Biologic Agents

Medications for Scleroderma, Arthritis, Autoimmune and Rheumatic Diseases

Author: Janey Willis. Scleroderma is highly variable. See Types of Scleroderma. Read Disclaimer
Overview of Biologic Agents
Abatacept (Orencia)
Alemtuzumab (Campath)
Etanercept (Enbrel, Benepali)
Infliximab (Remicade)
Rituximab (Rituxan)
TNF Inhibitors


Biologics or biologic agents are biologic response modifying agents that block specific pathways and signals of inflammation. Some of the biologics used to treat rheumatic diseases include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), abatacept (Orencia), and rituximab (Rituxan). (Also see What is Scleroderma?, Medical Overview, and Medications for Scleroderma, Arthritis, Autoimmune and Rheumatic Diseases)

Different biologics block different arm of the immune system. For example, etanercept, infliximab, and adalimumab block tumor necrosis factor (TNF), abatacept blocks an interaction between T cells and macrophages, and rituximab effectively eliminates B cells for several months.

Efficacy and safety of rituximab (RTX) in peripheral ulcerative keratitis (PUK) associated with rheumatoid arthritis (RA). RTX appears to be an efficient and safe therapeutic option in the treatment of RA-associated PUK. PubMed, RMD Open, 2021 Jan;7(1):e001472. (Also see Treatments for Rheumatoid Arthritis)

Low Incidence of Inflammatory Bowel Disease Adverse Events (IBD AEs) in Adalimumab Clinical Trials Across Nine Different Diseases. The rates of IBD AEs in adalimumab clinical trials were generally low across the evaluated diseases and all events occurred in adult patients. PubMed, Arthritis Care Res (Hoboken), 02/26/2020. (Also see Inflammatory Bowel Disease)

Remission in psoriatic arthritis: Definition and predictors. The use of biologic agents increased not only the chance of remission, but also the chance of sustained remission for at least 12 months. Seminars in Arthritis and Rheumatism, 02/03/2020. (Also see Psoriasis and Psoriatic Arthritis)

Risk of congenital anomalies in infants born to women with autoimmune disease using biologics before or during pregnancy: a population-based cohort study. These population-based data suggest that the use of biologics before and during pregnancy is not associated with an increased risk of congenital anomalies. PubMed, Clin Exp Rheumatol, 2019 Nov-Dec;37(6):976-982.

Evaluation of response criteria in rheumatoid arthritis treated with biological disease–modifying antirheumatic drugs. EULAR response criteria overestimate the response under Interleukin-6 inhibitors treatment because the acute–phase reactants improvement largely contributes to the Disease Activity Score 28 improvement. PubMed, Arthritis Care Res (Hoboken), 05/06/2019.

The Effect of Pregnancy on Disease Activity in Patients with Psoriatic Arthritis. Continuation of biologics therapy was associated with a low level of disease activity and a low probability of flare during pregnancy. PubMed, J Rheumatol, 2018 Dec;45(12):1651-1655. (Also see Psoriasis and Psoriatic Arthritis)

Association between autophagy and inflammation in patients with rheumatoid arthritis (RA) receiving biologic therapy. Elevated autophagy with significant correlation to inflammation suggests the involvement of autophagy in RA pathogenesis. PubMed, Arthritis Res Ther, 2018 Dec 5;20(1):268. (Also see Treatments for Rheumatoid Arthritis)

Drug Utilization Patterns and Adherence in Patients on Systemic Medications for the Treatment of Psoriasis: A Retrospective Comparative Cohort Study. We report greater adherence in new users of biologics when compared to methotrexate. PubMed, J Am Acad Dermatol, 07/04/2018. (Also see Psoriasis and Psoriatic Arthritis)

Precision medicine using different biological DMARDs based on characteristic phenotypes of peripheral T helper cells in psoriatic arthritis. Strategic treatment in which different bDMARDs were selected according to phenotypic differences in helper T cells showed significantly higher efficacy. PubMed, Rheumatology (Oxford), 04/02/2018. (Also see Psoriasis and Psoriatic Arthritis)

