Just about everyone has had the experience of going to the doctor with a symptom or complaint and exiting the doctor’s office with a prescription for some type of medicine. In most cases, the medicine prescribed is a pill or capsule that is swallowed, but there are many other ways in which drugs are administered. For example, there are pills that are held in the mouth and allowed to dissolve; creams, ointments, and patches that are applied to the skin; liquids that may be swallowed or placed into the eyes; and substances that are inhaled through the nose or mouth (usually with the aid of a special device). Increasingly, for people who have rheumatoid arthritis (RA) and certain other inflammatory or autoimmune rheumatic conditions, the prescription they receive from the doctor is likely to be for an injectable drug. It may be for a drug that they inject themselves (or have a caregiver inject), or it may be for a drug that is delivered by intravenous infusion by a health-care provider. Many of these injectable drugs are biologic response modifiers, or biologic drugs, for short. Biologics act on specific parts of the immune system to interfere with the inflammatory processes that lead to tissue damage in RA. For many people, they have helped to slow or even stop the progression of RA and/or other autoimmune conditions.
In spite of the potential benefits of biologics, hearing that you’ll need to inject yourself or come to a medical office periodically for intravenous infusions can come as an unwelcome surprise. For many people, the news is a source of anxiety and fear. However, with time, training on self-injection, the use of injection devices designed with hand disabilities in mind, and, most important, the ability of these drugs to reduce inflammation and interfere with the autoimmune response that causes symptoms, many people are able to overcome their reservations and make use of these medicines.
Injected and infused biologic drugs: What’s the difference?
The various biologics work in a number of different ways depending on which part of the body’s immune response they are designed to disrupt or slow down. Categories of biologics include anti-tumor necrosis factor (anti-TNF) drugs, also called TNF inhibitors; interleukin-1 blockers; T cell blockers; interleukin-6 (IL-6) inhibitors; and B cell blockers. Doctors often start by prescribing an anti-TNF drug (which include Enbrel, Humira, Cimzia, Simponi, and Remicade), but ultimately the choice is made based on what works best for the person taking the drug.
The following are the biologics currently on the market:
The first biologic approved for RA, Enbrel is also approved for plaque psoriasis, psoriatic arthritis, juvenile idiopathic arthritis (JIA), and ankylosing spondylitis. It is administered by self-injection in doses of either 25 or 50 milligrams (mg), usually once or twice a week. Enbrel is sold in prefilled, 50-mg autoinjectors; single-use, prefilled syringes; multi-use, 25-mg vials; and single-use, 25-mg vials that come with a vial adapter. The Enbrel SureClick autoinjector is designed so the user never sees the needle.
More than 10 years of safety data is available for Enbrel. The drug does not usually cause any burning sensation when injected, although occasional injection site irritation has been reported.
Humira is approved for RA, plaque psoriasis, Crohn disease, ulcerative colitis, anklylosing spondylitis, psoriatic arthritis, and JIA. It requires self-injection once every two weeks using either a preloaded pen or a preloaded syringe. The pen and adult syringe contain a 40-mg dose for adults; the pediatric syringe contains 20 mg.
Approved for RA, Crohn disease, and psoriatic arthritis, Cimzia is sold in specially designed, prefilled syringes for self-administration. Use of Cimzia requires an initial dosing period, during which three 400-mg doses are given over four weeks. Each of the three doses are given as two separate injections of 200 mg each. Subsequently, Cimzia can be taken as one 200-mg injection every two weeks, or two 200-mg injections every four weeks. Cimzia is more viscous (thicker) than the other injectables and may cause a slight burning sensation when injected.
Simponi is approved to treat RA, psoriatic arthritis, ankylosing spondylitis, and ulcerative colitis. It can be given intravenously by a health-care provider or self-administered as an injection, using either the Simponi SmartJect autoinjector or a prefilled syringe. For RA and other forms of arthritis, a 50-mg dose is taken once a month.
Approved for RA, Kineret is self-injected once daily using a prefilled syringe containing 100 mg. It should be taken at the same time every day. Kineret may be unsafe for people with kidney problems.
Orencia is approved for RA and JIA. It can be given as an infusion at a medical office or self-administered using a prefilled syringe. For adults with RA who are self-injecting, the usual dose is 125 mg, given weekly.
