RA Treatment Q&A: Biologics with Dr. Justin Peng

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While there is no cure for rheumatoid arthritis, by utilizing effective treatments, it is possible to suppress the disease, to essentially stop it from progressing and damaging your body. Biologics are one of many drugs used to treat RA. HealthCentral interviewed Dr. Justin Peng, a rheumatologist and the National Arthritis Foundation’s medical honoree, about this relatively new class of medications.

HealthCentral (HC): What is the difference between biologics and other medications used to treat rheumatoid arthritis (RA)?

Dr. Justin Peng (JP): Biologics are the newest form of medications designed specifically to target and inhibit parts of the immune system which are overactive in autoimmune diseases such as RA.  They target certain pathways and cytokines (ie. TNFalpha, IL-6, or B cells) in the immune system to decrease inflammation.  Examples include etanercept, adalimumab, infliximab, tocilizumab, rituximab, tofacitinib.  They are more potent and suppress the immune system more than non-biologic medications for RA, which makes them generally more effective.  Most biologics are given by self-injection or intravenous infusion, but some biologics come in oral form.

HC: What are some of the pros of using biologics? The cons?

JP: The pros of biologics are that they target the pathways that cause inflammation in RA more specifically than the older medications, and therefore very effectively decrease inflammation (pain, swelling, stiffness) in the joints.  They are the most potent treatments for RA. They do not have all the side effects of long-term prednisone (including weight gain, diabetes, bone thinning, glaucoma, cataracts) or of methotrexate, leflunomide, and sulfasalazine (liver abnormalities, stomach upset), and are usually well-tolerated.  Other pros are that studies show that many biologics decrease the progression of joint damage seen on x-rays which can lead to the prevention of deformities and disability in patients whose RA is still active despite maximum non-biologic therapy.

The cons depend on the individual patient. Some people prefer not to take a medication that requires an injection or infusion.  Other cons include potential side effects such as injection site or infusion reactions which are rare.  Biologics suppress the immune system (as do some non-biologic medicines) so people on these medicines may be more prone to infections, but this can be minimized with general precautions (such as hand-washing) and proper vaccinations.  Rarely, biologics are associated with heart failure in those who already have heart disease, and certain types of cancer – although studies are mixed and a causal relationship has not been proven.

HC: What are some of the most common side effects your patients might have experienced using biologics?  How do you recommend managing the side effects to your patients?

JP: Some common side effects of self-injection biologics include irritation around the inject site (most often the superficial skin of the thighs, or stomach area).  This reaction is often easily treatable with ice, topical agents, and making sure the medication is at room temperature prior to administration. Other potential side effects include infections, since the immune system is being suppressed more potently than with non-biologics.  This can be minimized by taking general precautions, ensuring proper vaccinations, and maintaining a healthy lifestyle.  Other potential side effects include blood count abnormalities, which can be detected with close monitoring of blood tests.

HC: What is the effect of biologics on pregnancy or fertility?

JP: It is not uncommon for people with rheumatic diseases to have reduced fertility, but a woman on a biologic should not have a lower chance of conceiving than a woman who is not on a biologic.  A study in Arthritis Care & Research in 2010 showed that biologics have no influence on fertility.  In general the best time to conceive is when the underlying autoimmune disease is controlled.  Fortunately, many women with RA tend to clinically improve during pregnancy.  The cause for this is unknown, but may have to do with hormonal or immunologic changes during pregnancy.

Biologics such as TNF alpha inhibitors (ie. etanercept and adalimumab) are considered relatively safe during pregnancy.  They are deemed by the FDA as pregnancy category class B, meaning that “animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.”  Some biologics are class C, meaning there may be more risk to the fetus, but potential benefits may warrant use of drug during pregnancy.  However, methotrexate (which is not a biologic) is not safe for use in pregnancy in any situation.

HC: Is there any criteria for people to use biologics? Are some people better suited to use it than others?