Residual disease activity (RDA) in rheumatoid arthritis (RA) patients treated with subcutaneous biologic drugs that achieved remission or low disease activity (LDA). RDA in RA was present even in patients with remission or LDA, especially for the patient's reported outcome and impaired function was also present in a significantly rate of patients. PubMed, Clin Rheumatol, 02/21/2018. (Also see Treatments for Rheumatoid Arthritis)

Abatacept (Orencia)

Risk of malignancy with non-TNFi biologic or tofacitinib therapy in rheumatoid arthritis: A meta-analysis of observational studies. Among RA patients, a small statistically significant increase in developing cancer was observed for abatacept exposure. Seminars in Arthritis and Rheumatism, 09/03/2020. (Also see Treatments for Rheumatoid Arthritis)

Abatacept in Early Diffuse Cutaneous Systemic Sclerosis – Results of a Phase 2 Investigator-Initiated, Multicenter, Double-Blind Randomized Placebo-Controlled Trial. In this Phase 2 trial, abatacept was well tolerated, but change in modified Rodnan skin score was not statistically significant. PubMed, Arthritis Rheumatol, 07/24/2019.

Alemtuzumab (Campath)

FDA Alert: Alemtuzumab (marketed as Campath) Information. Three patients in a clinical study of the drug Campath for the treatment of Multiple Sclerosis (MS) developed severe idiopathic thrombocytopenic purpura (ITP). One of the patients died. U.S. Food and Drug Administration.

Alemtuzumab (Campath): Side Effects. Safety data, except where indicated, are based on 149 patients with B-CLL enrolled in studies of Campath as a single agent administered at a maintenance dose of 30 mg intravenously three times weekly for 4 to 12 weeks. RxList.

Etanercept (Enbrel®, Benepali) by Biogen

Enbrel® is a rheumatoid arthritis medication that may also be used to treat scleroderma joint pain and stiffness.

Benepali® (Etanercept) is the first etanercept biosimilar referencing Enbrel ® approved in the European Union (EU). It is indicated for adults in the EU to treat moderate to severe active rheumatoid arthritis, psoriasis and psoriatic arthritis, and spondyloarthritis. Biogen.

Enbrel® (etanercept) treats moderate to severe plaque psoriasis from inside the body, rather than at the surface where you see skin symptoms. It works on your immune system to help stop skin cells from growing too quickly. Amgen.

Low Doses of Etanercept (ETN) Can Be Effective to Maintain Remission in Psoriatic Arthritis (PsA) Patients. The main reasons that hinder the dosing interval increase in ETN in PsA patients are peripheral polyarthritis pattern and exacerbation of cutaneous manifestations. PubMed, J Clin Rheumatol, 2018 Apr;24(3):127-131. (Also see Psoriasis and Psoriatic Arthritis)

Infliximab (Remicade)

Infliximab (Remicade). Patients treated with REMICADE are at increased risk for infections, including progression to serious infections leading to hospitalization or death. RxList.

An Open-Label Pilot Study Of Infliximab Therapy In Diffuse Cutaneous Systemic Sclerosis (dcSSc). In dcSSc infliximab did not show clear benefit at 26 weeks but was associated with clinical stabilisation and fall in two laboratory markers of collagen synthesis. The frequency of suspected infusion reactions may warrant additional immunosuppression in any future studies in SSc. C. P. Denton. (Also see Scleroderma Treatments)

Case Report: Successful treatment of infliximab in a patient with scleroderma. Signs and symptoms were continued improving during the course of treatment and skin biopsy showed significant reduction in fibroplasia finally. PubMed, Medicine (Baltimore).

Rituximab® (Rituxan) by Biogen and Genentech

People with serious infections should not receive Rituxan. It is not known if it is safe or effective in children.

RITUXAN® (Rituximab) is approved for treatment of rheumatoid arthritis, granulomatosis with polyangiitis (GPA) (formerly Wegener's Granulomatosis), microscopic polyangiitis (MPA), non-Hodgkin’s lymphoma (NHL), and chronic lymphocytic leukemia (CLL). Biogen and Genentech.

Rituxan® (Targeted B-cell Therapy). Indications and Uses. FDA Warning.

