Pharmacological Aspects of Immunology 2 : Biological Therapies

Question 1

Therapies for rheumatoid arthritis (RA)

• Anti-inflammatory drugs - only provide … …
  
  • …-… anti-inflammatory drugs (NSAIDs)
  • … anti-inflammatory drugs (glucocorticoids)
• Disease-modifying anti-rheumatic drugs (DMARDs) - Slow the clinical and radiographic progression of RA
  
  • Synthetic DMARDs: MTX, sulfasalazine, hydroxychloroquine, leflunomide
  • Targeted synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • Biologic agents (biologicals): TNF-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Answer 1

• Anti-inflammatory drugs - only provide symptom relief
  
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroidal anti-inflammatory drugs (glucocorticoids)
• Disease-modifying anti-rheumatic drugs (DMARDs) - Slow the clinical and radiographic progression of RA
  
  • Synthetic DMARDs: MTX, sulfasalazine, hydroxychloroquine, leflunomide
  • Targeted synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • Biologic agents (biologicals): TNF-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Question 2

Therapies for rheumatoid arthritis (RA)

• Anti-inflammatory drugs - only provide symptom relief
  
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroidal anti-inflammatory drugs (glucocorticoids)
• Disease-… anti-… drugs (DMARDs) - Slow the clinical and radiographic … of RA
  
  • Synthetic DMARDs: MTX, sulfasalazine, hydroxychloroquine, leflunomide
  • Targeted synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • Biologic agents (biologicals): TNF-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Answer 2

• Anti-inflammatory drugs - only provide symptom relief
  
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroidal anti-inflammatory drugs (glucocorticoids)
• Disease-modifying anti-rheumatic drugs (DMARDs) - Slow the clinical and radiographic progression of RA
  
  • Synthetic DMARDs: MTX, sulfasalazine, hydroxychloroquine, leflunomide
  • Targeted synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • Biologic agents (biologicals): TNF-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Question 3

Therapies for rheumatoid arthritis (RA)

• Anti-inflammatory drugs - only provide symptom relief
  
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroidal anti-inflammatory drugs (glucocorticoids)
• Disease-modifying anti-rheumatic drugs (DMARDs) - Slow the clinical and radiographic progression of RA
  
  • Synthetic DMARDs: …, sulfasalazine, hydroxychloroquine, leflunomide
  • … synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • … agents (…): TNF-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Answer 3

• Anti-inflammatory drugs - only provide symptom relief
  
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroidal anti-inflammatory drugs (glucocorticoids)
• Disease-modifying anti-rheumatic drugs (DMARDs) - Slow the clinical and radiographic progression of RA
  
  • Synthetic DMARDs: Methatrexate, sulfasalazine, hydroxychloroquine, leflunomide
  • Targeted synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • Biologic agents (biologicals): TNF-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Question 4

Therapies for rheumatoid arthritis (RA)

• Anti-inflammatory drugs - only provide symptom relief
  
  • Non-steroidal anti-inflammatory drugs (…)
  • Steroidal anti-inflammatory drugs (…)
• Disease-modifying anti-rheumatic drugs (DMARDs) - Slow the clinical and radiographic progression of …
  
  • Synthetic DMARDs: MTX, sulfasalazine, hydroxychloroquine, leflunomide
  • Targeted synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • Biologic agents (biologicals): …-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Answer 4

• Anti-inflammatory drugs - only provide symptom relief
  
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroidal anti-inflammatory drugs (glucocorticoids)
• Disease-modifying anti-rheumatic drugs (DMARDs) - Slow the clinical and radiographic progression of RA
  
  • Synthetic DMARDs: MTX, sulfasalazine, hydroxychloroquine, leflunomide
  • Targeted synthetic DMARDs: JAK inhibitors- tofacitinib, baricitinib
  • Biologic agents (biologicals): TNF-blockers, Drugs targeting IL-1, IL-6 , B-cells and T-cells

Question 5

Synthetic DMARDs – Methotrexate (MTX)

• … choice DMARD, the … standard - Introduced in 1947, used in high doses to treat …
• Antimetabolite (folate analogue), inhibits cell …
• Increases … level (anti-inflammatory)
• Reduces the production of damaging polyamines
• Induces … of activated CD4+ and CD8+ T-cells
• “Anchor drug” in … therapies
• Reduces inflammation quickly and keeps it under tight control
• Reduces the risk of death from cardiovascular disease in people with RA
• Taking supplements of folic acid reduces side-effects caused by folic acid depletion
• Administered between 7.5 and 25mg weekly per os or s.c. – at this dose no significant anti-cancer or immunosuppressive effect.

Answer 5

• First choice DMARD, the gold standard - Introduced in 1947, used in high doses to treat cancer
• Antimetabolite (folate analogue), inhibits cell proliferation
• Increases adenosine level (anti-inflammatory)
• Reduces the production of damaging polyamines
• Induces apoptosis of activated CD4+ and CD8+ T-cells
• “Anchor drug” in combination therapies
• Reduces inflammation quickly and keeps it under tight control
• Reduces the risk of death from cardiovascular disease in people with RA
• Taking supplements of folic acid reduces side-effects caused by folic acid depletion
• Administered between 7.5 and 25mg weekly per os or s.c. – at this dose no significant anti-cancer or immunosuppressive effect. ​

Question 6

Synthetic DMARDs – Methotrexate (MTX)

• First choice DMARD, the gold standard - Introduced in 1947, used in high doses to treat cancer
• Anti… (folate analogue), inhibits cell proliferation
• Increases adenosine level (anti-inflammatory)
• Reduces the production of damaging polyamines
• Induces apoptosis of activated CD4+ and CD8+ T-cells
• “… drug” in combination therapies
• Reduces … quickly and keeps it under tight control
• Reduces the risk of death from … disease in people with RA
• Taking supplements of folic acid reduces side-effects caused by folic acid depletion
• Administered between 7.5 and 25mg weekly per os or s.c. – at this dose no significant anti-cancer or immunosuppressive effect.

