Infliximab

Infliximab is a type of drug known as a biological therapy. It can be prescribed for:

• rheumatoid arthritis
• psoriatic arthritis
• axial spondyloarthritis, including ankylosing spondylitis.

In some cases, doctors may prescribe infliximab to treat certain types of vasculitis.

In rheumatoid arthritis and some other conditions, too much of a protein called TNF is produced in the body. This causes inflammation, pain and damage to your joints. Anti-TNF drugs, such as infliximab, block TNF and reduce this inflammation.

Anti-TNF drugs, such as infliximab, are not painkillers. They change or slow down how your condition affects your body. Your symptoms should start to improve within 2 to 12 weeks of starting infliximab.

There are guidelines about when infliximab can be used. It varies depending on which condition you have. You won’t be given infliximab if you haven’t tried other suitable drugs first.

Infliximab won’t be started if:

• your condition isn’t active
• you haven’t tried other treatments for your condition first
• you have an infection.

Before you're prescribed infliximab, doctors sometimes use a scoring system to assess how many of your joints are painful or swollen and how it makes you feel. This helps them work out how active your arthritis is.

You'll also need blood tests before treatment to see whether the drug is suitable for you.

Your doctor will also check whether you’ve had tuberculosis (TB) and hepatitis infections. This is because infliximab can increase the risk of these starting up again. If you test positive for either of these, you may need treatment before starting infliximab.

Your doctor may also suggest an HIV test. If you have HIV, this should be well controlled before starting infliximab.

Your doctor may decide not to prescribe infliximab if you’ve had or have:

• an active infection, or repeated or serious infections
• multiple sclerosis (MS) or there’s history of MS in your immediate family
• certain heart conditions
• scarring of the lung tissue, known as pulmonary fibrosis.

There’s no good evidence that using infliximab to control your immune system increases your risk of cancer. Even so, if you’ve had cancer before, you should always let your clinical team know in case this affects decisions about your treatment.

If infliximab isn’t suitable, your doctor will discuss other treatment options with you.

Infliximab is usually given through a drip into a vein. This is called an intravenous infusion. It’s usually done in a hospital and takes about two hours. You’ll need to wait for another hour or two before you go home in case you develop any side effects.

After the first infusion, you’ll have another about two weeks later. Then you’ll have a third about four weeks after that. After that, you’ll continue to have them around every eight weeks.

Once you’ve been on the treatment for a while, the infusions may take less time.

Because it’s a long-term treatment, it’s important to keep having your infliximab infusions, even if it doesn’t seem to be working at first. You’ll also need to keep taking it when your symptoms start to improve, to help keep the condition under control.

In some cases, you may take the biosimilar Remsima as an injection instead.

Biosimilars

Infliximab was originally only available as a drug called Remicade (BNF). However, newer versions of biological therapies are becoming available, so you may be prescribed infliximab under a different name, such as Flixabi, Inflectra, Remsima or Zessly. These drugs are known as biosimilars and work in a similar way.

If your rheumatology team suggests that you change from one type of infliximab to another, you should discuss this with them first before any changes are made.

Like all drugs, infliximab can sometimes cause side effects. Some common side effects include:

• a blocked or runny nose
• headaches
• dizziness
• flushing
• a rash
• stomach pain
• indigestion
• feeling sick.

A faster or irregular heartbeat is also quite common – you should speak to your doctor if this happens to you.

Because infliximab affects the immune system, it can make you more likely to pick up infections. In rare cases, your body might not produce enough of the blood cells that help to fight infections or stop bleeding.

Tell your doctor or rheumatology nurse straight away if you develop any signs of infection. These include a sore throat or fever, or any other new symptoms that concern you.

If any of these symptoms are severe, your infliximab may need to be stopped. Your doctor may also recommend that you temporarily stop infliximab if you are taking antibiotics.

You should also see your doctor if you develop chickenpox or shingles, or if you come into contact with someone who has chickenpox or shingles. These infections can be severe if you’re on infliximab. You may need antiviral treatment, and your infliximab may be stopped until you’re better.

Some people may have a negative reaction to the infusion. This is more likely during or soon after the first few infusions.

