Adalimumab for children and young people

JIA artwork

Picture by Jess Marsh, age 13

Biologic drugs explained

Adalimumab is a ‘biologic’ drug. Biologic drugs are often referred to as ‘targeted therapies’ because they work on specific cells of the immune system. Adalimumab works on the TNFα cells.

TNFα is an inflammatory chemical produced naturally as part of the immune system. In JIA, TNFα is present in excess in the lining of the joints causing pain, swelling, redness and heat, all of which are symptoms of inflammation.

Background

Adalimumab was made available for rheumatoid arthritis in 2003 and subsequently for JIA from 2008. Adalimumab can be prescribed alone if necessary but is often added to methotrexate and this combination is also prescribed for uveitis associated with JIA. 

How long does Adalimumab take to work?

The benefit from Adalimumab may take several weeks to be felt or seen (2-12 weeks).

When can Adalimumab be prescribed?

Adalimumab can only be prescribed for children and young people according to strict guidelines. When these guidelines are met, it may be prescribed together with methotrexate. When it has been established that methotrexate has not been effective in controlling the JIA, or when the child or young person has not been able to tolerate it for whatever reason, Adalimumab will be prescribed on its own.

There will always be careful pre-treatment screening, particularly to establish if there is any history of tuberculosis (as this can be reactivated by Adalimumab). A record is taken of the vaccinations completed and any other information the specialist team requires.

Whether you are a young person with JIA or the parent of a child with JIA, it is important that you understand the intended treatment and any possible precautions. Equally important is a discussion about the evidence of the benefits of Adalimumab and the need for ongoing research into the long-term unknown facts.

The prescribing doctor will register the child or young person (with the consent of the parent(s) in the case of children) with the Biologics Registry of the British Society for Paediatric and Adolescent Rheumatology (BSPAR). This is a database that stores information on the use of biologic drugs and helps to increase the knowledge of these treatments. There is more confidence in the benefit of a treatment when increasing numbers of patients take it for increasing lengths of time without significant side effects.

How is Adalimumab given?

Adalimumab is given as a subcutaneous (meaning ‘under the skin’ and often called ‘sub-cut’) injection with a pen device or syringe, every 2 weeks. There are various ways that this can be organised. For example:

  • the parent(s) may be willing to learn to give the injection 
  • the child/young person may attend the local hospital or doctor’s surgery to have the injection 
  • a young person may be taught to inject themselves 

The management of this treatment is always discussed in detail at the start. Regular blood test monitoring is required; the frequency of which will depend on the prescribing specialist’s advice 

Possible side effects

As with any medication, Adalimumab has a number of possible side effects, although it is important to remember that these are only potential side effects and may not occur at all.

1. Infections

Adalimumab, like other biologic drugs, has been associated with an increased susceptibility to infections; sometimes these can be severe eg. re-activation of tuberculosis or milder infections such as skin infections. Due to the risk of infection, tattoos and body piercings are not recommended.

2. Other possible side effects include:

  • An increased risk of food poisoning caused by salmonella or listeria 
  • Pruritis (itching), injection site reactions 
  • Nausea, tummy pain 
  • Hypersensitivity reactions such as rash, bronchospasm (mimicking asthma), angioedema (swelling of lips, tongue, around the eyes) 
  • Fever, headache, depression 
  • Blood disorders 

More information on side effects can be found in the patient information leaflet for Adalimumab. 

Remember to report any concerns about possible side effects to the doctors or nurses 

Adalimumab with other medicines 

There are currently no specific prescribed medicines to be avoided when taking Adalimumab, but remember to take care when using any other medications or complementary therapies (even if bought ‘over the counter’ for colds or flu). Remember to check with a doctor, nurse or pharmacist that they are safe to take with Adalimumab and any other medication taken.

Only one biologic drug is prescribed at any one time. Adalimumab (a biologic drug) alongside methotrexate (a disease modifying anti-rheumatic drug, or DMARD) is a common combination. 

Adalimumab and immunisation/vaccination 

Live vaccines [measles, mumps, rubella (MMR), chickenpox, oral polio (NOT injectable polio), BCG, oral typhoid and yellow fever] cannot be given to anyone already taking adalimumab. If adalimumab has not yet been started it is important to seek advice on how long a gap to leave after having a live vaccine.

Flu vaccine is now available in two forms, an injection and a nasal spray. Unlike the injection, the nasal spray is a live vaccine. There is limited research evidence around live vaccines in people with a lowered immune system (due to their medication). It is therefore important to discuss with the healthcare team which of these options would be best.

Vaccination of close family members can help to protect someone with a lowered immune system.

Adalimumab and pregnancy

There is not sufficient research information to give advice that either pregnancy or breastfeeding are safe.

A man or a woman taking Adalimumab should use reliable contraception during treatment and for 5 months after the last dose before planning to start a family.

Remember to ask your doctor or clinical nurse specialist for any further advice.

Adalimumab and alcohol

Alcohol can be consumed when taking adalimumab. However, caution may be required when taking other medications alongside this drug, for example methotrexate. Please see our separate articles on other JIA medications.

Hints and Tips

The following hints and tips may be useful when taking Adalimumab:

  • Stay safe on Adalimumab by remembering to have regular blood test monitoring as advised by the consultant or clinical nurse specialist
  • A single syringe or pen device should be removed from the fridge for 15-30 minutes before using, in order to bring it to room temperature as this will help to avoid any stinging at the injection site
  • To ease injection site reactions, choose alternate thighs for the injections and by differing the actual site around the mid thigh region 
  • An injection site reaction that includes a rash or redness can be eased with a cold compress 
  • Storage should be in a refrigerator (2°C – 8°C) and the syringes kept in the outer carton in order to protect them from light. Do not freeze 
  • A single adalimumab pre-filled syringe or pen device may be stored at temperatures up to a maximum of 25°C for a period of up to 14 days. The syringe must be protected from light and discarded if not used within the 14-day period 

Tips for travelling with Adalimumab 

  • Before travelling it is important to keep up to date with vaccinations 
  • Live vaccines (see above ‘Adalimumab with other medicines’) must be avoided. It is important to check whether any required vaccines are ‘live’ before booking a holiday 
  • Adalimumab can now be stored at room temperature (up to 25⁰C) for a single period of up to 14 days, which makes it easier to carry when travelling by air. It should not be refrigerated after this 
  • Both the company providing the medication and the airline can supply more information on travelling with Adalimumab 
  • Your healthcare team can provide you with a letter of authorisation to travel with this drug 

Table summary

Drug name How the drug is taken How it works Blood tests mandatory?
Adalimumab (ADA) Syringe or pen Reduces over activity of the immune system by targeting TNFα cells Yes- every 3 months initially

References available on request

By retired rheumatology clinical nurse specialist Nicky Kennedy BSc RN QN HV
Original article: 26/01/2016
Reviewed: N/A
Next review due: 26/01/2019