Answer 6

• First choice DMARD, the gold standard - Introduced in 1947, used in high doses to treat cancer
• Antimetabolite (folate analogue), inhibits cell proliferation
• Increases adenosine level (anti-inflammatory)
• Reduces the production of damaging polyamines
• Induces apoptosis of activated CD4+ and CD8+ T-cells
• “Anchor drug” in combination therapies
• Reduces inflammation quickly and keeps it under tight control
• Reduces the risk of death from cardiovascular disease in people with RA
• Taking supplements of folic acid reduces side-effects caused by folic acid depletion
• Administered between 7.5 and 25mg weekly per os or s.c. – at this dose no significant anti-cancer or immunosuppressive effect. ​

Question 7

Synthetic DMARDs – Methotrexate (MTX)

• First choice DMARD, the gold standard - Introduced in 1947, used in high doses to treat cancer
• Antimetabolite (folate analogue), inhibits cell proliferation
• … adenosine level (anti-inflammatory)
• Reduces the production of damaging polyamines
• Induces apoptosis of activated CD4+ and CD8+ T-cells
• v“Anchor drug” in combination therapies
• Reduces inflammation quickly and keeps it under tight control
• Reduces the risk of death from cardiovascular disease in people with RA
• Taking supplements of … acid reduces side-effects caused by … acid depletion
• Administered between 7.5 and 25mg … per os or s.c. – at this dose no significant anti-cancer or immunosuppressive effect.

Answer 7

• First choice DMARD, the gold standard - Introduced in 1947, used in high doses to treat cancer
• Antimetabolite (folate analogue), inhibits cell proliferation
• Increases adenosine level (anti-inflammatory)
• Reduces the production of damaging polyamines
• Induces apoptosis of activated CD4+ and CD8+ T-cells
• v“Anchor drug” in combination therapies
• Reduces inflammation quickly and keeps it under tight control
• Reduces the risk of death from cardiovascular disease in people with RA
• Taking supplements of folic acid reduces side-effects caused by folic acid depletion
• Administered between 7.5 and 25mg weekly per os or s.c. – at this dose no significant anti-cancer or immunosuppressive effect. ​

Question 8

What is the first choice DMARD (the gold standard)?

Answer 8

Methotrexate

Question 9

Methotrexate is used in high doses to treat what?

Answer 9

cancer

Question 10

Methotrexate:…

• … (folate analogue), inhibits cell proliferation
• Increases … level (anti-inflammatory)
• Reduces the production of damaging …
• Induces … of activated CD4+ and CD8+ T-cells

Answer 10

• Antimetabolite (folate analogue), inhibits cell proliferation
• Increases adenosine level (anti-inflammatory)
• Reduces the production of damaging polyamines
• Induces apoptosis of activated CD4+ and CD8+ T-cells

Question 11

Methotrexate is an “… drug” in combination therapies

Answer 11

Methotrexate is an “Anchor drug” in combination therapies

Question 12

Taking supplements of folic acid whilst taking … reduces side-effects caused by folic acid depletion

Answer 12

Taking supplements of folic acid whilst taking methotrexate reduces side-effects caused by folic acid depletion

Question 13

What is the dose for methotrexate? (range)

Answer 13

• Administered between 7.5 and 25mg weekly per os or s.c. – at this dose no significant anti-cancer or immunosuppressive effect.

Question 14

Adverse effects of synthetic DMARDs

• …-… weeks treatment required to achieve improvement of symptoms
• MTX – …% of patients experience adverse effects
  
  • Nausea
  • Loss of appetite
  • Diarrhoea
  • Rash, allergic reactions
  • Headache
  • Hair loss
  • Risk of infections (pneumonia)
  • Hepatotoxicity (metabolism)
  • Kidney toxicity (route of elimination)

Answer 14

• 8-12 weeks treatment required to achieve improvement of symptoms
• MTX – 30% of patients experience adverse effects
  
  • Nausea
  • Loss of appetite
  • Diarrhoea
  • Rash, allergic reactions
  • Headache
  • Hair loss
  • Risk of infections (pneumonia)
  • Hepatotoxicity (metabolism)
  • Kidney toxicity (route of elimination)

Question 15

Adverse effects of synthetic DMARDs

• 8-12 weeks treatment required to achieve improvement of symptoms
• MTX – 30% of patients experience adverse effects
  
  • Nausea
  • Loss of …
  • Diarrhoea
  • Rash, … reactions
  • Headache
  • … loss
  • Risk of … (e.g…)
  • … (metabolism)
  • Kidney toxicity (route of elimination)

Answer 15

• 8-12 weeks treatment required to achieve improvement of symptoms
• MTX – 30% of patients experience adverse effects
  
  • Nausea
  • Loss of appetite
  • Diarrhoea
  • Rash, allergic reactions
  • Headache
  • Hair loss
  • Risk of infections (pneumonia)
  • Hepatotoxicity (metabolism)
  • Kidney toxicity (route of elimination)

Question 16

Adverse effects of synthetic DMARDs

• 8-12 weeks treatment required to achieve improvement of symptoms
• MTX – 30% of patients experience adverse effects
  
  • What are the 9 side effects?

Answer 16

• 8-12 weeks treatment required to achieve improvement of symptoms
• MTX – 30% of patients experience adverse effects
  
  • Nausea
  • Loss of appetite
  • Diarrhoea
  • Rash, allergic reactions
  • Headache
  • Hair loss
  • Risk of infections (pneumonia)
  • Hepatotoxicity (metabolism)
  • Kidney toxicity (route of elimination)

Question 17

Adverse effects of synthetic DMARDs

• How many weeks treatment required to achieve improvement of symptoms?

Answer 17

• 8-12 weeks treatment required to achieve improvement of symptoms
• MTX – 30% of patients experience adverse effects
  
  • Nausea
  • Loss of appetite
  • Diarrhoea
  • Rash, allergic reactions
  • Headache
  • Hair loss
  • Risk of infections (pneumonia)
  • Hepatotoxicity (metabolism)
  • Kidney toxicity (route of elimination)

Question 18

Additional side effects of specific synthetic DMARDS:

• … – accumulation of the drug in the eye
• Leflunomide – hypertension

Answer 18

• Hydroxychloroquine – accumulation of the drug in the eye
• Leflunomide – hypertension

Question 19

Additional side effects of specific synthetic DMARDS:

• Hydroxychloroquine – accumulation of the drug in the …
• Leflunomide – …

Answer 19

• Hydroxychloroquine – accumulation of the drug in the eye
• Leflunomide – hypertension

Question 20

Targeted synthetic DMARDs

• When are they given instead of synthetic DMARDs?

