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Starting a Biologic for Rheumatoid Arthritis: What To Expect

Posted on May 03, 2021
See how 1834 members reacted on this article
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Joan Grossman

  • Before starting biologic drug therapy for rheumatoid arthritis, you must be screened for infections and baseline monitoring.
  • Biologics need to be taken by injection or IV infusion, and some can be self-injected at home.
  • Doses of biologic drugs are frequently reduced over time.
  • Many biologic drugs take a couple of months to take effect.

Before starting a biologic drug for rheumatoid arthritis (RA), you will need to undergo a screening process that evaluates your medical history and current health condition. You will want to discuss dosage, schedules, and methods for taking a biologic drug with your health care provider. You may also need to have some vaccinations to prevent infections while your immune system is suppressed by the biologic medication.

Biologic drugs work by targeting overactive proteins in the immune system that cause inflammation in joints and recurring joint pain and swelling. Biologics can be very effective in reducing disease activity in moderate to severe rheumatoid arthritis, but risk factors should be assessed before beginning biologic treatment.

Biologic therapy is considered appropriate for people with RA when other disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine, have not provided adequate relief from symptoms. Biologics are often used in combination with methotrexate.

Many myRAteam members have shared questions about starting a biologic drug. “My doctor is planning on starting me on a biologic soon, since my symptoms have not gotten better on methotrexate and plaquenil,” a member wrote. “To those who have tried or are currently on biologics: what was/is your experience?”

“I’m starting to feel a little optimistic,” another member said. “I went to my rheumatologist yesterday. Plans are in motion for biologics. I’m hopeful.”

Screening Tests

Tests are prescribed before starting a biologic drug to determine if you have an underlying — or silent — infection. Biologic drugs increase the risk for infection because they suppress agents in the immune system. An existing infection will usually need to be treated prior to beginning biologic treatment. People with RA are typically given these tests for silent infections:

  • Tuberculosis (TB) blood test, and possibly a chest X-ray and skin test to determine if you have a latent TB infection
  • Hepatitis B and hepatitis C blood tests

Other blood tests will determine baseline indicators that should be monitored while taking a biologic. Here are some baseline tests:

  • A liver enzyme test measures liver function, which is monitored when taking biologic or immunosuppressive drugs like methotrexate.
  • A complete blood count measures red blood cells, white blood cells, hemoglobin, hematocrit, and platelets to monitor for abnormal blood counts (a risk with biologics).
  • Lipids, such as cholesterol, are blood fats that are monitored because people with RA have a higher risk for heart disease.
  • An antinuclear antibodies (ANA) test can indicate other autoimmune conditions, such as lupus, and may be offered while taking a biologic.
  • A human immunodeficiency virus (HIV) blood test is recommended due to the effect of biologic drugs on immune system T cells, which may impact treatment for HIV/AIDS.

Medication Administration, Doses, and Schedules

Doctors prescribe several types of biologic drugs to treat RA, which are taken, dosed, and scheduled in a variety of ways. Biologics used to treat RA include Cimzia (certolizumab pegol), Enbrel (etanercept), Humira (adalimumab), and Remicade (infliximab). Talk to your rheumatologist and health care team about specifications for any biologic drug recommended for you.

Biologic Drug Administration

Currently available biologic drugs consist of large molecule compounds that cannot be effectively absorbed in the digestive system if taken orally. They must be taken by infusion or injection. Infusions require a clinical setting, as they are given through an IV needle that administers the drug directly into the blood system.

Biologic injections are administered by syringes and auto-injectors that release the drug subcutaneously — under the skin. Some biologic drugs can be safely and conveniently self-injected at home.

Read more about self-injection.

Dosing of Biologic Drugs

Dosage for biologic drug treatment can change over time. You may be prescribed a loading dose, which is a clinical term for an increased dose of medication that can quickly reach a steady state of concentration in the body. A loading dose of a biologic drug can achieve faster therapeutic results, which is why biologics are often administered in higher doses at the start of treatment. This process is known as dose loading. As treatment continues, dosage may then be tapered down. Loading doses vary between medications.

