Achieving Success With Biologic Therapy For Spinal Inflammatory Arthritis
Biologic drugs are advanced and innovative medications that may provide pain relief for people with spinal inflammatory arthritis conditionsfrom rheumatoid arthritis to ankylosing spondylitis. As with all medications, biologics may have side effects or adverse interactions with other drugs. Discuss all medicationseven if they’re over-the-counter and pose no apparent riskwith your doctor before starting this therapy.
Biologics. Arthritis Foundation Web Site. http://www.arthritis.org/living-with-arthritis/treatments/medication/drug-guide/drug-class/biologics.php. Accessed July 19, 2017.
Fields TR. Treating Early Inflammatory Arthritis: What are the Latest Options? https://www.hss.edu/professional-conditions_treating-early-ra-latest-options.asp. Published January 4, 2006. Reviewed and updated November 21, 2009. Accessed July 19, 2017.
Stöppler, MC. Biological Therapy. MedicineNet. http://www.medicinenet.com/biological_therapy/article.htm. Last reviewed August 29, 2016. Accessed July 19, 2017.
Venables PJW. Patient education: Rheumatoid arthritis treatment . UpToDate. https://www.uptodate.com/contents/rheumatoid-arthritis-treatment-beyond-the-basics. Last updated April 20, 2017. Accessed July 19, 2017.
What Are Biosimilars? Amgen Biosimilars Web site. http://www.amgenbiosimilars.com/the-basics/what-are-biosimilars/. Accessed July 19, 2017.
Biologic Therapy: Efficacy And Safety
Licensed biologics for RA are shown in .â These drugs, except denosumab, are approved to treat moderate to severe RA that has not responded to conventional DMARDs. The rate of biologic use in clinical practice is rising as more agents become available a recent analysis of US prescribing patterns reported an increase in biologic use from 3% of patients in 1999 to 26% in 2006.
When Should I Start On A Biologic Treatment
The decision of when to use a biologic to treat RA is a complex one that depends on several factors, including how active your disease is, whether you have already tried other conventional treatments that are considered the first option in RA treatment, and cost considerations. You and your doctor will work together to determine when and if a biologic treatment is appropriate for you. While biologic DMARDs are typically used after patients have not gotten a good response from conventional DMARDs, in some patients with aggressive disease, biologics may be used as a first-line treatment.1,2
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What Are The Best Rheumatoid Arthritis Medications For Pain
Most of the medications used for rheumatoid arthritis provide relief from pain. However, depending on current disease activity, some may be more effective than others.
- For acuteflare-ups, for example, short-term treatment with a corticosteroid, such as prednisone, may be highly beneficial.
- If there is excessive inflammation, a non-steroidal anti-inflammatory can address that symptom and also relieve pain.
- Over-the-counter analgesics, such as acetaminophen, may be used for minor pain.
- But for chronic, moderate-to-severe pain, an opioid analgesic would be more effective.
- Pain and inflammation are both addressed by biological drugs which have the added benefit of altering disease activity.
What Other Drugs Are Used In Combination With Dmards And/or Biologics
DMARDs, including the biologics are the backbone of rheumatoid arthritis treatment and help prevent pain and joint destruction.
Nonsteroidal anti-inflammatory drugs are also used to alleviate pain and decrease inflammation but do not reduce joint damage.
Common NSAID examples include:
- diclofenac
- celecoxib .
Glucocorticoids such as prednisone, prednisolone or triamcinolone can provide rapid relief and are given in pill form or by injection. However, these are usually given early in therapy to lower inflammation and pain while slower acting drugs like the DMARDs take effect. Glucocorticoids are also reserved for more severe RA or for flare-ups because they can cause severe side effects with long-term use.
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Classes Of Biologics For Rheumatoid Arthritis
There are four main classes of biologics used to treat RA, including B-cell inhibitors, tumor necrosis factor alpha inhibitors, selective costimulation modulators, and interleukin inhibitors. Each class of biologics interferes with different aspects of the immune system involved in inflammation and joint damage in RA.