Answer 20

• In moderate-to-severe active RA in patients who have had an inadequate response to, or are intolerant to one or more DMARDs (as monotherapy or in combination with MTX)

Question 21

Targeted synthetic DMARDs

• Used in what condition?
• What are the two main ones? (and what do they selectively inhibit?)

Answer 21

• Used in Rheumatoid Arthritis
• Tofacitinib
  
  • selectively inhibits the JAK1 and JAK3
  • Also used in psoriatic arthritis and ulcerative colitis.
  • Dosage: 5 mg twice daily per os
• Baricitinib
  
  • selectively and reversibly inhibits JAK1 and JAK2
  • Dosage: 4 mg once daily per os

Question 22

What does Tofacitinib selectively inhibit?

Answer 22

selectively inhibits the JAK1 and JAK3

Question 23

What does Baricitinib selectively and reversibly inhibit?

Answer 23

selectively and reversibly inhibits JAK1 and JAK2

Question 24

Oral … 5 mg twice daily is indicated for the treatment of moderate to severe active rheumatoid arthritis

Answer 24

Oral tofacitinib 5 mg twice daily is indicated for the treatment of moderate to severe active rheumatoid arthritis

Question 25

Tofacitinib is used for RA, but what else? (2)

Answer 25

psoriatic arthritis and ulcerative colitis

Question 26

What is the dosage of Tofacitinib?

Answer 26

5 mg twice daily per os

Question 27

What is the dosage of Baricitinib?

Answer 27

4 mg once daily per os

Question 28

Adverse effects of Targeted Synthetic DMARDs

• Anaemia, cough, diarrhoea, fatigue, fever, gastrointestinal discomfort, increased risk of infection (which DMARD?)
• Dyslipidaemia, herpes zoster, increased risk of infection, nausea, oropharyngeal pain, thrombocytosis (which DMARD?)

Answer 28

• Anaemia, cough, diarrhoea, fatigue, fever, gastrointestinal discomfort, increased risk of infection (tofacitinib)
• Dyslipidaemia, herpes zoster, increased risk of infection, nausea, oropharyngeal pain, thrombocytosis (baricitinib)

Question 29

Adverse effects of tofacitinib include … (7)

Answer 29

• Anaemia, cough, diarrhoea, fatigue, fever, gastrointestinal discomfort, increased risk of infection

Question 30

Adverse effects of baricitinib include… (6)

Answer 30

• Dyslipidaemia, herpes zoster, increased risk of infection, nausea, oropharyngeal pain, thrombocytosis

Question 31

New era in the treatment of RA – The biologics

Answer 31

• In RA - IL-1 production decreased
• In osteoarthritis, IL-1 production was not changed
  
  • Shows blocking TNF-alpha could reduce the level of IL-1

Question 32

Central role of TNF in the inflammatory cascade of RA

Answer 32

Question 33

The anti-TNF-a therapy

• In 1992, Ravinder Maini and his colleagues tested a TNF-a blocker on 20 patients with rheumatoid arthritis that was not responding to existing treatments. What were the results?

Answer 33

• In 1992, Ravinder Maini and his colleagues tested a TNF-a blocker on 20 patients with rheumatoid arthritis that was not responding to existing treatments. The results were remarkable – nearly every patient had a rapid reduction of pain and fatigue and improved mobility, and the swelling in their joints went down.
• Between 1993 and 1994 researchers from the Kennedy Institute carried out a larger study comparing a TNF-a blocker with a placebo. Almost 80 percent of patients receiving a high dose of the TNF-a blocker responded to treatment, compared to just 8 percent on placebo.
• Further research at the Kennedy Institute in the late 1990s showed that combining TNF-a blockers with MTX made the treatment even more effective.
• TNF blockade, both effective and relatively safe, has dramatically changed therapy for RA, Crohn’s disease, ankylosing spondylitis and psoriasis.
• Anti-TNF drugs have been the biggest pharmaceutical drug class with sales exceeding $25 billion per annum.

Question 34

The anti-TNF-a therapy

• In 1992, Ravinder Maini and his colleagues tested a TNF-a blocker on 20 patients with rheumatoid arthritis that was not responding to existing treatments. The results were remarkable – nearly every patient had a rapid reduction of pain and fatigue and improved mobility, and the swelling in their joints went down.
• Between 1993 and 1994 researchers from the Kennedy Institute carried out a larger study comparing a TNF-a blocker with a placebo. Almost … percent of patients receiving a high dose of the TNF-a blocker responded to treatment, compared to just … percent on placebo.
• Further research at the Kennedy Institute in the late 1990s showed that combining TNF-a blockers with MTX made the treatment even more effective.

Answer 34

• In 1992, Ravinder Maini and his colleagues tested a TNF-a blocker on 20 patients with rheumatoid arthritis that was not responding to existing treatments. The results were remarkable – nearly every patient had a rapid reduction of pain and fatigue and improved mobility, and the swelling in their joints went down.
• Between 1993 and 1994 researchers from the Kennedy Institute carried out a larger study comparing a TNF-a blocker with a placebo. Almost 80 percent of patients receiving a high dose of the TNF-a blocker responded to treatment, compared to just 8 percent on placebo.
• Further research at the Kennedy Institute in the late 1990s showed that combining TNF-a blockers with MTX made the treatment even more effective.
• TNF blockade, both effective and relatively safe, has dramatically changed therapy for RA, Crohn’s disease, ankylosing spondylitis and psoriasis.
• Anti-TNF drugs have been the biggest pharmaceutical drug class with sales exceeding $25 billion per annum.

Question 35

The anti-TNF-a therapy

• TNF …, both effective and relatively safe, has dramatically changed therapy for RA, Crohn’s disease, ankylosing spondylitis and psoriasis.
• …-… drugs have been the … pharmaceutical drug class with sales exceeding $25 billion per annum.

