Abatacept

What is abatacept and how is it used?

Abatacept (trade name Orencia) is a type of drug called a biological therapy. It works by interfering with the function of particular cells (T-cells) in the immune system. This action modifies the inflammation and immune activity which cause the symptoms of rheumatoid arthritis. It’s a long-term treatment, so it may be 6–12 weeks before you start to notice the benefits. Abatacept can be prescribed by a consultant rheumatologist for rheumatoid arthritis. It may be the first biological therapy you receive, or you may have tried others first, such as an anti-TNF drug or rituximab.

Abatacept won’t be started if:

• Your arthritis isn’t active
• Uou haven’t tried at least two disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine or leflunomide (abatacept is almost always used in combination with methotrexate).

Your doctor may decide not to prescribe abatacept if you’re pregnant or breastfeeding, or if:

• you have an infection
• you’re currently taking an anti-TNF drug
• you’ve had repeated infections
• you’ve had cancer

You’ll probably have blood tests before treatment starts to assess your disease and whether the drug is suitable for you. Your doctor will need to check if you’ve previously been exposed to tuberculosis (TB), and you may need a course of treatment for latent (asymptomatic) TB before starting abatacept.

If you’ve previously had hepatitis you may need regular checks for this as abatacept may increase the risk of the hepatitis being reactivated.

If you’re taking other drugs alongside your abatacept (such as methotrexate) you’ll also need to continue your blood tests for these.

When and how do I take abatacept?

Abatacept may be given:

• either through a drip into a vein (intravenous infusion) which takes 1–2 hours once a month, in hospital or at a special clinic
• or as an injection under the skin (subcutaneous injection) once a week using a pre-filled syringe or pen. You, your partner, or another family member can learn to give these injections at home.

Speak to your rheumatology team if you’re already having abatacept by infusion and wish to switch to injections – you’ll probably start your injections when your next infusion is due.

If you’re more than three days late taking a dose, ask your rheumatology team for advice on when to take your next dose.

Because it’s is a long-term treatment, it’s important to keep taking abatacept (unless you have severe side-effects):

• even if it doesn’t seem to be working at first
• even when your symptoms improve (to help keep the disease under control).

Possible risks and side-effects

Some side-effects can happen around the time of the infusion or injection. The most common are dizziness, headaches and feeling sick (nausea). These aren’t usually serious.

Because abatacept affects your immune system you may be more likely to pick up infections. It can also make them harder to spot. The most common are chest and urinary infections, rhinitis and conjunctivitis. Tell your doctor or rheumatology nurse straight away if you develop any symptoms such as a sore throat or fever, a persistent cough, weight loss or any other new symptoms that concern you. You should also tell your rheumatology team if you have any of these symptoms before having an infusion or injection. They may advise you to delay the treatment.

You should also see your doctor if you develop chickenpox or shingles or come into contact with someone who has chickenpox or shingles. These illnesses can be severe if you’re on abatacept. You may need antiviral treatment, and your abatacept may be stopped until you’re better.

Some people have an allergic reaction with sudden swelling, a rash or breathlessness. This is very rare, but if you do develop these symptoms, or any other severe symptoms, during or soon after a dose of abatacept you should seek medical advice immediately.

There may be a slightly increased risk of some cancers when using drugs like abatacept which interfere with the immune system, though research hasn’t so far confirmed this.

Reducing the risk of infection

• Try to avoid close contact with people with severe active infections.
• For advice on avoiding infection from food, visit: http://www.nhs.uk/conditions/food-poisoning/pages/prevention.aspx

Taking other medicines

You’ll probably be taking methotrexate as well as abatacept. Check with your doctor before starting any new medications, and remember to mention you’re on abatacept if you’re treated by anyone other than your usual rheumatology team.

• You can carry on taking nonsteroidal anti-inflammatory drugs (NSAIDs) or painkillers, if needed, unless your doctor
  advises otherwise
• Don’t take over-the-counter preparations or herbal remedies without discussing it first with your rheumatology team.

It’s recommended that you carry a biological therapy alert card, so anyone treating you will know that you’re on abatacept – ask your rheumatology team for a card.

Vaccinations

It’s usually recommended that people on abatacept avoid live vaccines such as yellow fever. Sometimes however, a live vaccine may be necessary – for example rubella vaccination in women of childbearing age.

If you’re offered shingles vaccination (Zostavax) it’s best if you can have this before starting abatacept. Shingles vaccination isn’t recommended for people who are already on abatacept.

Pneumococcal vaccine (which gives protection against the commonest cause of pneumonia) and yearly flu vaccines don’t interact with abatacept and are recommended.

Having an operation

Talk this over with your specialists. It’s likely you will be advised to stop abatacept for a time before and after surgery.

Alcohol

There’s no known interaction between abatacept and alcohol. However, if you’re also taking methotrexate, this can interact with alcohol and damage your liver so you should keep well within the recommended limits of no more than 14 units of alcohol per week for adults unless your doctor advises a lower limit.

Fertility, pregnancy and breastfeeding

If you’re planning to try for a baby, if you become pregnant or if you’re thinking of breastfeeding we suggest you discuss your medications with your rheumatologist.

We don’t yet know how abatacept might affect an unborn baby but it does not cross the placenta until 16 weeks of pregnancy so it’s unlikely to be harmful if taken in the first three months of pregnancy. To be on the safe side, however, women of childbearing age are advised to use contraception while on abatacept.

If you’re planning to become pregnant, you should continue to use contraception for three months after stopping abatacept. It’s also unknown whether abatacept affects men who are trying to father a baby. There’s no evidence to suggest that it’s harmful but it’s probably a good idea for men to take contraceptive precautions for at least three months after stopping treatment. For men who are also taking methotrexate, current guidelines state that this drug doesn’t need to be stopped when trying to father a child.

Breastfeeding isn’t recommended if you’re on abatacept because the effects are unknown You shouldn’t restart your abatacept until you’ve stopped breastfeeding.