What Are Common Side Effects With Methotrexate
Methotrexate side effects may include stomach upset, blurred vision, headache, mouth or lip sores, feeling tired, diarrhea and abnormal liver tests. MTX can reduce the production of certain blood cells and this may increase the risk for bleeding or bruising. There may be a greater risk for fevers and infections, too.
Regular blood tests may be ordered, and folic acid or leucovorin may be used to lessen the risk of some side effects. MTX and leflunomide should not be used in pregnancy or breastfeeding. Any woman with rheumatoid arthritis planning a pregnancy should consult with her doctor first.
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Who Should Not Be Treated With Biologics
You might not be a good candidate for treatment with biologic drugs. There are certain conditions in which the risks would most likely outweigh the benefits of treatment.
For example, if you have multiple sclerosis, symptomatic congestive heart failure, or a history of lymphoma, TNF inhibitors wouldn’t be right for you. It’s also too risky to use biologic drugs if you have a history of severe or recurring infections.
Biologic Drugs Versus Biosimilars
Because biologics are made with living cells and not chemicals, generic equivalents are not possible. However, a biologic alternative known as biosimilars are hitting the market to offer additional therapeutic options and increase access to people who could benefit from these drugs. One example of the growing biosimilar industry is the 2016 FDA approval of Erelzi for spinal inflammatory arthritis.
As the name suggests, a biosimilar is very similar to an approved biologic drug, but its not an exact replica. Thats what makes a biosimilar different from a generic drug, which has identical active ingredients to its brand name counterpart. Because biologic drugs are so complex, they are unable to be have an identical match.
Generic drugs are sought after for their low cost, and biosimilars are designed to be more affordable compared to biologics. But, biosimilars are not expected to drive as much cost savings as generic drugs, as they do take considerable time and money to develop.
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Treating Ra With A Mix
Traditional DMARDs are often used in combination with each other. A traditional DMARD can also be paired with a biologic, but only one biologic is prescribed at a time. If biologics dont help you achieve remission, your doctor may suggest trying a JAK inhibitor instead. If needed, a JAK inhibitor may also be used in combination with a traditional DMARD.
Today, if methotrexate isnt working, doctors are more likely to add on a biologic,” Kaplan says. “In some cases, methotrexate may be stopped if the biologic is working well. If the first biologic isnt working, your doctor may try switching you to a different type of biologic.”
When to start a traditional DMARD, add another, move to a biologic, or try a JAK inhibitor are . No matter what medication youre taking, its important to discuss potential side effects and risks. You may also need regular blood tests to make sure you’re not in danger from certain side effects.
Regardless, these medications are changing the way doctors think about treating RA.
Years ago, I wouldve said its better to have osteoarthritis than rheumatoid arthritis,” Kaplan says. “Today, I can say that there are actually better treatment options for RA.”
Additional reporting by Erica Patino and Kerry Weiss
What Are Biological Medicines
Biological medicines are a group of newer medicines that are used to ease the symptoms of rheumatoid arthritis and reduce the damaging effect of the disease on the joints. Biological medicines mimic substances produced by the human body, such as antibodies. They are made by living organisms such as cloned human white blood cells. This is unlike most medicines which are made by chemical processes.
There are quite a few biological medicines available to treat RA. They include adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, anakinra, abatacept, rituximab and tocilizumab. They come in various different brand names. Some biological medicines are sometimes called cytokine modulators or monoclonal antibodies.
There is another group of medicines called disease-modifying antirheumatic drugs which can also be used to treat RA. Like biological medicines they have a disease-modifying effect against RA. See separate leaflet called Disease-modifying Antirheumatic Drugs for more details.
Biological medicines are also used to treat other conditions – for example, some other forms of arthritis, and chronic inflammatory skin or bowel disease. However, the rest of this leaflet is only about biological medicines when they are used to treat RA.