Answer 35

• TNF blockade, both effective and relatively safe, has dramatically changed therapy for RA, Crohn’s disease, ankylosing spondylitis and psoriasis.
• Anti-TNF drugs have been the biggest pharmaceutical drug class with sales exceeding $25 billion per annum.

Question 36

TNF blockade, both effective and relatively safe, has dramatically changed therapy for …, Crohn’s disease, ankylosing spondylitis and …

Answer 36

TNF blockade, both effective and relatively safe, has dramatically changed therapy for RA, Crohn’s disease, ankylosing spondylitis and psoriasis.

Question 37

…drugs have been the biggest pharmaceutical drug class with sales exceeding $25 billion per annum.

Answer 37

Anti-TNF drugs have been the biggest pharmaceutical drug class with sales exceeding $25 billion per annum.

Question 38

Canada Gairdner International Award 2014 - what was it for?

Answer 38

Question 39

The targets of biologic agents in RA

• What are the 4 targets?

Answer 39

• Targets include IL-1, IL-6, T cell and B cell

Question 40

The biological therapies are administered how?

Answer 40

Protein drugs administered parenterally

Question 41

The biological therapies

• Biological therapy is recommended if:
  
  • Patient has failed to respond to treatment with at least two standard (synthetic) DMARDs, one of which must be … (unless patient cannot take … for medical reason)
  • Patient’s RA disease activity score (DAS 28) is measured as 5.1 or over, on two occasions, one month apart

Answer 41

• Biological therapy is recommended if:
  
  • Patient has failed to respond to treatment with at least two standard (synthetic) DMARDs, one of which must be methotrexate (unless patient cannot take methotrexate for medical reason)
  • Patient’s RA disease activity score (DAS 28) is measured as 5.1 or over, on two occasions, one month apart

Question 42

The biological therapies

• Biological therapy is recommended if:
  
  • Patient has failed to respond to treatment with at least … standard (synthetic) DMARDs, one of which must be MTX (unless patient cannot take MTX for medical reason)
  • Patient’s RA disease activity score (DAS 28) is measured as … or over, on two occasions, one month apart

Answer 42

• Biological therapy is recommended if:
  
  • Patient has failed to respond to treatment with at least two standard (synthetic) DMARDs, one of which must be MTX (unless patient cannot take MTX for medical reason)
  • Patient’s RA disease activity score (DAS 28) is measured as 5.1 or over, on two occasions, one month apart

Question 43

Currently licensed biologics for the treatment of RA in the UK

• …-…: infliximab, etanercept, adalimumab, golimumab,
• certolizumab pegol
• Monoclonal antibody against … cells: rituximab
• … cell co-stimulation inhibitor: abatacept
• Monoclonal antibodies against IL-6R: tocilizumab, sarilumab
• → Licenced in the US: IL-1R antagonist anakinra

Answer 43

• TNF-blockers: infliximab, etanercept, adalimumab, golimumab,
• certolizumab pegol
• Monoclonal antibody against B cells: rituximab
• T cell co-stimulation inhibitor: abatacept
• Monoclonal antibodies against IL-6R: tocilizumab, sarilumab
• → Licenced in the US: IL-1R antagonist anakinra

Question 44

Currently licensed biologics for the treatment of RA in the UK

• TNF-blockers: infliximab, etanercept, adalimumab, golimumab,
• certolizumab pegol
• Monoclonal antibody against B cells: rituximab
• T cell co-stimulation inhibitor: abatacept
• … antibodies against IL-…R: tocilizumab, sarilumab
• → Licenced in the US: IL-…R antagonist anakinra

Answer 44

• TNF-blockers: infliximab, etanercept, adalimumab, golimumab,
• certolizumab pegol
• Monoclonal antibody against B cells: rituximab
• T cell co-stimulation inhibitor: abatacept
• Monoclonal antibodies against IL-6R: tocilizumab, sarilumab
• → Licenced in the US: IL-1R antagonist anakinra

Question 45

What are the 5 TNF-blockers licensed in the UK?

Answer 45

• infliximab, etanercept, adalimumab, golimumab, certolizumab pegol

Question 46

Currently licensed biologics for the treatment of RA in the UK (what 4 types?)

Answer 46

TNF-blockers, Monoclonal antibody against B cells, T cell co-stimulation inhibitor, Monoclonal antibodies against IL-6R

Question 47

TNF-blockers, Monoclonal antibody against B cells, T cell co-stimulation inhibitor, Monoclonal antibodies against IL-6R are all currently licensed … for treatment of … in the UK

Answer 47

TNF-blockers, Monoclonal antibody against B cells, T cell co-stimulation inhibitor, Monoclonal antibodies against IL-6R are all currently licensed biologics for treatment of rheumatoid arthritis in the UK

Question 48

Rituximab is a drug known as a … antibody.

Answer 48

Rituximab is a drug known as a monoclonal antibody.

Question 49

abatacept is a …-cell co-stimulation inhibitor

Answer 49

abatacept is a T-cell co-stimulation inhibitor

Question 50

The TNF-blockers

• … – partially humanized mouse monoclonal anti-hTNF-a antibody
• Etanercept – soluble TNF receptor dimer
• Adalimumab – human IgG1 monoclonal anti-TNF-a antibody
• … – human IgG1 monoclonal anti-TNF-a antibody
• Certolizumab pegol – PEGylated anti-TNF-a monoclonal antibody fragment

Answer 50

• Infliximab – partially humanized mouse monoclonal anti-hTNF-a antibody
• Etanercept – soluble TNF receptor dimer
• Adalimumab – human IgG1 monoclonal anti-TNF-a antibody
• Golimumab – human IgG1 monoclonal anti-TNF-a antibody
• Certolizumab pegol – PEGylated anti-TNF-a monoclonal antibody fragment

Question 51

The TNF-blockers

• Infliximab – partially humanized mouse monoclonal anti-hTNF-a antibody
• … – soluble TNF receptor dimer
• Adalimumab – human IgG1 monoclonal anti-TNF-a antibody
• Golimumab – human IgG1 monoclonal anti-TNF-a antibody
• … pegol – PEGylated anti-TNF-a monoclonal antibody fragment

