MSK & Rheumatology/Biologic / targeted DMARDs

Biologic & targeted DMARDs

also: anti-TNF · etanercept · adalimumab · infliximab · rituximab · JAK inhibitor

Overview

Targeted therapies for DMARD-refractory rheumatoid arthritis (and other autoimmune disease) — cytokine/cell-targeted. TB reactivation screening is the key pre-treatment step (cross-references the dermatology biologics card).

Mechanism

Anti-TNF agents (etanercept = decoy receptor; adalimumab/infliximab = anti-TNF antibodies) neutralise TNF-α. Rituximab depletes CD20 B cells. JAK inhibitors (tofacitinib) block intracellular cytokine signalling.

Indications

Rheumatoid arthritis (inadequate response to ≥2 csDMARDs)
Other: ankylosing spondylitis, psoriatic arthritis, IBD, vasculitis

The agents

Anti-TNF (etanercept/adalimumab/infliximab)biologic

SC/IV

Screen + treat latent TB and hepatitis B before starting; reactivation risk.

Rituximabanti-CD20

Infusion reactions; also for vasculitis, lymphoma.

JAK inhibitors (tofacitinib, baricitinib)targeted synthetic

oral

VTE + serious infection + malignancy signal (MHRA restrictions).

Adverse effects

Serious infection / TB & hepatitis B reactivationserious

Pre-treatment screening mandatory.

Infusion/injection reactionscommon

JAK inhibitors: VTE, MACE, malignancy (MHRA)serious

Cautions & contraindications

Active serious infection / untreated latent TBall

Live vaccines while on biologicsall

Anti-TNF in moderate-severe heart failureall

Interactions

Live vaccines; combination immunosuppression

Monitoring & kinetics

Pre-biologic: TB (IGRA/CXR) + hepatitis B/C + HIV; ongoing infection vigilance

SC/IV (biologics) or oral (JAK). Specialist-initiated.

Source: NICE NG100 — Rheumatoid arthritis · BNF — Cytokine modulators