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Are Some Arthritis Patients Unsuitable Candidates for Biologic Drugs?

Biologics Aren't for Everyone

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Updated June 27, 2014

Question: Are Some Arthritis Patients Unsuitable Candidates for Biologic Drugs?

Treatment options for rheumatoid arthritis include the biologic drugs:

However, some patients are not considered suitable candidates for biologic drugs. Is there ever a point when their medical history doesn't preclude them from trying the biologics?

If it is the case that some people remain unsuitable candidates for the biologic drugs, what arthritis medications do you recommend so they can maintain an aggressive treatment plan?

Answer:

Weighing Benefits Versus Risks of Biologic Drugs

Due to potential side effects of biologics, there are a number of conditions where the risks of treatment would most likely outweigh the benefits. Some examples might include:

A history of mild recurrent infections, while considered a relative contraindication to therapy, would not necessarily exclude long term treatment with a biologic. For example, a patient with recurrent urinary tract infections whose condition is controlled on daily low dose antibiotic treatment might be able to tolerate these medications without problems.

In addition, one might feel comfortable prescribing these agents to a patient who gave a history of a serious infection in the past without any recent recurrence. On the other hand, an insulin dependent diabetic who has a history of recurrent infections, especially if they required hospitalization, would not be a good candidate.

Considering Individual Patient History Before Using Biologic Drugs

Unfortunately, the clinical studies did not look at patients who may be predisposed to infections, so the decision to treat is an individual one where both patient and doctor weigh the benefits of treatment versus the risk of infection. In all cases, the drugs should not be initiated if patients are having signs or symptoms of infection and in general, I will temporarily hold treatment during any active infection.

Other Options If Biologic Drugs Are Unsuitable

For patients who are not suitable candidates for biologics, drugs which are typically not associated with infection, unless an abnormality of the bone marrow occurs, include:

Methotrexate and Arava both may be associated with infection but are less likely to increase the risk of the more serious opportunistic infections such as tuberculosis or other organisms.

Answer provided by Scott J. Zashin, M.D., clinical assistant professor at University of Texas Southwestern Medical School, Division of Rheumatology, in Dallas, Texas. Dr. Zashin is also an attending physician at Presbyterian Hospitals of Dallas and Plano. He is a fellow of the American College of Physicians and the American College of Rheumatology and a member of the American Medical Association. Dr. Zashin is author of Arthritis Without Pain - The Miracle of Anti-TNF Blockers and co-author of Natural Arthritis Treatment.

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