Answer 51

• Infliximab – partially humanized mouse monoclonal anti-hTNF-a antibody
• Etanercept – soluble TNF receptor dimer
• Adalimumab – human IgG1 monoclonal anti-TNF-a antibody
• Golimumab – human IgG1 monoclonal anti-TNF-a antibody
• Certolizumab pegol – PEGylated anti-TNF-a monoclonal antibody fragment

Question 52

The TNF-blockers

• … – partially humanized mouse monoclonal anti-hTNF-a antibody
• Etanercept – soluble TNF receptor dimer
• … – human IgG1 monoclonal anti-TNF-a antibody
• Golimumab – human IgG1 monoclonal anti-TNF-a antibody
• Certolizumab pegol – PEGylated anti-TNF-a monoclonal antibody fragment

Answer 52

• Infliximab – partially humanized mouse monoclonal anti-hTNF-a antibody
• Etanercept – soluble TNF receptor dimer
• Adalimumab – human IgG1 monoclonal anti-TNF-a antibody
• Golimumab – human IgG1 monoclonal anti-TNF-a antibody
• Certolizumab pegol – PEGylated anti-TNF-a monoclonal antibody fragment

Question 53

When TNF-blockers are combined with MTX, they give excellent …. protection

Answer 53

When TNF-blockers are combined with MTX, they give excellent joint protection

Question 54

When TNF-blockers are combined with …, they give excellent joint protection

Answer 54

When TNF-blockers are combined with methotrexate, they give excellent joint protection

Question 55

When …-blockers are combined with MTX, they give excellent joint protection

Answer 55

When TNF-blockers are combined with MTX, they give excellent joint protection

Question 56

Infliximab – The chimeric antibody

• Partially humanized … monoclonal anti-human TNF-… antibody – first anti-TNF biologic
• Neutralizes free, membrane and receptor-bound TNF-… → antibody-dependent cell-mediated cytotoxicity (ADCC)
• Also used for the treatment of Crohn’s disease, ulcerative colitis, plaque psoriasis, ankylosing spondylitis
• NICE only approves infliximab, if combined with …
• Administered as … infusion 3mg per kg of body weight, repeated 2 weeks and 6 weeks after the first infusion, then every 8 weeks.

Answer 56

• Partially humanized mouse monoclonal anti-human TNF-a antibody – first anti-TNF biologic
• Neutralizes free, membrane and receptor-bound TNF-a → antibody-dependent cell-mediated cytotoxicity (ADCC)
• Also used for the treatment of Crohn’s disease, ulcerative colitis, plaque psoriasis, ankylosing spondylitis
• NICE only approves infliximab, if combined with MTX
• Administered as intravenous infusion 3mg per kg of body weight, repeated 2 weeks and 6 weeks after the first infusion, then every 8 weeks.

Question 57

Infliximab – The chimeric antibody

• Partially humanized mouse monoclonal anti-human TNF-a antibody – first anti-TNF biologic
• Neutralizes free, membrane and receptor-bound TNF-a → antibody-dependent cell-mediated cytotoxicity (ADCC)
• Also used for the treatment of … disease, … colitis, plaque …, ankylosing …
• … only approves infliximab, if combined with MTX
• Administered as intravenous infusion …mg per kg of body weight, repeated 2 weeks and 6 weeks after the first infusion, then every 8 weeks.

Answer 57

• Partially humanized mouse monoclonal anti-human TNF-a antibody – first anti-TNF biologic
• Neutralizes free, membrane and receptor-bound TNF-a → antibody-dependent cell-mediated cytotoxicity (ADCC)
• Also used for the treatment of Crohn’s disease, ulcerative colitis, plaque psoriasis, ankylosing spondylitis
• NICE only approves infliximab, if combined with MTX
• Administered as intravenous infusion 3mg per kg of body weight, repeated 2 weeks and 6 weeks after the first infusion, then every 8 weeks.

Question 58

Infliximab dosage - Administered as intravenous infusion 3mg per kg of body weight, repeated … weeks and … weeks after the first infusion, then every 8 weeks.

Answer 58

Infliximab dosage - Administered as intravenous infusion 3mg per kg of body weight, repeated 2 weeks and 6 weeks after the first infusion, then every 8 weeks.

Question 59

Etanercept – The soluble TNF receptor dimer

• … domain of the hu p75 TNFR fused with the Fc domain of hu Ig…
• Binds free and membrane-bound TNF, reducing the accessible TNF in … → ADCC
• Also used for the treatment of juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis
• 25mg twice a week, or 50mg weekly by subcutaneous injection

Answer 59

• Extracellular domain of the hu p75 TNFR fused with the Fc domain of hu IgG1
• Binds free and membrane-bound TNF, reducing the accessible TNF in RA → ADCC
• Also used for the treatment of juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis
• 25mg twice a week, or 50mg weekly by subcutaneous injection

Question 60

Etanercept – The soluble TNF receptor dimer

• Extracellular domain of the hu p75 TNFR fused with the Fc domain of hu IgG1
• Binds free and membrane-bound TNF, reducing the accessible TNF in RA → ADCC
• Also used for the treatment of juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis
• …mg twice a week, or …mg weekly by subcutaneous injection
• Binds both TNF… and TNF…

Answer 60

• Extracellular domain of the hu p75 TNFR fused with the Fc domain of hu IgG1
• Binds free and membrane-bound TNF, reducing the accessible TNF in RA → ADCC
• Also used for the treatment of juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis
• 25mg twice a week, or 50mg weekly by subcutaneous injection
• Binds both TNF-alpha and TNF-beta

Question 61

Adalimumab, golimumab – The fully human anti-TNF-a mAbs

• Adalimumab
  
  • Also used in juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease
  • … mg by subcutaneous injection every other week
• Golimumab
  
  • In combination with MTX
  • Also used in psoriatic arthritis, ankylosing spondylitis
  • Longer half-life
  • … mg monthly by subcutaneous injection

Answer 61

• Adalimumab
  
  • Also used in juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease
  • 40 mg by subcutaneous injection every other week
• Golimumab
  
  • In combination with MTX
  • Also used in psoriatic arthritis, ankylosing spondylitis
  • Longer half-life
  • 50 mg monthly by subcutaneous injection