Anti-CD20 monoclonal antibodies (mAb) in Systemic Lupus Erythematosus. In this review, we will focus on B cell abnormalities and the rationale behind B-cell depletion therapy with anti-CD20 mAb. PubMed, Biologicals, 2020 Dec 4;S1045-1056(20)30136-6. (Also see Antibodies in Lupus)

Rituximab (RTX) as a rescue treatment added on mycophenolate mofetil background therapy in progressive systemic sclerosis associated interstitial lung disease (SSc-ILD) unresponsive to conventional immunosuppression. Based on our results, RTX's use as an add-on treatment to MMF appears to be effective as a rescue therapy in patients with a more aggressive SSc-ILD phenotype. Seminars in Arthritis and Rheumatism, 08/08/2020. (Also see Cellcept)

Risk factors and treatment of relapses in autoimmune pancreatitis: Rituximab is safe and effective. In relapsing autoimmune pancreatitis, rituximab is more efficient than immunomodulator drugs and shows better tolerance. PubMed, United European Gastroenterol J, 2019 Oct;7(8):1073-1083. (Also see Pancreatitis, Autoimmune)

B cell depletion treatment decreases CD4+IL4+ and CD4+CD40L+ T cells in patients with systemic sclerosis (SSc). Our study demonstrates a link between rituximab treatment and CD4+IL4+ T cell decrease both in the skin and peripheral blood of patients with SSc. PubMed, Rheumatol Int, 06/21/2019. (Also see B Cells and T Cells)

Effects of treatment with rituximab on microcirculation in patients with long–term systemic sclerosis. Rituximab improves microcirculation in long–term SSc and stabilization and reduced progression of microcirculation abnormalities were achieved. PubMed, BMC Res Notes, 2018 Dec 10;11(1):874. (Also see Clinical Trials)

Rituximab for refractory rapidly progressive interstitial lung disease (RP–ILD) related to anti-MDA5 antibody–positive amyopathic dermatomyositis. Our results suggest that RTX may be a useful therapy for anti-MDA5 Ab-positive ADM associated with RP–ILD, although infection is the major risk. PubMed, Clin Rheumatol, 04/30/2018. (Also see Treatments for Dermatomyositis)

(Case Report) Rituximab (RTX) for eosinophilic granulomatosis with polyangiitis with severe vasculitic neuropathy: Case report and review of current clinical evidence. RTX seems to be effective in cases of severe EGPA refractory to standard of care immunosuppressive treatment, although support comes from case reports and non-controlled studies. PubMed, Semin Arthritis Rheum.

TNF Inhibitors

Tumor Necrosis Factor (TNF) inhibitors include etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira)

Pharmacodynamic biomarkers and differential effects of TNF- and GM-CSF-targeting biologics in rheumatoid arthritis. Our results revealed golimumab- and mavrilimumab-specific pharmacodynamic biomarkers, and demonstrated differential biomarker-treatment relationships in anti-TNF-IR and DMARD-IR patients, respectively. PubMed, Int J Rheum Dis, 2019 Apr;22(4):646-653. (Also see Treatments for Rheumatoid Arthritis)

Brief Report: Safety and Immunogenicity of Rituximab Biosimilar GP 2013 After Switch From Reference Rituximab in Patients With Active Rheumatoid Arthritis. No safety risks were detected when patients switched from reference RTX to GP2013. PubMed, Arthritis Care Res (Hoboken), 2019 Jan;71(1):88-94. (Also see Treatments for Rheumatoid Arthritis)

Improved patient–reported outcomes (PROs) in patients with psoriatic arthritis (PsA) treated with abatacept: results from a phase 3 trial. Abatacept treatment improved PROs in patients with PsA versus placebo, with better results in elevated baseline C-reactive protein and tumour necrosis factor inhibitor– na´ve subpopulations. BMC Journals, Arthritis Research & Therapy, 12/06/2018. (Also see Psoriasis and Psoriatic Arthritis)

Risk of active tuberculosis in patients with inflammatory arthritis receiving TNF inhibitors (TNFi): a look beyond the baseline tuberculosis screening protocol. ‘Early TB’ was exceeded by TB occurring after 1 year of TNFi treatment, thereby, suggesting that further TB prevention measures were required. PubMed, Clin Rheumatol, 2018 Sep;37(9):2391-2397. (Also see Extrapulmonary Tuberculosis)


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