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Adalimumab

Adalimumab belongs to the class of biological response modifiers called tumour necrosis factor (TNF) blockers. It is currently approved for the treatment of psoriatic arthritis and rheumatoid arthritis. Adalimumab Effectiveness in Psoriatic Arthritis Trial (ADEPT), one of the largest clinical trials using a biological response modifier for the treatment of psoriatic arthritis showed improvements in both skin lesions (psoriasis) and joint symptoms as early as two weeks after starting therapy and then continual improvement over time. Based on results from this trial, the US Food and Drug Administration (FDA) approved the use of adalimumab for psoriatic arthritis in October 2005.

How does it work?

Adalimumab is generated by phase display technology with amino acid sequences only from the human germline. It works by directly binding to TNF molecules in the blood and diseased tissue. Adalimumab-bound TNF cannot bind to or activate TNF receptors p55 and p75, which is the primary cause of the inflammation, redness, itching and flaky skin patches characteristic of psoriasis.

How is it given?

Adalimumab is administered by subcutaneous injection once every two weeks. After initial counselling and training by a doctor on how to prepare and inject the drug, patients can usually self-administer at home. Injections are usually into the thigh, stomach or upper arm. A different site should be used at each injection to reduce soreness and prevent the skin from becoming tender, red, bruised or hard. Regular follow up visits to the doctor is necessary whilst on adalimumab.

The recommended dose for treating psoriatic arthritis is 40mg administered fortnightly as a single dose. Glucocorticoids, salicylates, NSAIDs, analgesics or disease modifying anti-rheumatic drugs can be continued during treatment with adalimumab.

Precautions

Because adalimumab works by selectively targeting only those chemicals involved in causing psoriatic arthritis or psoriasis, theoretically it should not have an effect on the rest of the body's immune system. Even so caution must be taken when considering its use in patients prone to infections or in those with chronic or recurrent infections. It should not be used in patients with sepsis or active infections.

Patients should be tested for tuberculosis (TB) before starting adalimumab. Treatment should be stopped if serious infection occurs.

Adalimumab should also be used with caution in the following situations:

• Mild congestive heart failure (do not use in patients with moderate or severe CHF)
• Pre-existing or recent-onset CNS demyelinating disorders
• Pregnancy and breastfeeding
• Elderly patients

Side Effects

Adalimumab appears to be well tolerated. Mild to moderate injection site reactions (redness, swelling, itching, pain) appear to be the most common side effect, occurring in 20% of patients. Other most common side effects experienced include upper respiratory tract infection ('flu-like illness), headache, sinusitis and hypertension (high blood pressure).

If any of the following symptoms or signs are severe or do not go away you should contact your doctor.

• Coughing, wheezing or chest pain
• Nausea and/or vomiting
• Stomach pain
• Fever, headache, chills or other signs of infection
• Hot, red, swollen area on the skin or bruising