Question 62

Adalimumab, golimumab – The fully human anti-TNF-a mAbs

• Adalimumab
  
  • Also used in juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, … disease
  • 40 mg by subcutaneous injection every other week
• Golimumab
  
  • In combination with …
  • Also used in psoriatic arthritis, ankylosing spondylitis
  • … half-life
  • 50 mg monthly by subcutaneous injection

Answer 62

• Adalimumab
  
  • Also used in juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease
  • 40 mg by subcutaneous injection every other week
• Golimumab
  
  • In combination with MTX
  • Also used in psoriatic arthritis, ankylosing spondylitis
  • Longer half-life
  • 50 mg monthly by subcutaneous injection

Question 63

Adalimumab, golimumab – The fully human anti-TNF-a mAbs

• Adalimumab
  
  • Also used in juvenile idiopathic arthritis, plaque psoriasis, … arthritis, ankylosing spondylitis, Crohn’s disease
  • 40 mg by … injection every other week
• Golimumab
  
  • In combination with MTX
  • Also used in … arthritis, ankylosing spondylitis
  • Longer half-life
  • 50 mg monthly by … injection

Answer 63

• Adalimumab
  
  • Also used in juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease
  • 40 mg by subcutaneous injection every other week
• Golimumab
  
  • In combination with MTX
  • Also used in psoriatic arthritis, ankylosing spondylitis
  • Longer half-life
  • 50 mg monthly by subcutaneous injection

Question 64

What are the names of the fully human anti-TNF-a mAbs? (monoclonal antibodies)

Answer 64

Question 65

What is the name of the soluble TNF receptor dimer?

Answer 65

Etanercept

Question 66

What is the name for the chimeric antibody? (TNF-blocker licensed for use)

Answer 66

infliximab

Question 67

Certolizumab pegol – The Fab’ fragment

• … Fab’ fragment of humanized anti-TNF-a mAb – no … portion
• Also used for the treatment of Chron’s disease
• 400 mg by subcutaneous injection at weeks 0, 2 and 4 (given as two injections of 200 mg), and then 200 mg every other week thereafter

Answer 67

• PEGylated Fab’ fragment of humanized anti-TNF-a mAb – no Fc portion
• Also used for the treatment of Chron’s disease
• 400 mg by subcutaneous injection at weeks 0, 2 and 4 (given as two injections of 200 mg), and then 200 mg every other week thereafter

Question 68

Certolizumab pegol – The Fab’ fragment

• PEGylated Fab’ fragment of humanized anti-TNF-a mAb – no Fc portion
• Also used for the treatment of … disease
• … mg by subcutaneous injection at weeks 0, 2 and 4 (given as two injections of 200 mg), and then 200 mg every other week thereafter

Answer 68

• PEGylated Fab’ fragment of humanized anti-TNF-a mAb – no Fc portion
• Also used for the treatment of Chron’s disease
• 400 mg by subcutaneous injection at weeks 0, 2 and 4 (given as two injections of 200 mg), and then 200 mg every other week thereafter

Question 69

Clinical and functional efficacy following 26 weeks of adalimumab treatment in combination with different doses of MTX

• Figure shows combination of Adalimuma with MTX
• Higher dose of MTX combined with Adalimumab = … efficacy for RA

Answer 69

• Figure shows combination of Adalimuma with MTX
• Higher dose of MTX combined with Adalimumab = higher efficacy for RA

Question 70

Anti-TNF therapy: Considerations, side effects

• Patients screened before starting treatment to exclude an increased risk of side effects, in particular for a past history of … , multiple …, recurrent infection, leg ulcers and a past history of …
• … X-ray to be taken to exclude signs of previous … and to exclude signs of heart failure
• Increased risk of infections, reactivation of …
• Live vaccines, against e.g. yellow fever or polio, should be avoided
• Anti-TNF therapy can be administered for as long as 10 years.
• Patients can stay on the drug for as long as they continue to respond well to it.

Answer 70

• Patients screened before starting treatment to exclude an increased risk of side effects, in particular for a past history of tuberculosis (TB), multiple sclerosis, recurrent infection, leg ulcers and a past history of cancer
• Chest X-ray to be taken to exclude signs of previous TB and to exclude signs of heart failure
• Increased risk of infections, reactivation of TB
• Live vaccines, against e.g. yellow fever or polio, should be avoided
• Anti-TNF therapy can be administered for as long as 10 years.
• Patients can stay on the drug for as long as they continue to respond well to it.

Question 71

Anti-TNF therapy: Considerations, side effects

• Patients screened before starting treatment to exclude an increased risk of side effects, in particular for a past history of tuberculosis (TB), multiple sclerosis, recurrent infection, leg ulcers and a past history of cancer
• Chest X-ray to be taken to exclude signs of previous TB and to exclude signs of heart failure
• Increased risk of …, … of TB
• … vaccines, against e.g. yellow fever or polio, should be avoided
• Anti-TNF therapy can be administered for as long as … years.
• Patients can stay on the drug for as long as they continue to respond well to it.

Answer 71

• Patients screened before starting treatment to exclude an increased risk of side effects, in particular for a past history of tuberculosis (TB), multiple sclerosis, recurrent infection, leg ulcers and a past history of cancer
• Chest X-ray to be taken to exclude signs of previous TB and to exclude signs of heart failure
• Increased risk of infections, reactivation of TB
• Live vaccines, against e.g. yellow fever or polio, should be avoided
• Anti-TNF therapy can be administered for as long as 10 years.
• Patients can stay on the drug for as long as they continue to respond well to it.

Question 72

Anti-TNF therapy can be administered for as long as … years.

Answer 72

• Anti-TNF therapy can be administered for as long as 10 years.
  
  • Patients can stay on the drug for as long as they continue to respond well to it.

Question 73

Failure of anti-TNF treatment – use of other biologics

• Some patients may have
  
  • an … clinical response
  • lose their … over time
  • experience … side effects
  • have … issues
• precluding the use of anti-TNF medication.
• It is estimated that 30% of RA patients fail to respond adequately to a combination of a TNF inhibitor plus MTX.

