Counseling Points - March 2008 - (Page 10)

Additionally, the side effect profiles for all TNF inhibitors are similar. Although typically mild, injection site reactions may be experienced with the administration of injectable TNF antagonists.29 Individuals receiving TNF inhibitors are also at increased risk for infection.29 Patients should be educated to report any signs and symptoms of infection. Anti-TNF agents are generally discontinued until the infection is resolved. Reactivation of hepatitis B and disseminated tuberculosis (TB) due to reactivation of latent TB has also been associated with the use of these drugs; therefore, screening for these diseases should be conducted before initiating therapy.29 TNF inhibitors are not recommended in patients with congestive heart failure or in individuals who have demyelinating diseases, such as multiple sclerosis.29 once per week by subcutaneous injection.19,28 Compared with traditional DMARDs, etanercept works quickly— treatment benefits have been reported to occur within a few days to 12 weeks.19 Infliximab (Remicade®) Although typically mild, injection site reactions may be experienced with the administration of injectable TNF antagonists. Adalimumab (Humira®) Adalimumab is a fully human anti-TNF monoclonal antibody with high specificity for TNF. It is effective as monotherapy and also in combination with methotrexate or other DMARDs. Additionally, the drug is indicated for psoriatic arthritis, ankylosing spondylitis, and Crohn’s disease.30 Adalimumab binds specifically to TNF and blocks its interaction with cell surface TNF receptors p55 and p75, thereby interfering with endogenous TNF activity.30 Adalimumab is available in a 40-mg pre-filled syringe and is given by self-administered subcutaneous (SC) injection every other week.28,30 If response to this dose is inadequate, the frequency of injections can be increased to weekly. Adalimumab works quickly and treatment benefits can generally be seen in 1 to 4 weeks.29 Etanercept (Enbrel®) Infliximab, in combination with methotrexate, is approved for the treatment of RA. The compound is also indicated for psoriatic arthritis, ankylosing spondylitis, plaque psoriasis, Crohn’s disease, and ulcerative colitis. Infliximab works very quickly against RA—the time to clinical benefit is approximately 1 to 4 weeks.19,28,32 Infliximab inhibits the activity of TNF by binding to TNF in the joint and in the circulation, preventing its interaction with TNF receptors on the surface of inflammatory cells, and eventually clearing TNF from the system. The drug is administered intravenously and infusions typically take between 2 to 3 hours. For the treatment of RA, an initial dose of 3 mg/kg is given at baseline, 2 weeks, and 6 weeks, and every 8 weeks thereafter.19,28,32 If the clinical response is inadequate, infliximab may be titrated to a maximum dose of 10 mg/kg with frequency of infusions increased to every 4 to 6 weeks.32 Because infliximab is a chimeric monoclonal antibody, patients receiving the drug may develop a clinical syndrome of fever, chills, body aches, and headache associated with the infusion. However, in clinical trials evaluating infliximab, these symptoms were observed at relatively low frequency. These side effects can be reduced or prevented by slowing the infusion rate and by administering diphenhydramine, acetaminophen, and sometimes corticosteroids before an infliximab infusion.29 T-Cell Costimulatory Blocker: Abatacept (Orencia®) Although TNF inhibitors are efficacious for many individuals with RA, a significant number of patients have an inadequate response or develop antibodies against these agents. Notably, 25% to 49% of patients who underwent TNF antagonist therapy in clinical trials failed to achieve the ACR 20% improvement response.33 Abatacept is the first compound in a class of drugs known as T-cell costimulatory blockers. It is indicated for the treatment of RA in patients who have had an inadequate response to other DMARDs, such as methotrexate or TNF antagonists.33,34 Abatacept is a recombinant fusion protein that has a unique mechanism of action. It improves symptoms of RA by selectively blocking the costimulatory 10 Etanercept can be used either as monotherapy or in combination with methotrexate for the treatment of moderate to severe RA. Other conditions for which the agent is indicated are psoriatic arthritis, ankylosing spondylitis, and psoriasis.29,31 Etanercept binds to TNF in the circulation and in the joint, preventing interaction with cell surface TNF receptors, thereby reducing TNF activity. The components of the protein are entirely human, and anti-etanercept antibodies are relatively uncommon. Currently, the most commonly used dose of etanercept is 50 mg self-administered COUNSELING POINTS™

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Counseling Points - March 2008 Welcome Pharmacological and Nonpharmacological Treatment of Rheumatoid Arthritis

Counseling Points - March 2008

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