Immunosuppressant biologic treatment in rheumatology

• Varies according to individual drug
• Most are self-administered subcutaneously, but some can be used IV or SC
• Rituximab and Belimumab are IV
• Infliximab IV or subcutaneous.
• JAK inhibitors (jakinibs) are oral

• Pneumococcal and annual flu vaccination is recommended prior to treatment
• Passive immunization with VZIG is recommended if newly exposed to chicken pox
• No live vaccines can be given, including Herpes Zoster vaccination

• If the patient is receiving standard DMARDs continue usual monitoring for that drug.
• If on biologics alone - FBC, ESR and U+E, LFTs monthly for 3 months, then 6 monthly unless advised differently by rheumatology, 
• Exceptions are Tocilizumab and Sarilumab and also the JAK inhibitors (Upadacitinib, Baracitinib, Tofacitinib, Filgotinib)- also require Lipids at 3 months. 

Stop treatment if:

• Evidence of active infection or during antibiotic therapy (then restart unless the infection was serious/life threatening)
• Significant open wounds
• Planned or current Pregnancy, pruritis/rash or symptoms of significant allergy
• Suspected demyelination
• Tocilizumab and Sarilumab - stop if new abdominal symptoms (diverticulitis risk)
• Rituximab/Belimumab - stop if new cognitive/psychiatric/neurological symptoms - exceptionally rarely PML
• WCC -<3.5 - withhold and discuss with rheumatology
• Neutrophils <1.5
• Platelets <140
• AST or ALT >3 times upper limit normal

• Treatment is continued indefinitely as long as it remains effective and without side effects
• Biologics vary in their time to response – but they are generally stopped after 3 months if no benefit
• During this period there are likely to be continued symptoms or signs of disease activity
• It is reasonable to use IM Depomedrone 80mg or Triamcinolone (Kenalog) 80mg

• Unfortunately Biologic drugs will not prevent all flares
• Manage fares with IM Depot steroid as outlined under 'duration of treatment and time to response'
• If increasing frequency of flares, contact the rheumatologist

• Pregnancy (though early data reassuring - especially for Certolizumab Pegol)
• Breastfeeding (can breastfeed on Adalimumab and Certolizumab Pegol). Note: B_Live vaccines to infant contraindicated for 5 months in general after mother stops biologic agent (including Rotavirus vaccine)
• Active infection
• Open leg ulcers
• previously infected prosthetic joint (unless completely removed)
• Septic arthritis in the last year
• HIV or Hepatitis B carriers (usually)
• Previous malignancy within last 5 years (usually)
• NYHA grade 3 heart failure
• Demyelinating disease

Relative contraindications

• Uncontrolled diabetes
• Pulmonary fibrosis
• Bronchiectasis
• PUVA >1000 Joules
• NYHA grade 1/2
• previous TB or positive PPD test

Secretaries 01387 241776

Rheumatology Nurse Specialists Helpline 01387 241095 or dg.rheum-adviceline@nhs.scot 

Department of Rheumatology doctors via Switchboard if urgent or RMS Advice request