Answer 73

• Some patients may have
  
  • an inadequate clinical response
  • lose their responsiveness over time
  • experience unacceptable side effects
  • have medical issues
• precluding the use of anti-TNF medication.
• It is estimated that 30% of RA patients fail to respond adequately to a combination of a TNF inhibitor plus MTX.

Question 74

Failure of anti-TNF treatment – use of other biologics

• Some patients may have
  
  • an inadequate clinical response
  • lose their responsiveness over time
  • experience unacceptable side effects
  • have medical issues
• precluding the use of anti-TNF medication.
• It is estimated that …% of RA patients fail to respond adequately to a combination of a TNF inhibitor plus MTX.

Answer 74

• Some patients may have
  
  • an inadequate clinical response
  • lose their responsiveness over time
  • experience unacceptable side effects
  • have medical issues
• precluding the use of anti-TNF medication.
• It is estimated that 30% of RA patients fail to respond adequately to a combination of a TNF inhibitor plus MTX.

Question 75

It is estimated that 30% of RA patients fail to respond adequately to a combination of a TNF inhibitor plus …

Answer 75

It is estimated that 30% of RA patients fail to respond adequately to a combination of a TNF inhibitor plus MTX.

Question 76

Rituximab – The B-cell depleting agent

• Partially … anti-CD20 mAb
• Rituximab … B-cells are attacked and killed by three mechanisms:
  
  • 1)… mediated cytotoxicity
  • 2-3) Antibody-dependent cell mediated cytotoxicity (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) Apoptosis
• Also used for the treatment of SLE
• An intravenous infusion (1 g) on two occasions two weeks apart (although some centres give smaller weekly injections for four weeks).

Answer 76

• Partially humanized anti-CD20 mAb
• Rituximab opsonized B-cells are attacked and killed by three mechanisms:
  
  • 1)Complement mediated cytotoxicity
  • 2-3) Antibody-dependent cell mediated cytotoxicity (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) Apoptosis
• Also used for the treatment of SLE
• An intravenous infusion (1 g) on two occasions two weeks apart (although some centres give smaller weekly injections for four weeks).

Question 77

Rituximab – The B-cell depleting agent

• Partially humanized anti-CD20 mAb
• Rituximab opsonized B-cells are attacked and killed by three mechanisms:
  
  • 1)Complement mediated cytotoxicity
  • 2-3) Antibody-dependent cell mediated cytotoxicity (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) …
• Also used for the treatment of …
• An intravenous infusion (1 g) on two occasions two weeks apart (although some centres give smaller weekly injections for four weeks).

Answer 77

• Partially humanized anti-CD20 mAb
• Rituximab opsonized B-cells are attacked and killed by three mechanisms:
  
  • 1)Complement mediated cytotoxicity
  • 2-3) Antibody-dependent cell mediated cytotoxicity (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) Apoptosis
• Also used for the treatment of SLE
• An intravenous infusion (1 g) on two occasions two weeks apart (although some centres give smaller weekly injections for four weeks).

Question 78

Rituximab – The B-cell depleting agent

• Partially humanized anti-… mAb
• Rituximab opsonized B-cells are attacked and killed by three mechanisms:
  
  • 1)Complement mediated cytotoxicity
  • 2-3) Antibody-dependent cell mediated … (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) Apoptosis
• Also used for the treatment of SLE
• An … infusion (1 g) on two occasions two weeks apart (although some centres give smaller weekly injections for four weeks).

Answer 78

• Partially humanized anti-CD20 mAb
• Rituximab opsonized B-cells are attacked and killed by three mechanisms:
  
  • 1)Complement mediated cytotoxicity
  • 2-3) Antibody-dependent cell mediated cytotoxicity (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) Apoptosis
• Also used for the treatment of SLE
• An intravenous infusion (1 g) on two occasions two weeks apart (although some centres give smaller weekly injections for four weeks).

Question 79

Rituximab – The B-cell depleting agent

• Partially humanized anti-CD20 mAb
• Rituximab opsonized B-cells are attacked and killed by three mechanisms:
  
  • 1)Complement mediated cytotoxicity
  • 2-3) …-dependent cell mediated cytotoxicity (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) Apoptosis
• Also used for the treatment of SLE
• An intravenous infusion (1 g) on two occasions … weeks apart (although some centres give smaller weekly injections for … weeks).

Answer 79

• Partially humanized anti-CD20 mAb
• Rituximab opsonized B-cells are attacked and killed by three mechanisms:
  
  • 1)Complement mediated cytotoxicity
  • 2-3) Antibody-dependent cell mediated cytotoxicity (ADCC) – FcgR or CR mediated opsonic phagocytosis
  • 4) Apoptosis
• Also used for the treatment of SLE
• An intravenous infusion (1 g) on two occasions two weeks apart (although some centres give smaller weekly injections for four weeks).

Question 80

Abatacept – The T-cell co-stimulation inhibitor

• CTLA-4/ hu IgG1 soluble receptor fusion protein
• Competitive inhibitor of CD…
• Increases … for T-cell activation
• Suppresses the … of synovial recirculating T cells
• Reduces the level of inflammatory mediators
• Intravenous infusion of 500 mg, 750 mg or 1000 mg (depending on patient’s weight) over 30 to 60 minutes. After the first dose, it is given two weeks later, then two weeks after that, then monthly thereafter.

Answer 80

• CTLA-4/ hu IgG1 soluble receptor fusion protein
• Competitive inhibitor of CD28
• Increases threshold for T-cell activation
• Suppresses the proliferation of synovial recirculating T cells
• Reduces the level of inflammatory mediators
• Intravenous infusion of 500 mg, 750 mg or 1000 mg (depending on patient’s weight) over 30 to 60 minutes. After the first dose, it is given two weeks later, then two weeks after that, then monthly thereafter.

Question 81

Abatacept – The T-cell co-stimulation inhibitor

• …-4/ hu Ig… soluble receptor fusion protein
• … inhibitor of CD28
• Increases threshold for T-cell activation
• Suppresses the proliferation of synovial recirculating T cells
• … the level of inflammatory mediators
• Intravenous infusion of 500 mg, 750 mg or 1000 mg (depending on patient’s weight) over 30 to 60 minutes. After the first dose, it is given two weeks later, then two weeks after that, then monthly thereafter.

