Biologics: Benefits and Risks

Biologics can greatly improve your arthritis. But with those big pluses come some drawbacks.


All biologic drugs are designed to reduce inflammation and halt joint damage. They can be life-changing for many people with inflammatory forms of arthritis. By suppressing your immune system, however, you put yourself at increased risk for serious infection. Biologics are given as an injection or infusion, and as such, there is always a risk of an injection site reaction or an infusion reaction.

There are four classes of biologics, each is chosen for its unique target and the benefit it will have on your disease. In most cases, these drugs are prescribed when traditional disease-modifying antirheumatic drugs (DMARDs) have not worked. Because of the cost of development, biologics are expensive. In addition, many are not recommended for use in children and/or pregnant or nursing women. Here’s what you need to know.

Tumor Necrosis Factor-α Inhibitors

TNF-α inhibitors block tumor necrosis factor, a chemical that drives inflammation causing joint destruction. They include: adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), and infliximab (Remicade).

Benefits: These drugs reduce inflammation and suspend disease progression. They are sometimes used in combination with other medications, thereby increasing their effect. Many patients notice an improvement in their symptoms within 2 or 3 doses. Etanercept, adalimumab and infliximab are approved for use in children; the only TNF inhibitor that can be used during pregnancy is certolizumab.

Risks: The increased risk for infection specifically includes tuberculosis and fungal infections. The risk of tuberculosis may be lower with etanercept than other TNF inhibitors. Long-term use of these medications increases the risk of certain cancers. Adalimumab may worsen pre-existing heart failure or multiple sclerosis. The anti-inflammatory effect of anti-TNF drugs can diminish over time because some people form antibodies against the drug; using methotrexate with the biologic may reduce this likelihood.

B-cell Inhibitors

B-cell inhibitors inhibit the autoimmune response by interfering with the production of abnormal antibodies. This class of drugs includes belimumab (Benlysta) and rituximab (Rituxan).

Benefits: B-cell inhibitors are often used to treat rheumatoid arthritis when other treatments have not been effective. The effects of one rituximab treatment (two infusions approximately two weeks apart) can last nearly a year. A 2015 study evaluated the long-term safety of rituximab: the drug appears to be well tolerated over time and the rates of cardiac events, serious infection and malignancy were the same as the rates seen in the general RA population.

Risks: The infusion itself can have risks, such as a change in blood pressure, chest pain, difficulty breathing, rash, dizziness and/or flu-like symptoms. Medications can be given before the infusion to prevent or control these reactions. After treatment, you will be more susceptible to getting colds or sinus infections.

Interleukin Inhibitors

IL-inhibitors target proteins involved in inflammation, including IL-1, IL-6, IL-12, and IL-13. Drugs in this class include anakinra (Kineret), tocilizumab (Actemra), canakinumab (Ilaris), secukinumab (Cosentyx) and ustekinumab (Stelara).

Benefits: For people who don’t find relief from TNF inhibitors, IL inhibitors can be used. This class of drugs is effective and well tolerated by most patients.

Risks: In rare instances, you may get a small hole in your gastrointestinal tract (called a bowel perforation). You should be aware of changes in body temperature, abdominal discomfort, unusual bowel movements, headaches or symptoms of infection.

Selective Co-stimulation Modulators

These biologics interfere with the activation of white blood cells called T cells, preventing immune system reactions that result in inflammation. The only drug in this class is abatacept (Orencia).

Benefits: Abatacept can be used as a first-line treatment for moderate to severe rheumatoid arthritis, but it is more often prescribed after other DMARDs (such as methotrexate) don’t work adequately. Some people who do not get relief from an anti-TNF respond to abatacept. It is one of the biologics that can be used in children to treat juvenile idiopathic arthritis.

Patients have reported relief of inflammation, stiffness, joint pain and swelling after 4–6 weeks of treatment. Maximum response may not occur until after 4–6 months of treatment. Combined therapy with methotrexate is more effective than methotrexate alone. It has few interactions with other drugs.

Risks: Specific infections to be aware of include pneumonia, tuberculosis and influenza. Side effects include cough, sore throat, headaches and nausea. Infusion reactions can occur, and the health team will watch for signs of a reaction during your infusion. Your risk of getting cancer may increase, but this has not been well documented.

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