Biologics: What's your preference?

Choices, choices, choices! Better to have them than not when it comes to treating rheumatoid arthritis. But when it's your turn to make the big decision, what will you consider? Here are a few things to keep in mind when deciding on a biologic treatment.

What types of biologic therapy are available?
They are different types of biologics available for the treatment of rheumatoid arthritis. They are different in how they work, how they are taken, and what you should look out for. Whether it is under your skin or into a vein, all the biologics are taken by injection.

Tumor Necrosis Factor Inhibitors
TNF-alpha inhibitors were the first biologics approved for the treatment of rheumatoid arthritis. They include adalimumab (Humira®), certolizumab, etanercept (Enbrel®), golimumab, and infliximab.  Most of these are taken by an injection under the skin. People with RA can easily learn to inject these medications themselves at home. Some of these products offer in home training by nurses to help you learn to use them properly. Infliximab (Remicade®) is injected into a vein, and is administered by a health professional, usually in a hospital or clinic.

Interleukin Inhibitors
Interleukin inhibitors work by blocking interleukins, a group of cytokines that plays a role in the regulation of the immune system. Their anti-inflammatory effects can help with signs and symptoms of rheumatoid arthritis. Anakinra (Kineret®) blocks the interleukin-1 (IL-1) receptor, and tocilizumab (Actemra®) and sarilumab (Kevzara®) block the interleukin-6 (IL-6) receptors. They can be given subcutaneously (under the skin) or intravenously (into the vein [IV]). Anakinra was one of the first biologics approved, but it is no longer commonly used due to its relatively low efficacy compared to other biologics.

Abatacept (Orencia®) belongs to a group of medications called selective co-stimulation modulators. It is used alone or with other medications to reduce signs and symptoms of rheumatoid arthritis. Abatacept works by "turning down" parts of the body's immune system that are believed to be involved in rheumatoid arthritis and by keeping the immune system from attacking normal tissues.

Rituximab (Rituxan®) is a chimeric monoclonal antibody that was first approved for the treatment of non-Hodgkin's lymphoma. It was later approved for its use in rheumatoid arthritis after it had shown to be effective in clinical trials. If you're receiving rituximab, it is important that you get screened for Hepatitis B infection as there is a risk of reactivation.

How often do I take the treatment?
The biologics are all taken on different treatment schedules:

  • Adalimumab (Humira®) is taken once every two weeks.
  • Anakinra (Kineret®) is taken every day.
  • Certolizumab (Cimzia®) is taken every 2 or 4 weeks after the first 3 treatments. 
  • Etanercept (Enbrel®) may be taken once or twice a week.
  • Golimumab (Simponi®) is taken once monthly when given subcutaneously, and every 8 weeks after the first 2 treatments when given by IV.
  • Infliximab (Remicade®) is taken every 8 weeks after the first three treatments (the second and third treatments are taken 2 and 6 weeks after the first treatment).
  • Sarilumab (Kevzara®) is taken every 2 weeks.
  • Tocilizumab (Actemra®) may be given subcutaneously or by IV, and the dosage is based on body weight.  
  • Abatacept (Orencia®) may be given subcutaneously or by IV.
  • Rituximab (Rituxan®) is administered at weeks 0 and 2, and it can be repeated after 5 to 6 months.

Is there any preparation involved?
Many biologics come as pre-filled syringes, ready to be injected without any mixing or measuring. These include abatacept SC (Orencia), adalimumab (Humira®), certolizumab (Cimzia), and more. Some biologics have two options, and etanercept is one of them. Etanercept that comes in a vial must be mixed by adding sterile water. After the powder in the vial is dissolved, the dose is drawn up into a syringe and injected. Etanercept is also available in a pre-filled syringe at a higher cost. Infliximab must be prepared in a hospital by a trained professional.

Where do I take the treatment?
Most biologics can be taken at home, while infliximab is administered by a healthcare professional in a hospital or clinic. Ask your doctor where the nearest hospital or clinic that performs this service is located and their hours of operation. You may need to book an appointment ahead of time and arrange for some time off work to have your medication administered. If this is a problem for you, talk to your doctor about biologics that can be taken at home.

To help find the biologic that fits you and your lifestyle, it's important to let your rheumatologist know how you feel about the factors above so that they can be fully considered when deciding which treatment is right for you.

Your preferences are just that: your preferences. Therefore, be specific about them when you talk to your rheumatologist. For example, if you would prefer to use the medication at home and you have concerns about how often you have to take it, tell your rheumatologist. They can help you to choose the biologic treatment that's right for you, based on your condition and your preferences.

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