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Anti-tumor necrosis factor (anti-TNF) drugs are a class of drugs that are used worldwide to treat inflammatory conditions such as rheumatoid arthritis (RA), psoriatic arthritis, juvenile arthritis, inflammatory bowel disease (Crohn’s and ulcerative colitis), ankylosing spondylitis and psoriasis. These drugs are able to reduce inflammation and stop disease progression.
TNF is a chemical produced by the immune system that causes inflammation in the body. In healthy individuals, excess TNF in the blood is blocked naturally, but in those who have rheumatic conditions, higher levels of TNF in the blood lead to more inflammation and persistent symptoms.
There are five anti-TNF drugs that have been approved by the U.S. Food and Drug Administration for the treatment of rheumatic diseases. To decrease side effects and costs, most patients with mild or moderate disease may be treated with methotrexate before adding or switching to an anti-TNF agent. These agents can be used by themselves or in combination with other medications such as prednisone, methotrexate, hydroxychloroquine, leflunomide or sulfasalazine.
The starting doses for RA are shown in Table 1. Similar doses are used for other rheumatic conditions. Anti-TNF medications may be given by injection under the skin or by vein. There are pamphlets and videos that can teach you how to give yourself an injection under the skin. Physicians, nurses, and pharmacists can also teach you how to give the injection.
The medicine can be injected into the thigh or abdomen. The site of injection should be rotated so the same site is not used multiple times. In the case of infliximab and golimumab, the infusions are administered at a doctor’s office or at an infusion center. These treatments take up to 3 hours.
Initially: Given at the clinic or at an infusion center as an intravenous infusion (IV) at a dose of 3-5 mg/kg (according to body weight) at weeks 0, 2, and 6.
Maintenance: IV infusions every 4-8 weeks. Dose may be increased to 5-10 mg/kg.
Initially: 50 mg once a week or 25 mg twice a week as a self-administered subcutaneous injection.
Initially: 40 mg every other week as a self-administered subcutaneous injection.
Initially: 50 mg once per month as a self-administered subcutaneous injection.
Initially: Given at the clinic or at an infusion center as an IV at a dose of 2 mg/kg (according to body weight) at weeks 0 and 4.
Maintenance: IV infusions every 8 weeks.
The time that it takes for the medication to have an effect may vary by patient. Most patients have reported a change in their symptoms after 2 or 3 doses.
The most common side effect seen with the injectable drugs are skin reactions, commonly referred to as “injection site reactions.” The patients usually complain of a localized rash with burning or itching. These reactions can last up to a week. Infliximab has been associated with a severe allergic reaction with swelling of the lips, difficulty breathing and low blood pressure.
The most significant side effect is an increased risk for all types of infections, including tuberculosis (TB) and fungal infections. Some of these infections may be severe. Patients should be tested for TB before starting therapy. The usual way of testing is with a skin test, but a blood test is also available. Hepatitis B testing should be done because unrecognized hepatitis B infection may worsen during treatment.
Anti-TNF medications should be stopped if the patient has high fever or is being treated with antibiotics for an infection. Once the medication is stopped, it should not be restarted until the patient has discussed it with his or her doctor.
Long-term use of anti-TNF agents may increase the risk of cancers such as lymphoma and skin cancer. There are rare neurologic complications from the use of these medications. People who have a history of multiple sclerosis should not use them. People with significant heart failure should not be on anti-TNF therapy because of their heart disease could worsen.
These medications are expensive (more than $10,000 per year), but they are covered by most health care insurance plans. Ask your doctor about prescription assistance plans that can help you to get the medication at a lower price or free of charge.
Patients should talk to their doctors before getting any vaccines. Using these medications may make the vaccination less effective. Refer to the package insert for more information.
© 2015 American College of Rheumatology