibodies against Remicade, which can interfere with the drug’s action. Most doctors will prescribe methotrexate, or other drugs with Remicade, to prevent these antibodies from forming.

For more information, visit remicade.com.

Humira is given subcutaneously at a dose of 40 mg every two weeks, and can be increased to every week. The vials are 40 mg/0.8 mL. One box contains two vials (a one-month supply). Humira is a humanized antibody and side effects, such as infusion reactions in some Remicade users, are not seen. Humira is injected similarly to Enbrel, and our nurses can provide instruction.

For more information, visit humira.com.

Injection, infusion reactions. Enbrel and Humira are given subcutaneously. Sometimes, a red area of skin will occur at the injection site several days later, with mild discomfort. Normally, these are managed with topical hydrocortisone cream and do not necessitate stopping the medicine. If the red area continues to expand, notify your doctor. Remicade is given by infusion, which produces reactions including hives, elevated blood pressure or lowered blood pressure. Reactions can be treated in a variety of ways, including premedication with Tylenol®, Benadryl® or Solu-medrol®; slowing down the infusion; or giving intravenous fluids. Serious infusion reactions are rare.

Infections. With all TNF blockers, an increased risk of upper respiratory infections (colds, bronchitis) exists. More serious infections, including tuberculosis and certain fungal and bacterial infections, also can occur. If you become ill with fever, seek evaluation by your primary doctor, urgent care or an emergency room. During any infection beyond a simple cold or bladder infection, temporarily stop TNF blockers.

Tuberculosis (TB). If TB occurs, it usually happens in patients with previous exposure. For this reason, all patients should have a PPD (tuberculin) skin test before starting treatment with a TNF blocker. Some rheumatologists also will check a chest X-ray to look for evidence of previous lung infections. If the skin test is positive (more than 5 mm to 10 mm, depending on your conditions), then treatment with a drug for TB would be required before starting a TNF blocker.

Malignancy. Rheumatoid arthritis patients have a slightly increased risk of developing lymphoma, a blood cell cancer. There is a theoretical concern that TNF blockers may increase this risk of lymphoma. So far, there has been no observed increased rates of cancer in patients treated with TNF blockers.

Multiple sclerosis-like syndromes. Very rarely, patients on TNF blockers develop multiple sclerosis or other nerve problems.

Congestive heart failure. TNF blockers usually are avoided in patients who have had heart failure, but they do not cause heart failure in otherwise healthy patients with normal heart function.

Lupus-like syndromes. Very rarely, a patient may develop a lupus-like illness that includes rash, joint pain and pleurisy (fluid around the lung). Symptoms usually resolve after stopping the drug.

Blood problems. Rare cases of low white blood cell counts and low platelet counts have been reported with using TNF blockers. If your blood tests are not being monitored for methotrexate or other medications, it may be reasonable to check the blood count once or twice a year while on TNF blockers.

TNF blockers can start working within a few days to a few weeks, but usually several months pass before one can determine maximum benefit. About 75 percent of patients have good to excellent responses to TNF blockers. Besides reducing pain, swelling and stiffness, they can halt or slow down joint damage.

Monitoring blood tests for methotrexate and other drugs are sufficient to monitor for blood problems from TNF blockers. If you are on a TNF blocker and no other medication, then a blood count may be performed once or twice a year.

Our nurses can provide instruction on how to perform self-injections of Enbrel and Humira. TNF blockers are very expensive, ranging from about $12,000 to $40,000 a year. Therefore, it is extremely important that you be approved by your insurance before beginning therapy and that you understand what your copayment will be. Our nurses also help process the necessary paperwork.

Currently, Medicare helps pay for medications that are infused (Remicade), but not those that are injected. The company that produces Humira also has a program to help Medicare patients obtain it. If you are on Medicare, Remicade or Humira often will be the cheapest options. And remember, Medicare may change its policies at any time.

Deciding which TNF blocker to use depends on several factors, including the desired mode of administration (injection or IV), personal cost and frequency of administration (twice a week, weekly, every two weeks, and every one month to two months). One advantage to more frequent injections (Enbrel) is that if you develop an infection, the medication is out of your system faster.