Biologics

Biologic medications are similar to the antibodies that are produced by the human immune system to fight infections. They are made specifically using modern technology.

Biologics used in rheumatology target different molecules or cells that play role in inflammation. The are considered as the disease modifying anti-rheumatic drugs.

They can be divided as:

  • Anti-TNF alfa inhibitors (infliximab, adalimumab, golimumab, etanercept, certolizumab).
  • Targeting T cells (abatacept).
  • Targeting B cells (rituximab, belimumab).
  • Interleukin-1 inhibitors (anakinra).
  • Interleukin-6 inhibitors (tocilizumab).

Biologics are given through the injection or infusion. The intervals between the doses are different ranging from one day (anakinra) to 2 months (infliximab). Other DMARDs can be used along with the biologics (for ex., methotrexate).

Contraindications to anti-rheumatic biologics:

  • women who are pregnant or breastfeeding;
  • patients with cancer or have had a history of certain cancers;
  • patients with severe or uncontrolled heart failure;
  • patients with multiple sclerosis;
  • patients with chronic infections (for ex., tuberculosis).

Killed vaccinations (flu or pneumovacine) are safe while given along with biologics. Live vaccines such as shingles vaccination should be avoided. Those medications should be stopped before surgery (you should discuss it with your doctor). If you develop fever or other symptoms suggestive infection, you should hold the medication and contact your doctor.

Before initiation of biologics your doctor have to make sure that you do not have certain infections or cancers. Investigations that are done before the initiation of biologics may include: blood work for the hep B, C and HIV, PSA, TB skin test, pap smear, chest XR and mammogram.

Denozumab is another biologic medication that is used to treat osteoporosis. It is given once every 6 months. Its combination with other biologics is usually avoided.

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TNF inhibitor (TNFi) biologics and malignancy risk in Rheumatoid arthritis (recent research publications):

 

1. Relative risk of lymphoma in Rheumatoid arthritis (RA) patients treated with TNFi biologics:
  • Compared to TNFi-naive RA patients            1.35 (95% CI 0.82-2.11)
  • Compared to general population                  2.72 (95% CI 1.82-4.08)

Reference: Askling J et al. Ann Rheum Dis. 2009; 68:648-653.

Comment: risk appears mostly driven by the disease (RA) rather than the TNFi biologic, but such risk can not be excluded.

2. Risk of skin cancer in RA patients treated with TNFi biologics compared to other RA patients (Odds ratio):
  • Non melanoma skin cancer        1.5 (95% CI 1.2-1.8)
  • Melanoma                                2.3 (95% CI 0.9-5.4)

Reference: Wolfe F et al. Athritis Rheum. 2007. Sep; 56 (9):2886-95

Comment: TNFi biologics appear increase the risk of skin cancer.

3. Risk of solid cancers in RA patients (SIR):
  • All RA patients compared to general population      1.05 (95% CI 1.01-1.08)
  • TNFi biologics compared to other RA patients          0.9 (95% CI 0.7-1.2)

Reference: Askling J et al. Ann Rheum Dis. 2005 Oct; 64(10);1421-1426

Comment: RA patients appear to have a slightly increased overall risk of solid tumours. This is possibly on the basis of smoking-related cancers. Use of TNFi biologics do not appear to increase the risk of solid cancers (excluding skin cancer).

 

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