Update on Biologic therapy in Inflammatory arthritis

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Update on Biologic therapy in Inflammatory
arthritis

• Helen Linklater
• Consultant Rheumatologist
• Epsom and St Helier NHS Trust

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Biologic agents in Rheumatology
Anti-TNF-? Infliximab, Etanercept,Adalimumab Certo
lizumab pegol, (Golimumab) Anti-B-cell Rituximab
Anti-IL6 Tocilizumab Anti-T-cell Abatacept
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Anti-TNF uses
Gastro e.g. Crohns/UC
Derm e.g psoriasis
Rheumatology gt 20,000 patients recruited to
BSRBR to date RA PsA AS Other rheumatic
conditions
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Anti-TNF when to start in RA
2.6

• Active RA
• Measured on 2 occasions, 1 month apart
• Failure of 2 DMARDs including MTX over 6 month
  period

3.2
Tender joint count/28 Swollen joint
count/28 Patient Global Score/100 ESR/CRP
5.1
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Anti-TNF when to start in PsA

• Active peripheral PsA
• - ? 3 TJC and ? 3 SJC
• - Measured on 2 occasions, 1 month apart
• Failure of 2 DMARDs including MTX over 6 month
  period

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Anti-TNF when to start in AS

• Active spinal disease as defined by BASDAI gt4 cms
  spinal pain VAS gt4cms
• Failure of 2 NSAIDs x 4 weeks

• BASDAI measures 5 main symptoms (max score 10)
• Fatigue
• Spinal pain
• Joint pain/swelling
• Areas of localised tenderness
• Morning joint stiffness

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Which anti-TNF?

• Anti-TNF first line
• No head-to-head studies between biologics
• Infusion (infliximab) vs subcutaneous injections
• Need to consider adverse effects
• Risk of antibody formation with infliximab
• ?lower risk of LRTI with etanercept
• Duration of action

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Rituximab when to start in RA

• Adults with active RA
• - generally seropositive
• - usually in combination with methotrexate
• - after failure of anti-TNF

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Tocilizumab when to start in RA

• Adults with active RA
• - usually in combination with methotrexate
• - after failure of anti-TNF

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Safety

• Screen for TB (CXR /- TB clinic)
• Exclude active infection (Hep B,C,HIV). Assess
  ongoing infection risk (e.g. recurrent UTI,
  previous septic arthritis)
• Assess carefully in ILD, any history of
  neoplasm/premalignancy, CCF, MS, SLE,
  haematological conditions
• Avoid pregnancy and breast feeding

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Sept 2010 BSR report

• x 2 risk of serious infection vs general
  population
• especially early in therapy
• infections likely to be more severe if anti-TNF
  continued once apparent
• TB reactivation higher with infliximab and
  adalimumab
• more likely to be disseminated
• If stopping prior to surgery, consider stopping
  INF 27 days /ETAN 13 days/ADA 54 days beforehand)
• Avoid live vaccines but give influenza/pneumovax
• No evidence of ?risk of solid tumours or
  lymphoproliferative disease above risk in RA
  population, but appears to be ?risk of some skin
  cancers

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Administration

• Infusion or Syringe/Pen device
• Hospital prescription
• Patient training and drug Delivery through
  Healthcare at Home
• Ongoing support and assessment of response
  through Rheumatology CNS and consultant follow-up

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Efficacy
(Silman, 2011) (Haraoui, 2011)
(Yazici, 2011)
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The Future

• When do we stop anti-TNF?
• Treatment holidays?
• Tissue typing ? specific biologic treatment

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References

• www.nice.org.uk
• www.rheumatology.org.uk/resources/guidelines
• Silman, A (2011) Biologic Therapies in
  Inflammatory Joint Diseases Models, Evidence and
  Decision Making Rheumatology 50 (S4) iv3-iv4
• Haraoui B et al. Safety and Effectiveness of
  Rituximab in Patients with Rheumatoid Arthritis
  Following an Inadequate Response to 1 Prior Tumor
  Necrosis Factor Inhibitor The RESET Trial. J
  Rheumatol Oct 2011
• Yazici Y et al. ( Sep 2011) Efficacy of
  tocilizumab in patients with moderate to severe
  active RA and a previous inadequate response to
  DMARDs the ROSE study Ann Rheum Dis

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Any Questions?