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Other Immunomodulatory And Cytotoxic Agents
Some additional immunomodulatory drugs are used in RA including azathioprine , and cyclosporin A . Rarely cyclophosphamide and d-Penicillamine are used. Because the potential of high toxicity, these agents are typically utilized for life-threatening extra-articular manifestations of RA such as systemic vasculitis or with severe articular disease that is refractory to other therapy.
Azathioprine has some activity in rheumatoid arthritis but may take 8-12 weeks to see an effect. It is a purine analog that can cause bone marrow suppression and lowering of blood cell counts particularly in patients with renal insufficiency or when used concomitantly with allopurinol or ACE inhibitors. Increased risk of secondary malignancy due to azathioprine is controversial. Screening for levels of the enzyme thiopurine methyltransferase is recommended before initiating therapy with azathioprine. Certain individuals have deficiencies in this enzyme that metabolizes azathioprine with a concomitantly increased risk of toxicitiy for the medication. Side effects include nausea, and alopecia. Blood tests to monitor blood counts and liver function tests are necessary for patients on azathioprine.
What Special Precautions Are Needed For Tnf Blockers
TNF blockers suppress the immune system and may increase the risk of getting an infection report any signs or symptoms of an infection, such as a fever, to your doctor immediately. Also report any night sweats or weight loss that occurs during treatment.
You may need vaccinations prior to or during treatment with biologics. Tell your doctor if you have a history of congestive heart failure , cancer or hepatitis.
You will also be tested for tuberculosis before starting a biologic agent.
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Examples Of Biologics Available Today
Biologics are categorized by what part of the inflammatory process they target.
TNF blockers are the most common type of modern biologic. TNF blockers include but are not necessarily limited to:
- certolizumab
Examples of other biologics include:
- tocilizumab , targets the interleukin-6 pathway
- anakinra , an interleukin-1 receptor antagonist
- rituximab , a CD20-directed cytolytic antibody
- tofacitinib , first in a class of treatments RA called Janus kinase inhibitors
These list change as the FDA approves new drugs and they are introduced to the US market.
See Biologics, Biosimilars, and Interchangeable BiosimilarsWhat is the Difference?
Biological Therapy Treatment For Rheumatoid Arthritis
As you get older, chronic conditions or your genetic makeup can cause inflammation and your joints to stiffen. This is known as arthritis, and it impacts 23% of adults in the US. While there are different types of arthritis, rheumatoid arthritis is one of the most common. But, RA doesnt impact joints alone. It can also affect your skin, eyes, lungs, heart, and blood vessels. Thats why its important to find a solution that relieves your symptoms such as biological therapy treatment.
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What Are The Potential Risks And Benefits Of Injectable Medications For Rheumatoid Arthritis
Biologic agents used to treat RA need to be injected. The biggest benefit of these drugs is that they are very effective.
- Biologics not only relieve symptoms but also halt damage to joints and generally provide quick relief.
- The biggest drawback of biological agents is cost. Patients can spend thousands of dollars a month using biologics.
- Other drawbacks include side effects, which may be severe because biologics suppress the immune system, enhancing the possibility of infections.
- In addition, patients may not like receiving injections.
What Are The Possible Side
It is not possible to list all of the adverse effects of each biological medicine in this leaflet. However, as with all medicines, there are a number of side-effects that have been reported with each of the biological medicines. If you want more information specific to your biological medicine then you should read the information leaflet that comes with your medicine.
Most biological medicines make you more prone to infections. These can be quite serious and some people have had severe infections such as infection of the blood , as well as tuberculosis and hepatitis B reactivation. Screening for hepatitis B is now recommended before starting rituximab, whether you are at risk of infection or not. If the screen shows you are carrying hepatitis B you will be referred to a liver specialist. The specialist will do more tests to help decide if rituximab is right for you.
Some biological medicines may also cause damage to the blood-producing cells.
You should tell your doctor or nurse straightaway if you develop any of the following after starting a biological medicine:
- A sore throat.
- Any other symptoms of infection.
- Unexplained bruising.
- Itching .
- Injection site reactions.
Most hospitals will give you a biological therapy alert card to carry with you at all times. This is important because, if you become unwell, the doctor or nurse treating you needs to know you are being treated with a biological medicine, making you more at risk of infection.
