Biologic agents are a new group of highly effective drugs for JIA. They target key steps in the immune system that cause inflammation in the joints.
How do biologics work?
In the immune system, chemicals called cytokines are released into the body, which affect the behavior and function of other cells. During an infection, certain cytokines can be released to control other cells to help fight the infection. In JIA, the immune system is releasing too many cytokines that control cells causing inflammation in the joints or tissues. Some of these cytokines are called tumour necrosis factor (TNF), interleukin-1, and interleukin-6. Biologic agents block some of these cytokines from being made. Biologics are used when other drugs have not effectively controlled the JIA.
By blocking cytokines, biologics can dramatically reduce inflammation. In some people, biologics can also prevent joint damage.
Biologics often work quickly. Improvements may often be noticed for some people within one to two weeks of starting the drug. Other people find it takes a month or so to see the benefits.
Things to know if your child is taking a biologic agent
Before starting any biologic for JIA, your child must be tested to make sure they have not been exposed to tuberculosis (TB). Your child may have been exposed to it at school or in the community and never even know it. To test for TB, your child needs to have a TB skin test and chest X-ray. A person who takes a biologic drug when they have TB can get very sick.
There may be other vaccines you could consider for your child before starting treatment. One example is the chickenpox (varicella) vaccine. The flu shot is recommended every year; it is given in the fall. After starting a biologic, your child cannot take any live vaccines. Talk with your child's doctor about this.
All biologics make it harder to fight infections like colds, flu and skin infections. They can sometimes cause irritation at the injection site, flu-like symptoms and low blood counts (low white blood cells, red blood cells or platelets). For most people, however, the side effects are not a problem.
Finally, treatment with biologics is expensive. It can cost $15,000 to $25,000 or more a year. If your child's doctor recommends a biologic, you will need to look into what medication insurance you have for your child. This may include private health insurance plans, provincial drug benefit programs, or other programs. A social worker can help you find ways to cover the cost of this treatment.
Etanercept
Most common brand name: Enbrel
How it is given: Injection under the skin, once a week
How the medication comes: Injection
Side effects
Most common side effects:
- Injection site reactions (redness, itchiness, pain, swelling)
Rare side effects:
- Rash
- Flu-like symptoms
- Low blood counts
- Increased risk of infection
- Increased risk of malignancies
- Production of autoantibodies
Infliximab
Most common brand name: Remicaide
How it is given: Intravenously every 1–2 months in a clinic or hospital
How the medication comes: Infusion
Side effects
Most common side effects:
- Infusion reactions during or shortly after an infusion (hives, breathing difficulties, chest pain, stomach pain, nausea, diarrhea, blood pressure problems). Usually prevented with acetaminophen (Tylenol) and diphenhydramine (Benadryl) given before infusion.
Rare side effects:
- Flu-like symptoms
- Low blood counts
- Increased risk of infection
- Increased risk of malignancies
- Production of autoantibodies
Adalibumab
Most common brand name: Humira
How it is given: Injection under the skin, every 2 weeks
How the medication comes: Injection
Side effects
Most common side effects:
- Injection site reactions (redness, itchiness, pain, swelling)
Rare side effects:
- Rash
- Flu-like symptoms
- Low blood counts
- Increased risk of infection
- Increased risk of malignancies
- Production of autoantibodies
Anakinra
Most common brand name: Kineret
How it is given: Injection under the skin, once daily
How the medication comes: Injection
Side effects
Most common side effects:
- Injection site reactions (redness, itchiness, swelling, or stinging)
Rare side effects:
- Low white blood cell counts
- Headaches
- Flu-like symptoms
- Stomach upset
- Increased risk of infection
- Increased risk of malignancies
Canakinumab
Most common brand name: Ilaris
How it is given: Injection under the skin, once a month
How the medication comes: Injection
Side effects
Most common side effects:
- Injection site reactions (redness, itchiness, swelling or stinging)
Rare side effects:
- Low white blood cell counts
- Headaches
- Flu-like symptoms
- Stomach upset
- Increased risk of infection
- Increased risk of malignancies
Abatacept
Most common brand name: Orencia
How it is given: Intravenously, usually once a month in hospital
How the medication comes: Infusion
Side effects
Most common side effects:
- Infusion reactions during or shortly after an infusion (hives, breathing difficulties, chest pain, stomach pain, nausea, diarrhea, blood pressure problems). Usually prevented with acetaminophen (Tylenol) and diphenhydramine (Benadryl) given before infusion.
