Treating Rhaumatoid Arthritis (RA) and Ankylosing Spondylitis(AS) with Special Drugs:
An Overview of Newer Drugs

by Dr Arvind Chopra


Note: Treatment of RA and AS begin with providing relief of pain using analgesics and non-steroidal anti-inflammatory drug (NSAID). However, there are several other targets like inflammation swelling of joints, control of immune mediated inflammatory process, osteoporosis, anemia, poor health, preventing joint deformities and disability. RA is a systemic disease and can effect several other organs. It reduces quality of life and life span. It makes patients more prone  for infections and certain cancers. There is an important role of physiotherapy, exercise and proper body weight. It is also necessary to maintain good mental health. Patients must look after their nutrition and life styles. Tobacco is a major risk factor and must be avoided.  However, in this article, we focus on the special drugs used to treat RA and AS. 

It is essential to screen patients requiring DMARDs and in particular Biologic agents for general health blood hemogram & cell count and normal kidney and liver functions and to exclude any infection or even its carrier state. Some biologics like anti tumor necrosis factor agent carry a higher risk for infections. Biologic DMARD should not be given to patients with severe heart and/or lung problems. Several good studies show that overall biologic DMARDs do not increase the risk for cancer. Biologics are not advised to be given during pregnancy and lactation.
Some of the screening tests required are – blood tests fpr hepatitis B and hepatitis C, and human immunodeficiency virus (HIV), blood test for tuberculosis active or latent (TB GOLD Quantiferon), skin test for TB (,Mantaux Test),Sonography of abdomen and pelvis and Chest Xray. In case of doubt of TB, CT scan may be required.
Biologic DMARDs are expensive. Pharmaceutical companies manufacturing biologic agents have several patent rights and protection which are limited by a certain period mostly 10-12 years. It is very difficult to copy the formula of biologic drugs. However, once the patent expires, other companies can undertake special research to create similar version of biologics called 'biosimilars'.To ensure high standard of quality and safety, biosimilars are manufactured under tight regulations and have to be approved by a special system. In India, these rules are made and supervised by the Drug Controlled of India. The main advantage of biosimilar is that of price- it costs less and that increases the affordability. Generally, biosimilars are thought to cost 30% less than the original biologic agents. Biosimilars of Infliximab( trade name Infimab), etanercept(trade name Etacept,Intacept), adalimumab(trade name Exemptia) and Rituximab(Trade name Reditux RA,Mabtas RA, Tortiz RA) are now available in India are likely to cost less than original Biologic drugs. Several other biosimilar DMARD in india are in pipeline to be launched in hear future.Though the original biologic agent of Adalimumab named Humira is not available in India, several biosimilars are being marketed for this agent (Exemptia).It should also be noted that consistent with the socioeconomic burden in our  community especially for patients of arthritis, several companies of original Biologics and Biosimilars Annonuce special Concessional schemes from time to time.

We have included the mention of Itolizumab in the table because it has shown promising results in patients of RA in Indian  drug trials. However as of now it is approved for use in skin psoriasis.It is still under clinical development by Biocon, Bangalore for other arthritis disorders.
Biologic DMARD Trade Name Target App Cost per unit Indications Usuals Single Dose for adults 60kg Initial Regimen#
Infliximab Remicade TNF Rs 32,000/=per 100 gm via(as per 4 months course) RA, JIA, AS, SSA, Psoriasis Arthritis, Inflammatory COlitis-Arthritis 200-300 mg infused intravenously every 4-6 weeks 3-4 doses over 12-20 weeks
Etanercept Enbrel TNF Rs 14,000/=per 50 gm vial RA, JIA, AS, SSA, Psoriasis 50 mg injection subcutaneous weekly 12-16 weeks
Rituximab Mabthera, (Ristova) B cell Rs 28,000/= per 500 gm vial RA 1 gm start and repeat after 2 weeks; given as intravenous infusion Give once in 6 months to one year
Tocilizumab Actemra IL-6 Rs 15,000/= for 200 mg vial RA, JIA 8 mg/kg Body wt; intravenous infusion monthly At least 4-6 doses over 4-6 months
Abatacept Orencia T cell Rs 22,500/= for 250 mg vial RA, JIA, AS, SSA, Psoriasis 750 mg intravenous infusion every 2-4 weeks 3-4 doses over 12 weeks
Itolizumab Alzumab CD 6 Rs 7000/= for 25 mg vial Psoriasis arthritis, RA(under evalution) 1.6 mg/kg body wt intraveneous infusions infused every monthly twice monthly infusion for 3 months and then monthly for 6 months

Note: The above is an outline and rheumatologist needs to be consulted prior to prescribing biologic DMARD.

See text for abbreviations; RA: rheumatoid arthritis; JIA: juvenile idiopathic arthritis; AS: ankylosing spondylitis; SSA: seronegative spondyloarthritis; # the duration of the initial regimen use has been empirically worked out in Center for Rheumatic Diseases, Pune to control the intensity of the disease in a socioencomical and scientific manner; however the patients will continue to use oral traditional DMARD for long term control NOTE: the dose of biologic agent shown above is usually used to treat RA and may differs in other forms of arthritis.