TNF Inhibitors

Administration: Subcutaneous injection

Dose: 40mg subcutaneously once fortnightly

Time to response: 2 weeks to 3 months

Indications:

• Rheumatoid Arthritis.
• Psoriatic Arthritis.
• Ankylosing Spondylitis.
• Non-Radiographic Spondyloarthropathies.
• Juvenile Idiopathic Arthritis.

Contraindications:

• Pregnancy & breast feeding.
• Active infection.
• Active/untreated latent TB.
• Septic arthritis in last 12 months.
• Clear history of demyelinating disease.
• Malignancy excluding basal cell carcinoma and that diagnosed and treated more than 10yrs previously.

Cautions:

• Previous HBV or HCV.
• Pulmonary fibrosis.
• NYHA class III/IV heart failure.
• Patients who have received previous PUVA or UVB therapy should be discussed with dermatology.

Monitoring:

• FBC, U&E, LFT every 3-6 months

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Injection site reaction – usually settles without further intervention.
• Sore throat/fever/bruising/pallor – stop ADALIMUMAB and check FBC.
• Serious infection – stop ADALIMUMAB and restart once infection resolved.
• Surgery – stop 1 week prior to surgery and resume after wound healing.
• SLE syndrome – stop ADALIMUMAB and contact rheumatology.
• Increasing dyspnoea – stop ADALIMUMAB and arrange CXR.

Stop ADALIMUMAB if:

• WBC < 3.5 x10⁹/L
• ALT/AST > two times normal
• Neutrophils < 2.0 x 10⁹/l
• Platelets < 150 x 10⁹/l

Administration: Subcutaneous injection

Dose: 400mg at weeks 0,2 & 4 and 200mg once fortnightly as a maintenance dose

Time to response: 2 weeks to 3 months

Indications:

• Rheumatoid Arthritis.
• Psoriatic Arthritis.
• Ankylosing Spondylitis.
• Non-Radiographic Spondyloarthropathies.

Contraindications:

• Active infection.
• Active/untreated latent TB.
• Septic arthritis in last 12 months.
• Clear history of demyelinating disease.
• Malignancy excluding basal cell carcinoma and that diagnosed and treated more than 10yrs previously.

Cautions:

• Previous HBV or HCV.
• Pulmonary fibrosis.
• NYHA class III/IV heart failure.
• Patients who have received previous PUVA or UVB therapy should be discussed with dermatology.

Monitoring:

• FBC, U&E, LFT every 3-6 months

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars- Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Injection site reaction – usually settles without further intervention.
• Sore throat/fever/bruising pallor – stop CERTOLIZUMAB and check FBC.
• Serious infection – stop CERTOLIZUMAB and restart once infection resolved.
• Surgery – stop 1 week prior to surgery and resume after wound healing.
• SLE syndrome – stop CERTOLIZUMAB and contact rheumatology.
• Increasing dyspnoea – stop CERTOLIZUMAB and arrange CXR.
• Pregnancy – the drug can be continued throughout pregnancy.

Stop CERTOLIZUMAB if:

• WBC < 3.5 x10⁹/L
• ALT/AST > two times normal
• Neutrophils < 2.0 x 10⁹/l
• Platelets < 150 x 10⁹/l

Administration: Subcutaneous injection

Dose: 50mg once weekly

Time to response: 2 weeks to 3 months

Indications:

• Rheumatoid Arthritis.
• Psoriatic Arthritis.
• Ankylosing Spondylitis.
• Non-Radiographic Spondyloarthropathies.
• Juvenile Idiopathic Arthritis.

Contraindications:

• Active infection.
• Active/untreated latent TB.
• Septic arthritis in last 12 months.
• Clear history of demyelinating disease.
• Malignancy excluding basal cell carcinoma and that diagnosed and treated more than 10yrs previously.

Cautions:

• Previous HBV or HCV.
• Pulmonary fibrosis.
• NYHA class III/IV heart failure.
• Patients who have received previous PUVA or UVB therapy should be discussed with dermatology.