Actemra is approved to treat RA and some forms of JIA. Adults and children can receive Actemra as an infusion, which takes about an hour. Adults with RA can take it as an injection, using prefilled syringes. The frequency with which Actemra is taken by either method depends on the person’s weight and diagnosis.
Remicade is used to treat numerous inflammatory diseases, including RA, psoriatic arthritis, and ankylosing spondylitis. It is administered by infusion only, which takes about two hours. After three starter doses, maintenance infusions are given every eight weeks.
Rituxan is used to treat RA and is administered by infusion only. It is generally given every six months, in two infusions given two weeks apart. Each infusion typically lasts four to six hours.
Other injected drugs for rheumatoid arthritis
In addition to biologics, some other drugs commonly prescribed for RA can be injected.
Methotrexate, a cornerstone of RA treatment is usually taken orally once a week, but it can also be given by self-injection. In 2013, the FDA approved a single-dose, disposable autoinjector called Otrexup for self-administration of methotrexate. It is intended to be taken once weekly, and four dose sizes are available. Otrexup can be used by both adults with RA and children with one type of JIA.
Corticosteroids are drugs designed to mimic naturally occurring hormones in the body that help to reduce inflammation. Mostly commonly, corticosteroids are taken orally, but injections of corticosteroids into a joint can be used to relieve pain and swelling. These injections are performed by a doctor.
Tips for using self-injectable biologics
Your doctor or nurse should teach you how to use the drug and device you’ve been prescribed. You will also receive written instructions along with the device when you pick up your prescription. In addition, the makers of all of the drugs described here have Web sites with written instructions, and most have online video demonstrations as well. Many also have toll-free assistance numbers, often staffed by nurses. Storing and using a drug correctly is the best way to get the most benefit from it, so don’t hesitate to ask for help if you need it.
The specific instructions for self-injectables varies from product to product, so if you switch drugs or devices, be sure that you are trained on the new drug or device and also have written instructions available.
How to store injectables
Injectable biologics should be kept refrigerated at a temperature between 36˚F and 46˚F, protected from light, and used before the expiration date on the package. They should not be frozen. Prior to administration, the medicine should be allowed to warm to room temperature for 30–60 minutes to increase comfort at the time of injection. The medicine should not be administered if it looks discolored or has particles in the liquid or if it has passed its expiration date.
Otrexup should be stored at room temperature between 68˚F and 77˚F and protected from light. It should not be frozen.
In what area of the body are biologics supposed to be injected?
Self-injectables are injected into the subcutaneous fat layer (the layer of fat just under the skin), so they must be injected into body areas where there is adequate fat. All of the injectables described here can be injected into the thighs or abdomen, as long as the injection is done no closer than 2 inches from the navel (belly button). Some can also be injected into the backs of the upper arms by a caregiver, but check the instructions for your product to make sure this is OK.
It is important to rotate your injection sites—or to change where you inject each time—to avoid skin irritation. It helps to keep a chart or use a calendar to document the dates, times, and sites of your injections so you can remember when your next injection is due and which sites you have used recently.
Tips for injecting yourself
For all injections, the first steps are to assemble everything you’ll need for the injection—including the injection device (which has been allowed to warm to room temperature), an alcohol pad for cleaning the injection site, a cotton ball or gauze pad to stop any bleeding after the injection, and a sharps container (see below) to dispose of the device afterward—and to wash your hands thoroughly. You’ll also want to inspect your medicine for particles or discoloration, and clean your injection site with the alcohol pad, allowing the skin to air-dry without blowing on it or fanning it.
What you should know about using syringes
When injecting with a syringe, first remove the syringe cap (covering the needle). You may be instructed to tap the side of the syringe to move any air bubbles to the needle end of the syringe, then gently press on the plunger to expel them. Read your medicine instructions to make sure this step is recommended.
Next, pinch up a section of skin in the area cleaned for the injection, and insert the needle at the angle specified in your instructions. Keeping the needle in your skin with one hand, let go of the pinched-up skin with the other. For some devices, you will be instructed to pull back on the syringe plunger at this point and observe whether any blood enters the syringe. Other devices do not require this step. If your device instructs you to pull back on the plunger and you see blood in the syringe, you should pull out the needle, discard the prefilled syringe in the sharps container, and start again with another prefilled syringe. If there’s no blood, or your device doesn’t require this step, slowly push the plunger all the way down to deliver the full dose of medicine.