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What Is A Biologic
Biologics are medications that can be used to treat certain types of arthritis. They are a type of medication called a disease-modifying anti-rheumatic drug or DMARD for short which may prevent the development of joint damage. DMARDs, including biologics, are different to medicines that simply block the pain or other symptoms youre feeling. They work by blocking specific substances in the immune system.
Usually the immune system fights infections to keep you healthy. In autoimmune diseases such as rheumatoid arthritis, the immune system mistakenly takes aim at itself, attacking its own healthy tissues. This leads to very high levels of certain natural substances, called cytokines, in the body that then cause joint inflammation and pain. Biologics are very effective at blocking these substances. This dampens down the immune system, and reduces inflammation, pain and damage to the joint.
Biologics mimic substances naturally produced by the body. They are made from living cells, which is the key difference from most other medicines that are made from man-made or chemical compounds. They can be very effective in treating inflammatory arthritis and tend to work more quickly than conventional DMARDs . There are a number of biologics that target different parts of the immune system. If your arthritis does not respond to one type of biologic, your rheumatologist may use a different biologic to see if it works better for you.
Storing And Handling Biologics
Every biologic will have storage and handling instructions that must be followed, or the drug will lose some or all of its effectiveness. Most biologics should not be:
- Exposed to rapid temperature changes. For example, do not use a heat source to warm up a drug that has been stored in the refrigerator. Let it gradually warm to room temperature before injection.
- Exposed to multiple temperature changes. For example, people are advised against storing a biologic in a refrigerator, then warming it up to room temperature, and then putting it back into the refrigerator for later.
- Shaken. Rapid shaking is usually not necessary and may be harmful.
Why are guidelines like these necessary? Most medications are made up of small, stable moleculesaspirin molecules have just 21 atomsbut biologics are made up of huge molecules with thousands of atoms. The chemical bonds that hold those atoms together are relatively weak, and they can be broken by rapid temperature changes and other factors. A drug will not work as prescribed if too many if its molecules bonds are broken.
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Your Doctor May Decide Not To Prescribe A Biologic If:
You are pregnant or breastfeeding
You have had tuberculosis in the past
You have had other repeated infections
You have had cancer
You have or had a serious heart condition
You have lung fibrosis
Rheumatoid arthritis is characterized by pain, swelling, and inflammation of the joints. It most commonly starts in the small joints of the hands and feet. Eventually all joints can be affected. Your joints can feel stiff, particularly in the morning. Symptoms often come and go, and are often accompanied by fever or feeling tired or unwell. As the disease progresses, sufferers can experience severe joint damage and fatigue, making it difficult for them to complete everyday tasks. Flare-ups of rheumatoid arthritis are often unpredictable and difficult to manage. Pain, stiffness, and swelling are worse on some days and easier to bear on others.
The exact cause of rheumatoid arthritis is unknown. Some studies show that rheumatoid arthritis may run in families, suggesting a genetic component, yet having a family member who suffers from rheumatoid arthritis does not necessarily mean that you will also develop the disease.
Rheumatoid arthritis can be difficult to diagnose because many other conditions can cause joint stiffness, pain, swelling, and inflammation.
Abbvies Oral Jak Inhibitor Rinvoq Ok’d For Ra
In August of 2019 the FDA cleared AbbVie’s Rinvoq , a 15 mg, once-daily oral Janus Associated Kinase inhibitor, for adults with moderate-to-severe rheumatoid arthritis who have had an inadequate response or intolerance to methotrexate .
- In the SELECT Phase 3 studies, roughly 4,400 patients were evaluated. Across all treatment arms in five SELECT studies, Rinvoq met all primary and ranked secondary endpoints.
- In SELECT-COMPARE, 71% of MTX patients treated with Rinvoq 15 mg plus MTX achieved ACR20 compared to 36% treated with placebo plus MTX at week 12.
- Common side effects included upper respiratory tract infections , nausea, cough, and pyrexia .
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