Rheumatoid Arthritis – The Era of Biologics

Rheumatoid Arthritis (RA) is a chronic, lifelong and potentially disabling disease. We treat patients early, in order to avoid permanent disability and deteriorating quality of life.

Over the past 10 years, we have moved forward in leaps and bounds offering new and effective targeted treatment with biologic therapies that can slow, stop and perhaps even reverse the effects of this chronic disease.

As rheumatologists, we initially approach rheumatoid arthritis management with traditional disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate and leflunomide, but swiftly move on to combination therapy or escalate to biologic DMARDs in partial or non-responders.

Biologic DMARDs – what are they?

Biologic DMARDs have revolutionized RA treatment. They target components of the RA inflammatory cascade and can be effective as monotherapy as well as combination therapy. They are often superior to traditional DMARDS, have fairly rapid onset of action with better side effect profiles and sustained effectiveness.

The first targeted biologic for RA – a TNF inhibitor – Etanercept was approved for use by the FDA in 1998. Since then, several other biologics have become available including other TNF inhibitors (adalimumab, infliximab, golimumab), T-cell modulators (abatacept), B-cell depleters (rituximab), IL-6 inhibitors (tocilizumab) and IL-17 inhibitors (ixekinumab). These therapies are given subcutaneously (SC) or through intravenous (IV) infusions. Also available are new oral medications which are not biologics but small molecules that have cytoplasmic targets such as the JAK inhibitors (tofacitinib, baricitinib).

Expensive but effective

Unfortunately, one of the major setbacks of these highly effective drugs is the high cost involved. Within government and university hospitals, an annual budget is allocated for funding biologic treatment but access is limited. In the private sector, the cost is either born by private insurance providers or self-funders. New biosimilars are being introduced and new targeted therapies continue to be developed. The market will continue to become more competitive and hopefully this will result in lower prices.

Biologics are however extremely effective in reducing the symptoms of RA, slowing disease progression, improving general quality of life. The response is most often rapid, with patients noticing an improvement within several weeks or even occasionally, within several days.

How safe are biologics?

The most commonly reported adverse cases (occurs in <10% of patients) associated with the subcutaneous injections are injection site reactions such as burning or stinging.

Biologics can cause relative immunosuppression and as a consequence leave the patient moderately at risk of serious infections, particularly patients with comorbidities. There is a particular risk with TNF inhibitors of reactivation of latent TB, hence the need to screen patients prior to treatment and if necessary, treat for this prior to initiation of therapy.