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Anti-TNF Therapy (Adalimumab, Etanercept, Infliximab) In NZ, anti-TNF therapy is used for the treatment of severe, erosive RA after failure of MTX alone and in combination with other conventional DMARDs. They are most commonly used in combination with MTX or other conventional DMARDs. These medications are given by s/c injection (Adalimumab & Etanercept) or iv infusion (Infliximab).
These agents are potent immunosuppressants and predispose particularly to reactivation of latent tuberculosis. This can often manifest in extra-pulmonary locations. Baseline testing therefore includes screening for past TB exposure.
Monitoring Baseline: CBC, LFT, Hepatitis B & C serology, Quantiferon TB Gold, chest radiograph. Monitoring: as per conventional DMARD used in combination. Skin examinations for development of non-melanoma and melanoma skin cancer are recommended.
Clinical AEs Rash – Injection site reactions are frequent
Rituximab (Mabthera) Rituximab is available for the treatment of RA refractory to treatment with anti-TNF agents or where their use is contraindicated. It is administered 6-monthly as two iv infusions given two weeks apart. Rituximab is an antibody directed against CD-20, a marker expressed on B-cells. It is generally combined with conventional DMARDs.
Monitoring Baseline: CBC, LFT, immunoglobulins, hepatitis B & C serology. Monitoring: immunoglobulin levels pre infusion.
Laboratory AEs Hypogammaglobulinaemia – this can predispose to infection including Pneumocystis jiroveci and caution should be exercised administering Rituximab to those with low IgG levels.
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