What to Know About Biologics for Rheumatoid Arthritis (RA)

Rheumatoid arthritis (RA) is an inflammatory, autoimmune disease in which your immune system mistakenly attacks your joints and other body systems. Treatment includes medications that target inflammation and slow disease progression, such as methotrexate, a type of disease-modifying antirheumatic drug (DMARD).

Biologics are usually considered when a person isn't responding to traditional DMARDs. Biologics are genetically engineered proteins made from complex molecules using living microorganisms like plants or animal cells. They work by targeting the proteins in the body responsible for the immune response, zeroing in on the affected areas without impacting the rest of the body.

What Are Biologics?

Biologics work by targeting specific parts of the inflammatory process. Each biologic drug targets a different molecule. RA medications such as DMARDs work by stopping or reducing inflammation.

DMARDs that treat RA include Plaquenil (hydroxychloroquine), Arava (leflunomide), and Otrexup (methotrexate).

Biologics are a type of DMARD, but they are made differently. You may be prescribed biologics if one or more traditional DMARDs aren't relieving your symptoms.

Types of Biologics for RA

Biologics for RA differ in what they are targeting in the body during the inflammatory process. There are various biologics and biosimilars, which are biologics similar to other biologics.

TNF Inhibitors

Tumor necrosis factor (TNF) inhibitors are a type of biologic used to reduce the inflammation in RA and similar conditions caused by TNF, which is a substance produced by your immune system. While TNF is natural, it is a significant driver of inflammation and the progression of RA.

TNF inhibitors aren't considered the best initial option to treat RA, but they can be added to another treatment like methotrexate.

TNF inhibitors include:

• Enbrel (etanercept)
• Remicade (infliximab)
• Humira (adalimumab)
• Simponi (golimumab)
• Cimzia (certolizumab pegol)
  

B-cell Inhibitors

B-cell inhibitors are commonly used to treat autoimmune diseases, especially RA. They are usually considered when other treatments haven't worked.

B lineage cells produce pathogenic autoantibodies, which cause inflammation and tissue injury but also significantly contribute to the regulation of inflammation. Therefore, B-cell inhibitors manage inflammation and help prevent increased inflammation and RA progression.

Rituxan (rituximab) is the primary B-cell inhibitor in the treatment of RA.

Interleukin Inhibitors

Interleukins are a group of proteins that respond to infections (cytokines). They are involved in the regulation of the immune system. Interleukin inhibitors are immunosuppressive agents that prevent the action of interleukins.

Interleukin inhibitors are typically used after ineffective treatment with TNF inhibitors. Generally, interleukin inhibitors are tolerated and effective.

Interleukin inhibitors include:

• Kineret (anakinra)
• Ilaris (canakinumab)
• Taltz (ixekizumab)
• Kevzara (sarilumab)
• Cosentyx (secukinumab)
• Actemra (tocilizumab)
• Stelara (ustekinumab)

Not all of these interleukin inhibitors are used in the treatment of RA.

Selective Costimulation Modulators

Selective costimulation modulators are usually used when other DMARDs haven't worked. They can also be used in combination with other medications.

Selective costimulation modulators work by blocking the activity of T cells, a type of white blood cell that causes swelling and damage related to arthritis. Selective costimulation modulators include Orencia (abatacept).

Before Taking

Your healthcare provider will run tests to identify if you're a good candidate for biologics. Your likelihood of having side effects or complications will also be evaluated.

Biologics work by targeting specific cells in the body and have a serious effect on the immune system, leading to a higher chance of infection. When the immune system is compromised or suppressed, it becomes more difficult for your body to fight off infections. Clinicians will work with you to determine if the benefits of use of biologics outweigh the risks and what to expect with treatment.

Before starting biologics, your healthcare team may run the following tests:

• Full medical assessment
• Imaging
• Echocardiogram
• Disease screening
• Blood tests
• Vaccine assessment

If you have had a recent infection, have a recurring infection, or presently have an infection, your healthcare provider will likely not start you on biologics. The medications that people with tuberculosis, hepatitis, cancer, a heart condition, or diabetes take may interact with biologics, but a full medical evaluation will help your healthcare provider come to a decision.

Additional facts to keep in mind when using biologics are vaccination interactions, upcoming surgeries, pregnancy, breastfeeding, and allergies.

Biologic Drug Alternative: Biosimilars

Biosimilar drugs are a similar medication to biologic drugs. The Food and Drug Administration (FDA) has approved several biosimilar products. They are often much more affordable than comparable biologics and alternative drugs.

Types of biosimilars include:

• Zarzio (filgrastim-sndz)
• Mvasi (bevacizumab-awwb)
• Ogiviri (trastuzumab-dkt)
• Fulphila (pegfilgrastim-jmdb)
• Truxima (Rituximab-abbs)

Dosage

Your healthcare provider will determine if biologics are right for you based on your medical profile, what symptoms you are experiencing, and prior treatments. If approved to move forward with a biologic regimen for RA, you should follow your healthcare provider's instructions.

Dosage and mode of administration vary between drugs. Additionally, some people with rheumatoid arthritis are able to reduce the dosage over time. Always discuss any new medications or changes to medications with your provider.

Biologics can be taken by injection into the skin of the thigh or abdomen. They also can be administered in a healthcare provider's office or infusion center intravenously (IV, through a vein). Treatments can take up to four hours, and most people will see a full benefit around three months.

Side Effects of Biologics for RA

Biologics for RA can cause side effects ranging from mild to serious to life-threatening.

Mild side effects from biologics include:

• Headaches
• Minor infections
• Injection site reaction
• Fever
• Chills
• Body aches

Serious side effects include:

• Severe skin or lung infection
• Skin cancer
• Serious allergic reactions

While mild side effects are usually no cause for alarm, they can be mitigated by changing the dose or rate of injection or infusion.

Warnings and Interactions

Biologics for rheumatoid arthritis are used alone or in combination with other non-biologics. Methotrexate is a DMARD commonly used with a biologic.

Using biologics puts you at risk for infection from infusion, at the injection site, or due to suppression of the immune system. Report any concerns to your provider, and speak with them about possible interactions or warnings.

Which of the Biologics Should You Use?

Biologics are all a part of the same drug class, but each has a unique target and its own risks. Choosing a biologic requires a discussion with your provider, medical evaluation, consideration of risks and current treatments, efficacy, cost, and convenience.

A Word From Verywell

Living with rheumatoid arthritis affects many aspects of your daily life, and some medications work better than others. Biologics can be a great option, with biosimilars not far behind as a cheaper option. Work with your healthcare provider to create a treatment plan that's right for you, and continue to revisit the efficacy and risks over time to ensure your treatment is still your best option.