Practice Therapeutics

Biologicals for rheumatoid arthritis

BMJ 2011; 343 doi: (Published 28 July 2011) Cite this as: BMJ 2011;343:d4027
  1. Peter Tugwell, professor of medicine 1,
  2. Jasvinder A Singh, associate professor of medicine2,
  3. George A Wells, professor of epidemiology and community medicine3
  1. 1Department of Medicine, Institute of Population Health, and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada K1N 6N5
  2. 2Department of Medicine, Birmingham VA Medical Center and University of Alabama at Birmingham, Birmingham AL 35294, USA
  3. 3Department of Epidemiology and Community Medicine, University of Ottawa, and University of Ottawa Heart Institute, Ottawa
  1. Correspondence to: P Tugwell{at}

Case scenario

A 45 year old woman had seropositive erosive rheumatoid arthritis diagnosed three years ago with involvement of the hands, wrists, shoulders, and feet. She found it difficult to dress, cook, do the housework, and control her dog on her morning walk. She improved initially on triple disease modifying antirheumatic drug (DMARD) therapy (methotrexate 25 mg intramuscularly weekly with oral folic acid 1 mg daily, hydroxychloroquine 400 mg daily, sulfasalazine 1 g twice daily) and naproxen 500 mg twice daily. Her symptoms have now flared up despite continuation of triple DMARD therapy, with multiple swollen and tender joints. Radiographs show that since last year she has developed three new erosions in her metacarpophalangeal joints. She wants to discuss the new biological drugs that you mentioned would be an option if she did not respond to the above therapy

The term biological describes treatments developed and produced in live cell systems. The drugs may also be referred to as biological therapies or cytokine modulators.1 By targeting molecules involved in the inflammatory response, such as tumour necrosis factor-α, some biologicals help to reduce or suppress inflammation, potentially reducing joint damage in rheumatoid arthritis. They are used for an increasing number of indications and are approved in some countries for conditions such as rheumatoid arthritis, ankylosing spondylitis, psoriasis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis. Most of these conditions are autoimmune diseases characterised by upregulation of cytokines such as interleukins; tumour necrosis factor and T and B lymphocytes contribute to the inflammation, a central pathophysiological feature of these conditions. The following are approved for treatment of rheumatoid arthritis in the United Kingdom or the United States, or both:

  • Five tumour necrosis factor inhibitors: adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade)

  • Anti-interleukin 1 therapy: anakinra (Kineret)

  • T cell costimulator modulator: …

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