Adalimumab

What is adalimumab and how is it used?

In rheumatoid arthritis and some other conditions, too much of a protein called TNF (tumour necrosis factor)
is produced in the body, causing inflammation, pain and damage to the bones and joints. Anti-TNF drugs such as adalimumab (trade name Humira) block the action of TNF and so reduce this inflammation. Adalimumab isn’t a painkiller but can modify the disease and improve your symptoms over a period of 2–12 weeks.

Adalimumab can be prescribed by a consultant rheumatologist for:

• rheumatoid arthritis
• psoriatic arthritis
• ankylosing spondylitis
• juvenile idiopathic arthritis (JIA).

There are national and local guidelines that determine when it can be used, and these vary according to which condition you have. It’s often prescribed along with a diseasemodifying drug such as methotrexate.

Adalimumab won’t be started if:

• the disease isn’t active
• you have an infection
• you haven’t tried other treatments appropriate for your condition first.

Your doctor may decide not to prescribe adalimumab if you’ve had:

• repeated or severe infections
• multiple sclerosis (MS)
• cancer
• a serious heart condition
• lung fibrosis (scarring of the lung tissue).

Before starting adalimumab you’ll have a chest x-ray and tests to check if you’ve ever been exposed to tuberculosis (TB). You may need treatment for latent (asymptomatic) TB before starting adalimumab. You’ll also be checked for previous hepatitis infection, as adalimumab may increase the risk of hepatitis being reactivated.

You may have further blood tests while you’re on adalimumab to monitor its effects.

When and how do I take adalimumab?

The usual dose of adalimumab is 40 mg once every 2 weeks, given by injection under the skin (subcutaneous injection). You, your partner, or another family member can learn to give the injections at home.

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

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

Possible risks and side-effects

The most common side-effects are reactions at the injection site, such as redness, swelling or pain, but these aren’t usually serious. Regularly changing the injection site will help reduce the chances of this irritation.

Because adalimumab affects the immune system, it can make you more likely to pick up infections. It can also make them harder to spot. Tell your doctor or rheumatology nurse straight away if you develop any signs of infection – for example, a sore throat, fever, diarrhoea, coughing up green phlegm – or any other new symptoms that concern you. If any of these symptoms are severe, you should stop taking adalimumab and see your doctor straight away.

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 more severe if you’re on adalimumab. You may need antiviral treatment, and your adalimumab may be stopped until you’re better.

Rarely, people may have an allergic reaction. Contact your healthcare team if you think this may be happening. If the reaction is severe the drug will have to be stopped.

Anti-TNF drugs have been associated with some types of skin cancer – these can be readily treated when diagnosed early. Research so far hasn’t confirmed an increased risk of other cancers.

Very rarely, adalimumab may cause a condition called drug-induced lupus, which can be diagnosed by a blood test. Symptoms include a rash, fever and increased joint pain. If you develop these symptoms you should contact your rheumatology team. This condition is usually mild and clears up if adalimumab is stopped.

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

Adalimumab may be prescribed alongside other drugs, including methotrexate. Check with your doctor before starting any new medications, and remember to mention you’re on adalimumab 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 healthcare team.

It’s recommended that you carry a biological therapy alert card so anyone treating you will know that you’re on adalimumab – you can get a card from your rheumatology department.

Vaccinations

It’s best to discuss vaccinations with your healthcare team before starting adalimumab.

It’s usually recommended that people on adalimumab avoid live vaccines such as yellow fever. However, sometimes a live vaccine may be necessary (for example rubella immunisation in women of childbearing age).

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

Pneumococcal vaccine (which gives protection against the commonest cause of pneumonia) and yearly flu vaccines are safe and recommended.

Having an operation

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

Alcohol

There’s no known interaction between adalimumab and alcohol. However, if you’re also taking methotrexate, you should keep well within the recommended limits of no more than 14 units of alcohol per week for adults because methotrexate and alcohol can interact and affect your liver. Your doctor may advise lower limits.

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.

Current guidelines state that adalimumab can be used during pregnancy and in men trying to father a child. If it’s used during pregnancy it will usually be stopped after six months. If it’s used after this, then it’s possible (though not proven) that it may increase the risk of infection in the newborn baby. However, if there’s concern that your arthritis may flare up if adalimumab is stopped then you can continue with it throughout your pregnancy – in this case, your baby should not have any live vaccines (such as BCG) until they’re seven months old.

Women who are also on methotrexate should stop taking it and use contraception for at least three months before trying for a baby. The guidelines state that there’s no need for men to stop methotrexate when trying to father a baby.

There’s only limited information about the use of adalimumab while breastfeeding. Small amounts of adalimumab may pass into the breast milk, but this doesn’t appear to be harmful. If you were also taking methotrexate before your pregnancy this should not be restarted until you stop breastfeeding.