Next line in the treatment of RA

TNF inhibitors/TNF blockers are a group of biologic medicines that suppress the body’s response to TNF. TNF (Tumor Necrosis Factor) is a complex protein produced by the white blood cells in response to inflammatory events in the body. Those who have rheumatoid arthritis may be given a TNF inhibitor as part of their therapy.

This is the third article in a series about the treatment options for rheumatoid arthritis. You can download the articles or you can read them on Marysarthritis.com.

Many insurance plans may require that you start your therapy with a nonbiologic such as methotrexate (MTX). As troublesome as the side effects are in the beginning, methotrexate has a good success rate. When MTX isn’t enough the doctor may order a combination of methotrexate with sulfasalazine and/or leflunomide. A TNF inhibitor may be the added to the methotrexate.

Although the TNF inhibitors are basically similar, they do have different
properties. If one doesn’t work for you, another might.

Your doctor will order a TB test and will order a shingles vaccine. These diseases are checked out because if these diseases are inactive in your body when you start the TNF inhibitor, they may become active again.

Some of these drugs are given by injection under the skin (subcutaneous, sc).
Drug companies make this process easy with tiny needles and clear instructions.

There are five TNF inhibitors.
• Humira(adalimumab)
• Enbrel(etanercept)
• Remicade(infliximab)
• Simponi(golimumab)
• Cimzia(certolizumab pegol)

Humira is available in a prefilled syringe or a Humira pen of 40mg.
Administered sc every other week. Sometimes the dose is every week. When you sign up for Humira complete, you will be assigned a nurse who can help you optimize your use of Humira. Humira was FDA approved in 2002.

Enbrel was the first TNF inhibitor to be approved by the FDA in 1998; Enbrel is administered sc 50 mg once a week using a prefilled cartridge and reusable auto injector.

Remicade is given in an infusion center by IV over two-hours. There is a series of initial starter doses at baseline, two, and six weeks. Then a maintenance dose is infused every eight weeks. FDA approval 1998.

Simponi FDA approval 2009. Simponi is injected sc with a 50mg prefilled
syringe once a month. Simponi aria is given by a 30-minute infusion initially and at four weeks. The maintenance dose is a thirty minute infusion determined by weight every eight weeks.

Cimzia FDA approval 2008. Loading dose two 200mg prefilled syringes sc
initially and at two and four weeks. Maintenance dose 200mg sc every other
week or two 200mg prefilled syringes once a month.

Black box warnings* have been issued for all the TNF inhibitors. These are a few.
• They suppress the immune system and can cause serious infections that
result in death.
• Those who have a history of histoplasmosis, TB or hepatitis B may have
their disease reactivated when using the TNF inhibitors.
• The TNF inhibitors are associated with new onset or worsening of nervous
diseases multiple sclerosis and Guillain-Barre syndrome.
• Heart failure can occur or get worse on the TNF inhibitors.
• Higher rates of cancer have been reported including lymphoma and skin
cancer. Hepatosplenic T cell lymphoma has been seen in young males
who are on TNF inhibitors.

Pregnancy If you are pregnant or planning to be, it is important to discuss your pregnancy with your doctor. Some RA drugs are safer than others during
pregnancy.

The big question for the TNF inhibitors as it is for all the biologics is ‘does the
benefit outweigh the risk?’ The TNF inhibitors have made life much better for
many people. It is important to note that they are powerful drugs with powerful side effects. . When you choose to use them in your treatment program for rheumatoid arthritis follow the recommended protocols.

*A black box warning is a very serious warning from the FDA. These things are
happening to RA patients.