Answer 81

• CTLA-4/ hu IgG1 soluble receptor fusion protein
• Competitive inhibitor of CD28
• Increases threshold for T-cell activation
• Suppresses the proliferation of synovial recirculating T cells
• Reduces the level of inflammatory mediators
• Intravenous infusion of 500 mg, 750 mg or 1000 mg (depending on patient’s weight) over 30 to 60 minutes. After the first dose, it is given two weeks later, then two weeks after that, then monthly thereafter.

Question 82

Abatacept is a competitive inhibitor of CD…

Answer 82

Abatacept is a competitive inhibitor of CD28

Question 83

Abatacept is a …-cell co-… inhibitor

Answer 83

Abatacept is a T-cell co-stimulation inhibitor (CTLA-4/ hu IgG1 soluble receptor fusion protein)

Question 84

CTLA4-Ig fusion protein (IgG1) (a…)

Answer 84

CTLA4-Ig fusion protein (IgG1) (abatacept)

Question 85

Tocilizumab and sarilumab – The IL-6R inhibitors

• Tocilizumab: … anti-IL-6 receptor monoclonal antibody
  
  • Also used in systemic juvenile idiopathic …
  • Intravenous infusion 8 mg/kg of body weight
• Sarilumab: fully … monoclonal antibody against IL-6Ra
  
  • 200 mg once every two weeks, administered as a subcutaneous injection

Answer 85

• Tocilizumab: humanized anti-IL-6 receptor monoclonal antibody
  
  • Also used in systemic juvenile idiopathic arthritis
  • Intravenous infusion 8 mg/kg of body weight
• Sarilumab: fully human monoclonal antibody against IL-6Ra
  
  • 200 mg once every two weeks, administered as a subcutaneous injection

Question 86

Tocilizumab and sarilumab – The IL-6R inhibitors

• Tocilizumab: humanized anti-IL-6 receptor monoclonal antibody
  
  • Also used in systemic juvenile idiopathic arthritis
  • Intravenous infusion … mg/kg of body weight
• Sarilumab: fully human monoclonal antibody against IL-6Ra
  
  • … mg once every two weeks, administered as a subcutaneous injection

Answer 86

• Tocilizumab: humanized anti-IL-6 receptor monoclonal antibody
  
  • Also used in systemic juvenile idiopathic arthritis
  • Intravenous infusion 8 mg/kg of body weight
• Sarilumab: fully human monoclonal antibody against IL-6Ra
  
  • 200 mg once every two weeks, administered as a subcutaneous injection

Question 87

Tocilizumab and sarilumab are the IL-… inhibitors

Answer 87

Tocilizumab and sarilumab are the IL-6R inhibitors

Question 88

Tocilizumab and … have been authorized for UK patients with critical COVID-19 infection.

Answer 88

Tocilizumab and sarilumab have been authorized for UK patients with critical COVID-19 infection.

Question 89

Anakinra – The IL-1R antagonist

• … IL-1ra
  
  • Differs from native human IL-1ra: it has the addition of a single … residue at its amino terminus
• In RA:
  
  • Reduces bone …
  • Decreases osteoclast production
  • Blocks IL-1-induced MMP release from synovial cells
• Not used in the UK to treat RA, but licensed in the US

Answer 89

• Recombinant IL-1ra
  
  • Differs from native human IL-1ra: it has the addition of a single methionine residue at its amino terminus
• In RA:
  
  • Reduces bone erosion
  • Decreases osteoclast production
  • Blocks IL-1-induced MMP release from synovial cells
• Not used in the UK to treat RA, but licensed in the US

Question 90

Anakinra – The IL-1R antagonist

• Recombinant IL-1ra
  
  • Differs from native human IL-1ra: it has the addition of a single methionine residue at its amino terminus
• In RA:
  
  • Reduces bone erosion
  • … osteoclast production
  • … IL-1-induced MMP release from synovial cells
• Not used in the … to treat RA, but licensed in the …

Answer 90

• Recombinant IL-1ra
  
  • Differs from native human IL-1ra: it has the addition of a single methionine residue at its amino terminus
• In RA:
  
  • Reduces bone erosion
  • Decreases osteoclast production
  • Blocks IL-1-induced MMP release from synovial cells
• Not used in the UK to treat RA, but licensed in the US

Question 91

Adverse effects of biological therapies

• Increased risk of infections:
  
  • … respiratory tract infections (nasopharyngitis)
  • …
  • Urinary tract infections
• It is recommended to receive influenza and pneumococcal vaccines before embarking on biological therapy
• Avoid … vaccines
• Nausea
• Headache
• Hypertension
• Allergic reactions
• Contraindicated in … and while … … (rituximab, tocilizumab, sarilumab, abatacept, anakinra)

Answer 91

• Increased risk of infections:
  
  • Upper respiratory tract infections (nasopharyngitis)
  • Pneumonia
  • Urinary tract infections
• It is recommended to receive influenza and pneumococcal vaccines before embarking on biological therapy
• Avoid live vaccines
• Nausea
• Headache
• Hypertension
• Allergic reactions
• Contraindicated in pregnancy and while breast feeding (rituximab, tocilizumab, sarilumab, abatacept, anakinra)

Question 92

Adverse effects of biological therapies

• Increased risk of …
• N…
• H..
• …tension
• … reactions
• Contraindicated in pregnancy and while breast feeding (rituximab, tocilizumab, sarilumab, abatacept, anakinra)

Answer 92

• Increased risk of infections:
  
  • Upper respiratory tract infections (nasopharyngitis)
    
    • Pneumonia
  • Urinary tract infections
  • It is recommended to receive influenza and pneumococcal vaccines before embarking on biological therapy
  • Avoid live vaccines
• Nausea
• Headache
• Hypertension
• Allergic reactions
• Contraindicated in pregnancy and while breast feeding (rituximab, tocilizumab, sarilumab, abatacept, anakinra)

Question 93

Summary of the biologics in RA

Answer 93

Question 94

Summary of the biologics in RA

Answer 94

Question 95

Summary of the biologics in RA

Answer 95

Question 96

Summary of the biologics in RA

Answer 96

Question 97

Summary of the biologics in RA

• Fill in the blanks

Answer 97