JP: There are no formal criteria or indications for people to use biologics, but there are guidelines to help providers and rheumatologists decide when a biologic is appropriate.  In general, if a patient has not responded well enough to NSAIDs, or to a non-biologic medicine, and/or requires prednisone for a prolonged period of time despite conservative measures, then a biologic is usually recommended.  Biologics can be used in adults, children, or elderly patients.  However, certain populations with high risk conditions including those with heart failure, untreated malignancies, active hepatitis or those with serious infections, may not be suited for biologics.

HC: What are some tips you give to patients who are to go on biologics for the first time? What about tips on self-injecting for the first time?  What are some things patients should be aware of after their first biologics treatment?

JP: It is important to take a biologic as instructed.  A trained professional (usually a nurse or medical assistant) should instruct patients on how to self-inject biologic medications for the first time.  Most self-injectable medicines now come as pen injectors, or auto-injectors.  They need to be refrigerated for storage, but should be brought to room temperature before injecting.  Alcohol swabs should be used to clean the area to be injected, usually the thigh, stomach or arm.  Rotating the sites can help reduce irritation or injection reactions. Patients should look out for local reaction including itching, redness, warmth, tenderness, pain.  Systemic reactions can include fever, chills, or muscle aches.  If any of these occur or persist, then the patient should contact his/her rheumatologist.  Travel with biologics should be straightforward with an ice pack/container that can be brought onto the plane with a note from the rheumatologist.

HC: What are some steps patients can take to get their biologics treatments covered?

JP: Most biologics require a pre-authorization process with insurance which the doctor’s office will usually initiate.  Patients can also call their insurance companies to check which biologics are covered under their plan.  Sometimes pharmaceutical companies have support programs for those who have financial hardship.  Patients should also talk with their rheumatologist to ensure that all steps have been taken (including checking for hepatitis B or C and tuberculosis exposure) prior to starting a biologic.

HC: What are some things patients can do in order to avoid infections that you recommend?

JP: Proper vaccines are recommended prior to initiating treatment for RA such as the vaccinations for the flu, shingles, and pneumonia.  Some vaccines can be given while taking a biologic, but they must be dead (inactivated or killed) vaccines.  Patients on biologics should not receive any live vaccines (ie. shingles, yellow fever).  It is best to check with the doctor regarding timing of vaccines, and whether they can be administered while on a biologic.  General precautions should always be taken including washing hands, personal hygiene, avoiding sick contacts, and avoiding foods that may contain harmful bacteria.

HC: What are some questions patients should ask their doctor before starting biologics?

JP: Patients should understand the reason why a biologic is being started (usually due to prednisone dependency and persistent disease activity despite non-biologic medications).  Patients should ask about all the different options, the effectiveness of each one, and the potential side effects of each one, as they may be different.  Patients should ask which biologic will likely be most effective for them.  Patients should also inform doctors of other medical conditions, other medicines, and whether travel plans or family planning is in the near future.

HC: Any last thoughts or words of advice you want to give our community of people living with RA who are considering biologics?

JP: If you had to pick any decade to have arthritis, this is the best decade because there are many different options to treat rheumatoid arthritis.  There are many effective biologics now and even newer ones on the horizon.  Biologics are generally more effective in treating RA symptoms than non-biologic medicines, and even in some cases, safer.  As with all medications, the risks and benefits should be discussed with the doctor so that the best treatment program can be developed for the individual patient.

From the Arthritis and Rheumatism Associates, P.C. website: Dr. Justin Peng has co-authored numerous publications in rheumatology and has been the recipient of multiple awards. He is board certified in Internal Medicine and Rheumatology and is a member of the American College of Physicians and a fellow of the American College of Rheumatology. He has also earned the recognition and praise of the medical community by being named as an outstanding specialist in Rheumatology in Washingtonian Magazine. His areas of interest also include systemic lupus, rheumatoid arthritis, psoriatic arthritis, osteoarthritis, gout, and myositis. He is currently with the Arthritis and Rheumatism Associates in the Washington, D.C. area.