The healthcare professional giving the infusion will be looking out for any problems so that they can be quickly dealt with. The infusion will be stopped if the reaction is severe. If you think you may be having a reaction to infliximab at any other time, contact your specialist team straight away for advice.

If you have a break in your infliximab treatment of more than 16 weeks, there may be a higher risk of an allergic reaction when you start the treatment again. Your doctor or nurse will monitor you more closely when you restart the treatment.

Some drugs, like infliximab, may make you more sensitive to the sun and could put you at a higher risk of skin cancer. To be on the safe side, make sure to wear sunscreen and regularly check your skin for any new spots or changes to your freckles or moles.

Very rarely, infliximab may cause a condition called drug-induced lupus. Symptoms include a rash, fever and increased joint pain. If you have any of these symptoms, you should tell your rheumatology team. It’ll usually clear up when you stop taking infliximab. Before starting infliximab, you may have a blood test to see if you have had lupus before. If you have had the condition, you will have the lupus antibody in your blood.

Regular check-ups and tests while you’re on infliximab will help to pick up any problems. This should happen at least every six months, though in some cases your doctor may suggest more frequent checks.

Tips to reduce your risk of infection

• Try to avoid close contact with people you know have an infection.
• Wash your hands regularly and carry around a small bottle of antibacterial hand gel.
• Keep your mouth clean by brushing your teeth regularly.
• Stop smoking if you’re a smoker.
• Make sure your food is stored and prepared properly.
• Try to keep your house clean and hygienic, especially the kitchen, bathrooms and toilets.

It’s recommended that you carry a biological therapy alert card so anyone treating you will know that you’re on infliximab. Ask your rheumatology team for a card.

Check with your doctor before starting any new medications. Always remember to mention you’re on infliximab if you’re treated by anyone other than your usual healthcare team.

You can carry on taking non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or painkillers, if needed, unless your doctor advises otherwise.

Don’t use complementary treatments, such as herbal remedies, without discussing this first with your doctor or pharmacist as some of them could react with infliximab.

Vaccinations

It’s best to discuss vaccinations with your healthcare team before starting infliximab. If possible, it's best to have any vaccinations you may need before you start infliximab because some vaccines may be less effective once you’ve started infliximab.

If you’ve never had chickenpox, it’s good to get a vaccination against it before starting infliximab. But discuss this with your rheumatology team first. It’s possible that you may have had chicken pox without developing a skin rash. So, if you or your healthcare team are unsure whether you’ve had chickenpox before, you may have a blood test to check.

It’s recommended that any family or household members are vaccinated against chickenpox before you start taking infliximab.

The Zostavax shingles vaccine is a live vaccine and isn’t recommended for people who are on infliximab. However, a non-live shingles vaccine, Shingrix, is available so you may be able to have this instead.

It’s also recommended that you have the vaccination against COVID-19. It’s recommended that you have the pneumonia vaccine and yearly flu vaccine injection while taking infliximab. These vaccines are not live, so it’s safe for you to have them.

It’s usually recommended that people on infliximab avoid live vaccines such as measles, mumps and rubella (MMR), chickenpox and yellow fever. But sometimes a live vaccine may be necessary, so you should discuss this with your rheumatology team.

Having an operation

Talk this over with your specialist doctors and surgeon. Depending on the type of surgery, they may advise you to stop infliximab for a while before and after the operation. This is because infliximab affects your immune system, so there may be an increased risk of infection following surgery.

There’s no need to avoid alcohol while taking infliximab.

Guidelines state that adults shouldn’t have more than 14 units a week, and that they should spread them out over the course of the week. In some circumstances your doctor may advise lower limits.

If you’re planning to try for a baby, if you become pregnant, or if you’re thinking of breastfeeding, we suggest you discuss your medications with your specialist.

Current guidelines state that infliximab can be used during pregnancy and in men trying to father a child. If it’s used during pregnancy, it may be stopped after 16 weeks. If it’s used after this, your baby may need an altered vaccination schedule.

If there’s concern that your arthritis may flare then you can continue taking infliximab throughout the whole pregnancy – in this case, your baby should not have any live vaccines (such as BCG) until they’re seven months old.

You should be fine to breastfeed when taking infliximab but there’s only limited research, so it’s important to discuss this with your doctor.