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biologic immunosuppressive agent (biologic agent, biologic immune modulator)

A collective group of immunsuppressive agents. Indications: - used as to treat rheumatologic disease Contraindications: - active infection treated with antibiotics - hold biologic immunosuppressive agent during antibiotic therapy [1] - latent tuberculosis - patients should be treated for at least 6 months before treatment with a biologic agent - 2 biologic immunosuppressive agents used in combination not significantly more effective than either alone [1,2] - coadministration of live virus vaccines [1] - live virus vaccine may be administered 4 weeks prior to starting biologic immunosuppressive agent [1] * breast feeding apparently not a contraindication [5] Laboratory: - screening for tuberculosis, hepatitis B, hepatitis C & HIV1 infection prior to initiation of aggressive immunosuppressive therapy [1,2,3]* * antibiotic therapy must be started (& probably in most cases completed) prior to initiation of immunosuppressive agent * also see ARUP consult [6] Complications: - all diminish resistance to infection - risk of cancer similar for DMARDs vs biologic agents in patients with rheumatoid arthritis [4] - biologic agent infusions administered at home, rather than at a facility, are associated with more adverse events requiring escalation of care [7] Mechanism of action: - all specifically inhibit endogenous protein(s) involved in immunologic response (abatacept may be an exception) Management: - whenever possible bring patients up to date on vaccinations prior to initiating biologic immunosuppressive agent [1]

Interactions

drug interactions drug adverse effects (more general classes) monitor with immunosuppressive agents

Specific

abatacept (Orencia) anakinra (Kineret) baricitinib (Olumiant) belimumab (Benlysta) canakinumab (Ilaris) guselkumab (Tremfya) rilonacept (Arcalyst) rituximab (Rituxan, Mabthera, Truxima, Ruxience, Riabni) sarilumab (Kevzara) tocilizumab; atlizumab (Actemra, RoActemra, Tofidence, Tyenne) tofacitinib (Xeljanz) tumor necrosis factor (TNF) inhibitor ustekinumab (Stelara, Wezlana, Pyzchiva, Selarsdi)

General

immunosuppressive agent

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
  2. Singh JA, Furst DE, Bharat A 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res, 64: 625-629 PMID: 22473917 http://onlinelibrary.wiley.com/doi/10.1002/acr.21641/abstract
  3. Vassilopoulos D, Calabrese LH Viral hepatitis: review of arthritic complications and therapy for arthritis in the presence of active HBV/HCV. Curr Rheumatol Rep. 2013 Apr;15(4):319. PMID: 23436024
  4. Wadstrom H, Frisell T, Askling J et al. Malignant neoplasms in patients with rheumatoid arthritis treated with tumor necrosis factor inhibitors, tocilizumab, abatacept, or rituximab in clinical practice: A nationwide cohort study from Sweden. JAMA Intern Med 2017 Sep 18 PMID: 28975211
  5. Matro R, Martin CF, Wolf D et al. Exposure concentrations of infants breastfed by women receiving biologic therapies for inflammatory bowel diseases and effects of breastfeeding on infections and development. Gastroenterology 2018 May 29 PMID: 29857090
  6. ARUP Consult: Immunosuppressive Drug Optimization and Monitoring - Organ Transplantation Drugs The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/organ-transplantation
  7. Baker MC, Weng Y, Fairchild R et al Comparison of Adverse Events Among Home- vs Facility-Administered Biologic Infusions, 2007-2017. JAMA Netw Open. 2021;4(6):e2110268. PMID: 34081140 PMCID: PMC8176330 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780573 - Calip GS, Yerram P, Ascha MS Nonrandomized Comparison of Adverse Events Following Facility- and Home-Infused Biologics Using Real-World Data. JAMA Netw Open. 2021;4(6):e2111156 PMID: 34081142 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780575