Schedules for Taking Biologics

Biologic drugs are prescribed on a wide range of schedules. Higher doses may be given on a weekly basis at the beginning of treatment and then tapered off to one dose every few weeks. Some biologics are taken only once every eight weeks, after doses are reduced.

“I'm on a biologic, infused every six weeks, and personally, it's been a miracle,” said one myRAteam member. “I'm now in remission and feel so blessed to feel like my old self!”

Talk to your doctor and find out if your biologic treatment allows you any choice in your treatment schedule. Be sure you thoroughly understand your treatment plan. It’s important to carefully adhere to the schedule required for the particular biologic drug you are taking.

Common Side Effects

When taking a biologic drug, you have an increased risk for infection because the medication is designed to suppress parts of the immune system. Other common side effects for biologics include reactions at the site of injection, headache, and nausea. If you have a sign of a serious infection, report it immediately to your rheumatologist and health care team. Signs of serious infection include any of the following symptoms:

  • Fever or chills
  • Muscle pain or tingling
  • Rash or painful sores
  • Diarrhea or abdominal pain
  • Abnormal urination

Discuss side effects with your doctors and get medical advice about how best to manage them.

How Quickly Do Biologics Work?

Biologic drugs often take time to start taking effect. Some people with RA feel better after their first treatment, but more commonly, biologic drugs can take a few weeks or months for the initial response. With biologic drugs, it’s essential to maintain treatment and be patient as the medication takes effect.

“I feel like a million bucks after my infusion. I wouldn't trade that for anything. I can do things, it's amazing,” one myRAteam member said. “It really is worth it.”

Talk With Others Who Understand

On myRAteam, the social network for people with rheumatoid arthritis and their loved ones, more than 147,000 members come together to ask questions, give advice, and share their stories with others who understand life with rheumatoid arthritis.

Are you living with rheumatoid arthritis and considering biologic treatment? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Choice of Biologic Therapy for Patients With Rheumatoid Arthritis: The Infection Perspective — Current Rheumatology Reviews
  2. Use of Biologics in Rheumatoid Arthritis: Where Are We Going? — American Journal of Health System Pharmacy
  3. Rheumatoid Arthritis: Medication To Prevent Joint Damage — InformedHealth.org
  4. 9 Medical Tests You Need Before Starting a Biologic Drug — CreakyJoints
  5. Complete Blood Count (CBC) — Mayo Clinic
  6. The Cardiac Risks of Rheumatoid Arthritis — Cleveland HeartLab
  7. The British Society for Rheumatology Biologic DMARD Safety Guidelines in Inflammatory Arthritis — Executive Summary — Rheumatology
  8. Biologics — Arthritis Foundation
  9. Patient Experience With Intravenous Biologic Therapies for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis, Psoriasis, Rheumatoid Arthritis, and Ulcerative Colitis — Patient Preference and Adherence
  10. Recent Advances in the Oral Delivery of Biologics — The Pharmaceutical Journal
  11. The Pharmacological and Clinical Aspects Behind Dose Loading of Biological Disease Modifying Anti-rheumatic Drugs (bDMARDs) in Auto-immune Rheumatic Diseases (AIRDs): Rationale and Systematic Narrative Review of Clinical Evidence — BMC Rheumatology
  12. Patterns of Care for Biologic-Dosing Outliers and Nonoutliers in Biologic-Naive Patients With Rheumatoid Arthritis — Journal of Managed Care and Specialty Pharmacy
  13. Side Effects of Biologic Medications — Johns Hopkins Arthritis Center
  14. Rheumatoid Arthritis: A Brief Overview of the Treatment — Medical Principles and Practice

A myRAteam Member said:

I take oral Imuran since April with not so great results. I started Infixamab in July. After my second dose I noticed a shift. Not a great change but a hint of better days. I became sick with a severe… read more

posted 29 days ago

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Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Joan Grossman is a freelance writer, filmmaker, and consultant based in Brooklyn, NY. Learn more about her here.

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