Monitoring:

• FBC, U&E, LFTs every 3-6 months

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Injection site reaction – usually settles without further intervention.
• Sore throat/fever/bruising/pallor – stop drug and check FBC.
• Serious infection – stop ETANERCEPT and restart once infection resolved.
• Surgery – stop 1 week prior to surgery and resume after wound healing.
• SLE syndrome – stop drug and contact rheumatology.
• Increasing dyspnoea – stop drug and arrange CXR.
• Pregnancy – can be used during first 6 months.
• Breastfeeding – there is no evidence that it is harmful.

Stop ETANERCEPT if:

• WBC < 3.5 x10⁹/L
• ALT/AST > two times normal
• Neutrophils < 2.0 x 10⁹/l
• Platelets <150 x 10⁹

Administration: Subcutaneous injection

Dose: 50mg subcutaneously once monthly

Time to response: 2 weeks to 3 months

Indications:

• Rheumatoid Arthritis.
• Psoriatic Arthritis.
• Ankylosing Spondylitis.
• Non-Radiographic Spondyloarthropathies.

Contraindications:

• Active infection.
• Active/untreated latent TB.
• Septic arthritis in last 12 months.
• Clear history of demyelinating disease.
• Malignancy excluding basal cell carcinoma and that diagnosed and treated more than 10yrs previously.

Monitoring:

• FBC, U&E, LFTs every 3-6 months

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Injection site reaction – usually settles without further intervention.
• Sore throat/fever/bruising/pallor – stop GOLIMUMAB and check FBC.
• Serious infection – stop drug and restart once infection resolved.
• Surgery – stop 1 week prior to surgery and resume after wound healing.
• SLE syndrome – stop drug and contact rheumatology.
• Increasing dyspnoea – stop drug and arrange CXR.
• Pregnancy – can be taken during first 3 months.
• Breastfeeding – can be used with caution.

Stop GOLIMUMAB if:

• WBC < 3.5 x10⁹/L
• ALT/AST > two times normal
• Neutrophils < 2.0 x 10⁹/l
• Platelets <150 x 10⁹/l

Administration: Intravenous infusion

Dose:

• Usually 3mg/kg given at weeks 0,2 & 6 and then once every 8 weeks.
• In selected cases 5mg/kg may be given.

Time to response: 2 weeks to 3 months

Indications:

• Rheumatoid Arthritis.
• Psoriatic Arthritis.
• Ankylosing Spondylitis.
• Non-Radiographic Spondyloarthropathies.

Contraindications:

• Active infection.
• Active/untreated latent TB.
• Septic arthritis in last 12 months.
• NYHA class III/IV heart failure.
• Clear history of demyelinating disease.
• Malignancy excluding basal cell carcinoma and that diagnosed and treated more than 10yrs previously.

Cautions:

• Previous HBV or HCV.
• Pulmonary fibrosis.

Monitoring: Will be performed on the medical day bed unit prior to infusion.

Vaccinations:

• Avoid live attenuated vaccines.
• Offer annual influenza vaccination.
• In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing biologic treatment.
• Assuming no contraindications before starting treatment:
  • Patients >50 should undergo vaccination against HZV.
  • Those who are varicella zoster negative should be offered varicella vaccination.

In the event of:

• Infusion reaction – affects 10% of patients usually consisting of nausea, headache or rash. This will be managed on the day unit.
• Sore throat/fever/bruising/pallor – check FBC.
• Serious infection – stop INFLIXIMAB and restart once infection resolved.
• Surgery – stop 4 weeks prior to surgery and resume after wound healing.
• SLE syndrome – contact rheumatology.
• Increasing dyspnoea – arrange CXR.
• Pregnancy – may be used during first 4 months of pregnancy.
• Breastfeeding – may be used with caution.

Stop INFLIXIMAB if:

• WBC < 3.5 x10⁹/L
• ALT/AST > two times normal
• Neutrophils < 2.0 x 10⁹/l
• Platelets <150 x 10⁹/l