Biologic DMARDs (bDMARDs)

• Biologic DMARDs (bDMARDs) are a class of disease-modifying antirheumatic drugs.
• Etanercept, a tumor necrosis factor (TNF) inhibitor, serves as the prototype medication for bDMARDs.

Classification and Other Medications

• Medication Classification of bDMARDs: Antirheumatic
• Other TNF inhibitors include infliximab, adalimumab, golimumab, and certolizumab pegol.
• Additional medications: abatacept (T cell costimulatory inhibitor), tocilizumab and sarilumab (IL-6 receptor inhibitors), and rituximab (anti-CD20 antibody).

Pharmacologic Action

• bDMARDs inactivate tumor necrosis factor (TNF), reducing inflammation and immunosuppression.
• These medications are tumor necrosis factor antagonists, binding to naturally occurring TNF and preventing it from attaching to cells in synovial joint tissue.
• This action inhibits inflammatory reactions in the joints of clients with rheumatoid arthritis (RA).
• Combining bDMARDs with methotrexate, a nonbiologic DMARD, enhances the therapeutic effect.

Adverse Drug Reactions

• Clients are more susceptible to infections due to TNF suppression.
• Other adverse effects: dizziness, pharyngitis, upper respiratory infections, abdominal pain, psoriasis, and pancytopenia (low levels of platelets, RBCs, and WBCs).
• Heart failure can reoccur in clients with a previous history.
• Reactivation or new development of tuberculosis (TB) can occur.
• Certolizumab is the only biologic DMARD considered safe during pregnancy.

Interventions

• Monitor for infection manifestations (redness, warmth, itching).
• Injection site reactions occur in 37% of clients on etanercept.
• Assess for infection manifestations before each injection and monitor for reactions during therapy.
• Monitor for heart failure manifestations, including cough, shortness of breath, elevated blood pressure and heart rate, and pink sputum.
• Monitor CBC for myelosuppression and liver enzymes for liver dysfunction.
• Test clients for tuberculosis before and periodically during therapy.

Administration

• Etanercept is administered via subcutaneous injection once weekly.
• Monitor the injection site for redness, pain, and swelling after administration.

Client Instructions

• Report infection manifestations and skin rashes immediately.
• Report injection site reactions that persist for more than a few days.
• Clients are at risk for acquiring or transmitting infections if immunized with a live virus vaccine.
• Update all vaccines prior to starting etanercept.

Contraindications and Precautions

• Contraindicated for clients with active infection, hematologic disease, or malignancy.
• Not appropriate for clients with autoimmune demyelinating disorders of the central nervous system, such as multiple sclerosis.

Interactions

• Concurrent use with chemotherapeutic medications like methotrexate may cause bone marrow suppression.
• Avoid giving etanercept with anakinra to decrease the risk of infections.
• Avoid live vaccines with bDMARDs.

Questions

• A primary care provider prescribes etanercept to treat a client’s rheumatoid arthritis. Prior to beginning the treatment, the client requires testing for tuberculosis.
• A nurse is caring for a client taking etanercept. Which of the following adverse effects is most important to mention when educating this client? Injection site reaction can occur.

Biologic DMARDs are a class of disease-modifying antirheumatic drugs. Etanercept, a TNF inhibitor, is a prototype. These medications inactivate tumor necrosis factor, reducing inflammation and immunosuppression, inhibiting inflammatory reactions in the joints.