• derived from biological systems

    • immunomodulators

      • often used to treat immune mediated inflammatory disease

        • RA/IBD

      • unlike other immunosuppressives

        • MTX

      • specific cell signalling pathways targeted

      • TNF inhibitors

    • vasccines

    • blood products

    • chemotherapy agents

  • response often variable

  • may also develop antibodies against biologics

    • more likely to occur with use of chimeric

  • methotrexate often co-prescribed

Precautions

  • contraindicated in:

    • severe active infections

    • moderate to severe heart failure

    • multiple sclerosis or optic neuritis

    • untreated or latent Tb

    • hepatitis B

    • malignancy within last 5yrs

Testing for latnet Tb

  • Wuantiferon Gold

  • more sensitive in people who are immunocompromised thatn tuberculin skin testing

    • e.g. in people on MTX or corticosteroids

  • also more sensitive than previous BCG vaccination

  • infliximab most frequently associated with tuberculosis reactivation

Check immunisation status

  • live vaccines contraindicated

    • should be completed prior to treatment initiation

  • Hep A. B vaccination reommended if no immunity

    • reactivation hep B common

  • Influenza

  • Pneumococcal

  • varicella

  • HPV

Pregnancy

  • not recommended

  • safety not established

  • prescribe effective contraception and also for several months afterwards

monitoring

  • reducing risk of infection = important role for primary care team

  • good food hygiene

  • adverse events

    • injection site reactions

      • local

      • advised to space each new injection site at least 3cm from previous site

      • apply damp towel or ice pack to site

  • increase risk of developing serious infections

    • pneumonia

    • soft tissue infections

    • opportunistic infection

      • latent infections

  • heart failure

    • etanercept and infliximab

    • should be discontinued

  • interstitial lung disease

    • associated with RA

  • periodic skin examination for non-melanoma skin cancer

  • lymphoma

    • RA 2-2.5x more likely to develop lymphoma

  • surgery

    • biologics withheld prior to surgery