When the syringe is empty, pull the needle out from your skin, and press the area with a clean cotton ball or gauze pad for 10 seconds, but do not rub. Do not recap the syringe needle with the needle cover. Dispose of the needle and cap in your sharps container. If the injection spot bleeds a little, you can apply gentle pressure for a little longer with the cotton ball or pad, then apply a small bandage, if necessary.
How to use autoinjectors
To inject with an autoinjector, first pull the needle cap off as directed. Some caps pull straight off, while others require twisting. For some devices, you should then stretch the injection site using your thumb and forefinger, so the skin is taut. Other autoinjectors do not require this stretching step, and some give the option of pinching the skin rather than stretching it.
Press the needle end of the autoinjector firmly against your skin at a 90-degree angle. For some autoinjectors this pressure starts the injection, while for others, it just unlocks a safety mechanism (usually with an audible click). In the latter case, you must then press a release, or activation, button to deliver the medicine. All autoinjectors must be held against the skin for at least 3 seconds and up to 15 seconds to make sure all of the medicine is delivered. Sometimes a second click is heard at this point, indicating that the injection is completed, and you can release pressure on the device. Check the viewing, or inspection, window to make sure the medicine was delivered. Typically the window changes color to indicate that the injection was successful.
If there is bleeding at the injection spot, press a cotton ball or gauze pad over it for 10 seconds or longer, if necessary. You can also cover it with a small bandage.
How to properly dispose syringes and needles
All used injection equipment should be placed in a puncture-proof container. This can be a sharps container purchased from your pharmacy, or you can use a hard plastic container with a top, such as a used bleach bottle. When the container is 3/4 full, put the top on and dispose of it according to your community’s guidelines for sharps disposal. Check with your local trash removal service or health department to find out what those are.
Some communities have designated medical waste collection sites, which may be doctors’ offices, hospitals, pharmacies, or police or fire stations. Others have household hazardous waste collection sites that will accept sharps. There are also mail-back programs where, for a fee, you can mail your used sharps back to the manufacturer.
For more information on sharps disposal, go to the Web site of the Coalition for Safe Community Needle Disposal, www.safeneedledisposal.org, or call the Coalition at (800) 643-1643. Your physician’s office or local pharmacy may also be able to help.
Tips for traveling with biologic drugs
Traveling with biologics requires planning ahead, since they should be kept refrigerated. Some, however, can be kept at room temperature for a limited number of days. Check the information for the drug you take for specifics. The other alternative is to use an insulated travel container and keep the medicine cool with cold packs. You will also need to bring a small container to dispose of your sharps on the go.
When traveling by airplane, all medically necessary equipment, including syringes, other injection devices, and anything needed to keep those items cool, such as frozen gel packs, are allowed onboard in your carry-on luggage. The Transportation Security Administration (TSA) advises passengers to declare these items and separate them from other belongings before screening begins at the security checkpoint. It’s also best to carry medicines in their original containers, with labels attached. You may want to take along a doctor’s letter explaining the need for your medicines and related injection devices to show at security checkpoints.
No matter how you travel, it’s a good idea to always carry a list of all medicines you take in your wallet, purse, or backpack. You may additionally want to wear a medical alert bracelet listing your health conditions.
Deciding whether or not to start a biologic drug regimen
You are an important part of making the decision about whether to try a biologic and which to use. Many factors need to be considered. These may include your insurance coverage, whether you have access to an office or clinic that does infusions, your ability to use a syringe or autoinjector, your interest in and willingness to give yourself injections, the availability of a caregiver to help you, and any other health conditions you may have that affect the safety of using a biologic.
At this point, injectable biologics are the most common choice to control inflammation that has not responded to initial treatments, such as nonsteroidal anti-inflammatory drugs and methotrexate. If the first biologic you try does not work for you, your health-care provider may suggest trying another, continuing until you find one that is effective for you. Close monitoring of symptoms and side effects is important to help avoid problems and find the right drug regimen.
If you are able to inject your own medicines at home, you may appreciate the sense of freedom and normalcy that can give you. However, there are a variety of reasons people may need or want to have their prescribed biologic administered by IV, even though infusions take more time, require more medical visits, and may limit a person’s sense of freedom from illness-related activities.
Whichever route of delivery you choose, the ultimate goal is the same: to help you feel better and be able to do the things you want to do in life.