Rare side effects:
- Headache
- Flu-like symptoms
- Nausea
- Increased risk of infection
- Increased risk of malignancies
Rituximab
Most common brand name: Rituxan
How it is given: Intravenously, high dose every 2 weeks for 2 doses or low dose once a week for 4 doses in hospital
How the medication comes: Infusion
Side effects
Most common side effects:
- Infusion reactions during or shortly after an infusion (hives, breathing difficulties, chest pain, stomach pain, nausea, diarrhea, blood pressure problems). Usually prevented with acetaminophen (Tylenol) and diphenhydramine (Benadryl) given before infusion.
Rare side effects:
- Abdominal pain, nausea, vomiting, diarrhea
- Headaches and dizziness
- Aching in the joints and muscles
- Increased risk of infection
- Increased risk of malignancies
- Low blood cell counts
Tocilizumab
Most common brand name: Actemra
How it is given: Intravenously, every 2–4 weeks in hospital
How the medication comes: Infusion
Side effects
Most common side effects:
- Infusion reactions during or shortly after an infusion (hives, breathing difficulties, chest pain, stomach pain, nausea, diarrhea, blood pressure problems). Usually prevented with acetaminophen (Tylenol) and diphenhydramine (Benadryl) given before infusion.
- Flu-like symptoms
- Headaches
Rare side effects:
- Increase in liver function tests
- High blood pressure
- Increased risk of infection
- Increased risk of malignancies
Important safety points about taking biologics
- Deciding to start treatment with a biologic agent is a big decision. You and your child should talk with your child's doctor about any special risks before your child starts, so that you both understand what you need to watch for. If your child has a history of tuberculosis (TB), recurrent infections, heart problems, multiple sclerosis or cancer, they should avoid starting a biologic agent. Please discuss the use of this medication with their doctor.
- Your child will need regular blood tests to check for any side effects from the biologic agent.
- Find out from the doctor or nurse who you should call if your child gets sick while taking a biologic. If your child develops a fever, chills or any signs of infection like a cough, sore throat, diarrhea or a new rash, DO NOT give the next dose of biologic. Call the health-care provider that your child's doctor or nurse has recommended you contact if they get sick, and make an appointment with your child's doctor. Your child needs to be well again before they take the next dose. Speak with your child's doctor for further instructions.
- Your child should not receive live vaccines (MMR, varicella, nasal flu shot) while receiving biologics.
- Your child should be vaccinated against, or already have had, chickenpox before starting treatment with biologics.
- If your child is exposed to or develops chickenpox, DO NOT give the next dose of biologic. Call your child's doctor for further instructions.
- Young people taking biologics should practice birth control. Because biologics are new drugs and have not been studied in pregnant women, it is not known if they are safe in pregnancy.
- Biologics have been used for a long time in adults with inflammatory arthritis. The use in children and teens is shorter since biologics were approved for use in children later than in adults. To date, biologics appear to be safe in both adults and children. However, the long-term safety in children and teens is unknown.
- There is a very small increase in risk of malignancy (cancer) in people who have taken biologics.
- A very small number of people on biologic drug therapy have developed other diseases of the immune system like lupus.
Upcoming medications
There are other biologic agents that are currently being developed and tested. Ask the health-care team about these newer agents. They may be available in the near future.