Precautions to Take Before Starting Biologics

Tips for reducing the risk of harmful infections.


While biologic medications have revolutionized the treatment of many kinds of arthritis, like all drugs, in addition to their benefits, they come with new risks. Biologic drugs work by suppressing the immune system, an action that can open the door for infections.

We asked Arthritis Today Medical Advisory Board member Robert Shaw, MD, an instructor of medicine at Johns Hopkins University and a practicing rheumatologist, what precautions people with arthritis should take before starting a biologic medication. Here is his checklist:  

1) Have a skin or blood test for tuberculosis, or TB.

Experts estimate that 90 percent of people who are infected with tuberculosis, which can cause a deadly infection, don’t know it because the bacteria can lie    dormant in the body for years. Taking medications that suppress the immune increases the risk that the infection will become active.

2) If you need any live virus vaccines, get them one to three months before starting biologics.

Flu vaccine injections are dead viruses and can be given anytime. But any live virus vaccine needs to be given one to three months before starting immunosuppressant drugs. Discuss how to handle live virus vaccines with your doctor, including:

• Flu Mist vaccine, which comes in nasal form

• Shingles vaccine

• Measles, mumps and rubella vaccines

• Typhoid, varicella, small pox and yellow fever vaccines for people who need to travel

3) Finish antibiotics before starting a biologic.

Anyone with any infection or fever who is on antibiotics should not start a biologic until the infection and fever have passed because your immune system is impaired.

4) Wait if you are going in for surgery.

Dr. Shaw says patients going in for surgery should hold off on biologics like etanercept (Enbrel) and adalimumab (Humira) for two weeks before surgery and they should hold off on infliximab (Remicade) and abatacept (Orencia) for four weeks before surgery. Additionally, patients should not start or restart the biologics until after their sutures or staples are removed and there is no sign of infection because biologics will make it harder to heal.

5) Get scanned before you take rituximab (Rituxan).

Dr. Shaw says patients should have a Hepatitis B scan before going on Rituxan because the drug impairs immune system cells called B cells and that predisposes people to hepatitis. If you are harboring the Hepatitis B virus, it will make you worse.

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