TNF inhibitors
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Dosing and administration[3]
Given subcutaneously, or intravenously for infliximab and the IV golimumab formulation. The doses below are the standard approved rheumatoid arthritis doses; several are commonly combined with methotrexate. Screen for latent tuberculosis and viral hepatitis before starting.
| Agent | Route | Dose and frequency |
|---|---|---|
| Adalimumab (Humira and biosimilars) | Subcutaneous | 40 mg every 2 weeks (some indications allow weekly dosing if not on methotrexate). |
| Etanercept (Enbrel and biosimilars) | Subcutaneous | 50 mg once weekly, or 25 mg twice weekly. |
| Certolizumab pegol (Cimzia) | Subcutaneous | 400 mg at weeks 0, 2, and 4 (loading), then 200 mg every 2 weeks or 400 mg every 4 weeks. |
| Golimumab (Simponi) | Subcutaneous (IV form available) | 50 mg once monthly subcutaneously; the intravenous form is 2 mg/kg at weeks 0 and 4, then every 8 weeks. |
| Infliximab (Remicade and biosimilars) | Intravenous infusion | 3 mg/kg at weeks 0, 2, and 6, then every 8 weeks, usually with methotrexate; may be escalated in dose or frequency. |
Onset. Onset over about 2 to 12 weeks.
Doses shown are the standard approved rheumatoid arthritis doses from the respective Health Canada product monographs; regimens differ for other indications such as psoriatic arthritis and axial spondyloarthritis.
Monitoring
- Screen for latent tuberculosis (treat before or at initiation) and for hepatitis B and C before starting.
- Assess vaccination status; avoid live vaccines during treatment.
- Monitor for serious infection; periodic complete blood count and liver function.
Contraindications
- Active serious infection, including active tuberculosis.
- Moderate to severe heart failure (NYHA class III to IV), particularly at higher doses.
- Demyelinating disease (relative).
Key interactions
- Do not combine with other biologic DMARDs or with JAK inhibitors (additive immunosuppression and infection risk).
- Avoid live vaccines.
- Combination with anakinra or abatacept increases infection risk.
Clinical notes
Common side effects
Injection-site or infusion reactions; increased infection risk. Not sourced on this draft.
Tests and monitoring
Before starting, screen for latent tuberculosis (a tuberculin skin test or an interferon-gamma release assay, with IGRA preferred after prior BCG vaccination; induration of 5 mm or more is a positive skin test) and for hepatitis B where risk factors are present, and obtain baseline complete blood count, liver transaminases, and serum creatinine. Give indicated killed or inactivated vaccines, including pneumococcal and influenza, before starting where possible; live vaccines are not recommended during treatment. ACR does not set a fixed on-treatment laboratory interval for this class and lists biologic laboratory monitoring as an evidence gap, so ongoing monitoring follows the product monograph. Recommendations derived for rheumatoid arthritis.[1, 2]
Important cautions
Caution with a history of serious or recurrent infection, demyelinating disease, and certain heart failure; live-vaccine and peri-operative timing apply. To confirm from primary sources.
References
- Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59(6):762-784. doi:10.1002/art.23721 https://doi.org/10.1002/art.23721
- Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res. 2016;68(1):1-25. doi:10.1002/acr.22783 (published simultaneously in Arthritis & Rheumatology) https://doi.org/10.1002/acr.22783
- Standard approved rheumatoid arthritis doses from the respective Health Canada product monographs: adalimumab (Humira), etanercept (Enbrel), certolizumab pegol (Cimzia), golimumab (Simponi), and infliximab (Remicade and biosimilars). https://health-products.canada.ca/dpd-bdpp/