TNF Blockers—Should Arthritis Patients Fear Side Effects?

Three vials of medication and a syringe.

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Arthritis patients are sometimes afraid of biologics, also known as biologic response modifiers. The first biologic drugs approved by the FDA for inflammatory types of arthritis were anti-TNF drugs, also commonly called TNF (tumor necrosis inhibitor) blockers. There are potentially serious side effects associated with TNF blockers, such as serious infection and lymphoma, so some degree of fear is not illogical. But, is it not appropriate to weigh the risks and benefits of treatment with TNF blockers?

TNF blockers, which are considered biologic DMARDs, include Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab), Simponi (golimumab), and Cimzia (certolizumab pegol). They have a very good benefit/risk ratio. In other words, while potentially serious side effects may develop, they are not common. It is also noteworthy that most patients experience significant improvements from taking the drugs.

TNF blockers have been studied in patients for years and have been on the market since 1998. Two major concerns with these drugs include the risk of serious infection or lymphoma. Even without taking TNF blockers, rheumatoid arthritis patients have an increased risk of developing these two problems (infection or lymphoma) compared to the general population. In fact, patients who have the most severe cases of rheumatoid arthritis are more likely to develop lymphoma than those with milder disease.

There is evidence that biologic drugs increase the risk of developing unusual infections, such as tuberculosis (TB). Therefore, it is recommended that all patients be screened with a skin test and chest x-ray to check for prior exposure to TB before beginning therapy with a TNF blocker.

You should be extra cautious about taking TNF blockers if you are an insulin-dependent diabetic or have another reason to be at increased risk for infection, recurring infections, or open wounds or sores. Many rheumatoid patients may do very well on the traditional DMARDs, such as Plaquenil (hydroxychloroquine), Azulfidine (sulfasalazine) or Rheumatrex (methotrexate) and may never need to take a TNF blocker. In patients who have significant disease and have reasons they should not take methotrexate (e.g., liver disease), TNF blockers can be used as a first-line treatment.

The Bottom Line

If you are prescribed a TNF blocker and agree to try it, remember to:

  • Know the potential side effects associated with TNF blockers.
  • Be vigilant. Pay attention to the new symptoms which may have developed after starting the TNF blocker.
  • Don't downplay the new symptoms. Report the changes to your doctor and let your doctor decide the significance and what should be done.
  • While awareness and vigilance are essential when starting any new drug, and especially one with potentially serious side effects, keep in mind that most side effects or adverse reactions are not common. Temper your fear of reality.
  • Discuss your concerns with your doctor. Weigh the benefits versus risks of treatment with a TNF blocker. Take into account the severity of your condition, comorbid conditions, and other treatment options. Together with your doctor, formulate a plan and understand the goals for treatment as well as what will be the course of action if something adverse does develop. 
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Additional Reading
  • Answer provided, in part, by Scott J. Zashin, M.D.  Dr. Zashin is clinical assistant professor at University of Texas Southwestern Medical School and an attending physician at Presbyterian Hospitals of Dallas and Plano. Dr. Zashin is author of Arthritis Without Pain - The Miracle Of TNF Blockers and co-author of Natural Arthritis Treatment.