IMMUNOSUPPRESSANTS›TUMOR NECROSIS
FACTOR ALPHA (TNF-a) INHIBITORSAdalimumab 21-Feb-2018
lINDICATIONS AND DOSE
Plaque psoriasis (initiated by a specialist)
▶BY SUBCUTANEOUS INJECTION
▶Child 4–17 years (body-weight 15–29 kg):Initially 20 mg
once weekly for 2 doses, then 20 mg every 2 weeks,
review treatment if no response within 16 weeks
▶Child 4–17 years (body-weight 30 kg and above):Initially
40 mg once weekly for 2 doses, then 40 mg every
2 weeks, review treatment if no response within
16 weeks
Polyarticular juvenile idiopathic arthritis (initiated by a
specialist)
▶BY SUBCUTANEOUS INJECTION
▶Child 2–17 years (body-weight 10–29 kg): 20 mg every
2 weeks, review treatment if no response within
12 weeks
▶Child 2–17 years (body-weight 30 kg and above): 40 mg
every 2 weeks, review treatment if no response within
12 weeks
Enthesitis-related arthritis (initiated by a specialist)
▶BY SUBCUTANEOUS INJECTION
▶Child 6–17 years (body-weight 15–29 kg): 20 mg every
2 weeks
▶Child 6–17 years (body-weight 30 kg and above): 40 mg
every 2 weeks
Crohn’s disease (initiated by a specialist)
▶BY SUBCUTANEOUS INJECTION
▶Child 6–17 years (body-weight up to 40 kg):Initially
40 mg, then 20 mg after 2 weeks; maintenance 20 mg
every 2 weeks, increased if necessary to 20 mg once
weekly, review treatment if no response within
12 weeks of initial dose
▶Child 6–17 years (body-weight 40 kg and above):Initially
80 mg, then 40 mg after 2 weeks; maintenance 40 mg
every 2 weeks, increased if necessary to 40 mg once
weekly, maximum 40 mg administered at a single site,
review treatment if no response within 12 weeks of
initial dose
Crohn’s disease (accelerated regimen) (initiated by a
specialist)
▶BY SUBCUTANEOUS INJECTION
▶Child 6–17 years (body-weight up to 40 kg):Initially
80 mg, then 40 mg after 2 weeks; maintenance 20 mg
every 2 weeks, increased if necessary to 20 mg once
weekly, maximum 40 mg administered at a single site,
review treatment if no response within 12 weeks of
initial dose
▶Child 6–17 years (body-weight 40 kg and above):Initially
160 mg, dose can alternatively be given as divided
injections over 2 days, then 80 mg after 2 weeks;
maintenance 40 mg every 2 weeks, then increased if
necessary to 40 mg once weekly, maximum 40 mg
administered at a single site, review treatment if no
response within 12 weeks of initial dose
Hidradenitis suppurativa (initiated by a specialist)
▶BY SUBCUTANEOUS INJECTION
▶Child 12–17 years (body-weight 30 kg and above):Initially
80 mg, given as two 40 mg injections in one day,
followed by 40 mg after 1 week, then maintenance
40 mg every 2 weeks; increased if necessary to 40 mg
once weekly, review treatment if no response within
12 weeks; if treatment interrupted—consult product
literatureUveitis (initiated by a specialist)
▶BY SUBCUTANEOUS INJECTION
▶Child 2–17 years (body-weight up to 30 kg):Initially 40 mg,
then 20 mg after 1 week; maintenance 20 mg every
2 weeks, alternatively 20 mg every 2 weeks
▶Child 2–17 years (body-weight 30 kg and above):Initially
80 mg, given as two 40 mg injections in one day, then
40 mg after 1 week; maintenance 40 mg every 2 weeks,
alternatively 40 mg every 2 weekslCONTRA-INDICATIONSModerate or severe heart failure.
severe infection
lCAUTIONSChildren should be brought up to date with
current immunisation schedule before initiating therapy.
demyelinating disorders (risk of exacerbation).
development of malignancy.do not initiate until active
infections are controlled (discontinue if new serious
infection develops).hepatitis B virus—monitor for active
infection.history of malignancy.mild heart failure
(discontinue if symptoms develop or worsen).
predisposition to infection
CAUTIONS, FURTHER INFORMATION
▶TuberculosisActive tuberculosis should be treated with
standard treatment for at least 2 months before starting
adalimumab. Patients who have previously received
adequate treatment for tuberculosis can start adalimumab
but should be monitored every 3 months for possible
recurrence. In patients without active tuberculosis but
who were previously not treated adequately,
chemoprophylaxis should ideally be completed before
starting adalimumab. In patients at high risk of
tuberculosis who cannot be assessed by tuberculin skin
test, chemoprophylaxis can be given concurrently with
adalimumab.
lINTERACTIONS→Appendix 1 : monoclonal antibodies
lSIDE-EFFECTS
▶Common or very commonAgranulocytosis.alopecia.
anaemia.anxiety.arrhythmias.arterial occlusion.
asthma.broken nails.chest pain.coagulation disorder.
connective tissue disorders.cough.dehydration.
depression.dyspnoea.electrolyte imbalance.embolism
and thrombosis.eye inflammation.fever.flushing.
gastrointestinal discomfort.gastrointestinal disorders.
haemorrhage.headaches.healing impaired.
hyperglycaemia.hypersensitivity.hypertension.
increased risk of infection.insomnia.leucocytosis.
leucopenia.mood altered.muscle spasms.
musculoskeletal pain.nausea.neoplasms.nerve disorders
.neutropenia.oedema.renal impairment.seasonal
allergy.sensation abnormal.sepsis.skin reactions.sweat
changes.thrombocytopenia.vasculitis.vertigo.vision
disorders.vomiting
▶UncommonAortic aneurysm.congestive heart failure.
demyelinating disorders.dysphagia.erectile dysfunction.
gallbladder disorders.hearing impairment.hepatic
disorders.inflammation.lupus erythematosus.
meningitis viral.myocardial infarction.nocturia.
pancreatitis.respiratory disorders.rhabdomyolysis.
sarcoidosis.solid organ neoplasm.stroke.tremor
▶Rare or very rareCardiac arrest.pancytopenia.Stevens-
Johnson syndrome
SIDE-EFFECTS, FURTHER INFORMATIONAssociated with
infections, sometimes severe, including tuberculosis,
septicaemia, and hepatitis B reactivation.
lCONCEPTION AND CONTRACEPTIONManufacturer advises
effective contraception required during treatment and for
at least 5 months after last dose.
lPREGNANCYAvoid.
lBREAST FEEDINGAvoid; manufacturer advises avoid for at
least 5 months after last dose.642 Arthritis BNFC 2018 – 2019
Musculoskeletal system10