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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 behaviour 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.
| Generic name | Most common brand name | How it is given | How the medication comes | Side effects |
|---|---|---|---|---|
| Etanercept | Enbrel | Injection under the skin, once a week | Injection | Most common side effects:
Rare side effects:
|
| Infliximab | Remicaide | Intravenously every 1–2 months in a clinic or hospital | Infusion | Most common side effects:
Rare side effects:
|
| Adalibumab​ | Humira | Injection under the skin, every 2 weeks | Injection | Most common side effects:
Rare side effects:
|
| Anakinra | Kineret | Injection under the skin, once daily | Injection | Most common side effects:
Rare side effects:
|
| Canakinumab | Ilaris | Injection under the skin, once a month | Injection | Most common side effects:
Rare side effects:
|
| Abatacept | Orencia | Intravenously, usually once a month in hospital | Infusion | Most common side effects:
Rare side effects:
|
| Rituximab​ | Rituxan | Intravenously, high dose every 2 weeks for 2 doses or low dose once a week for 4 doses in hospital | Infusion | Most common side effects:
Rare side effects:
|
| Tocilizumab | Actemra | Intravenously, every 2–4 weeks in hospital | Infusion | Most common side effects:
Rare side effects:
|
Important safety points about taking biologics
• Deciding to start treatment with a biologic agent is a big decision. You should talk with your doctor about any special risks before you start, so that you understand what you need to watch for. If you have a history of tuberculosis (TB), recurrent infections, heart problems, multiple sclerosis or cancer, you should avoid starting a biologic agent. Please discuss the use of this medication with your doctor.
• You will need regular blood tests to check for any side effects from the biologic agent.
• Find out from your doctor or nurse who you should call if you get sick while taking a biologic. If you develop fever, chills or any signs of infection like a cough, sore throat, diarrhea or a new rash, DO NOT take the next dose of biologic. Call the health-care provider that your doctor or nurse has recommended you contact if you get sick, and make an appointment with your doctor. You need to be well again before you take the next dose. Speak with your doctor for further instructions.
• You should not receive live vaccines (MMR, varicella, nasal flu shot) while receiving biologics.
• You should be vaccinated against, or already have had, chicken pox before starting treatment with biologics.
• If you are exposed to or develop chickenpox, DO NOT take the next dose of biologic. Call your 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, we do not know 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.