Rheumatoid Arthritis — Advanced Nursing Guide (Biologics & Monitoring)

ACR/EULAR 2010 Classification Criteria

ℹApplies to patients with at least one joint with definite clinical synovitis not explained by another diagnosis. Score ≥6/10 = classified as RA.

Domain	Criteria	Score
A. Joint Involvement	1 large joint	0
	2–10 large joints	1
	1–3 small joints (with or without large joint involvement)	2
	4–10 small joints / >10 joints including at least 1 small joint	3 / 5
B. Serology	Negative RF and negative anti-CCP	0
	Low positive RF or low positive anti-CCP (≤3× ULN)	2
	High positive RF or high positive anti-CCP (>3× ULN)	3
C. Acute Phase Reactants	Normal CRP and normal ESR	0
C. Acute Phase Reactants	Abnormal CRP or abnormal ESR	1
D. Duration of Symptoms	<6 weeks	0
D. Duration of Symptoms	≥6 weeks	1

Small joints = MCPJs, PIPJs, 2nd–5th MTPs, thumb IPJs, wrists

Serology — Key Points

Rheumatoid Factor (RF)

Sensitivity ~70%, specificity ~80% for RA
Also positive in: Sjogren's, SLE, infection, elderly
High-titre RF associated with severe/extra-articular disease

Anti-CCP (ACPA)

Specificity ~95% — more specific than RF
Sensitivity ~70% — positive in ~70% of RA patients
Predicts erosive, aggressive disease
Present years before clinical onset (pre-clinical RA)

✓Seronegative RA: both RF and anti-CCP negative — still RA if clinical criteria met. Consider rituximab less effective in seronegative.

Disease Activity Scores

<2.6

DAS28 Remission

2.6–3.2

Low Activity

3.2–5.1

Moderate Activity

>5.1

High Activity

DAS28 Components

28 tender joint count (TJC28)
28 swollen joint count (SJC28)
ESR (mm/hr) or CRP (mg/L)
Patient global assessment (0–100 VAS)

CDAI / SDAI

CDAI: TJC28 + SJC28 + PGA + EGA (no bloods) — useful when labs delayed
SDAI: CDAI + CRP — remission <3.3, low ≤11, mod ≤26, high >26

Pattern of Joint Involvement

Symmetrical small joint polyarthritis — hallmark of RA
Wrists — very commonly involved; carpal tunnel may occur
MCPJs & PIPJs — swelling, tenderness, early morning stiffness
MTPs (metatarsophalangeal) — forefoot pain, difficulty walking
DIPJs spared — involvement suggests OA or psoriatic arthritis
Morning stiffness >30 minutes — hallmark; correlates with inflammation
Cervical spine (C1-C2 subluxation) — rare but serious; screen pre-GA

Extra-Articular Manifestations

Rheumatoid nodules — pressure points, associated with RF+
ILD (Interstitial Lung Disease) — UIP pattern; risk with MTX
Vasculitis — digital infarcts, mononeuritis multiplex
Pericarditis / pleuritis — serositis
Scleritis / episcleritis — ocular involvement
Felty's syndrome — RA + splenomegaly + neutropenia
Lymphoma risk increased (especially NHL) — particularly in active disease
Anaemia of chronic disease — normocytic normochromic
Secondary Sjogren's — dry eyes/mouth common

Functional Assessment — HAQ (Health Assessment Questionnaire)

HAQ-DI Score

0 = no disability
0–1 = mild
1–2 = moderate
2–3 = severe disability

Domains Assessed

Dressing & grooming
Rising from chair
Eating, walking, hygiene
Reach, grip, activities

Clinical Use

Baseline and 3–6 monthly
Required for biologic prescribing (DAS28 >5.1 + HAQ >1 typically)
Predicts long-term work disability

★Goal: Start csDMARD at diagnosis. Target remission or low disease activity within 6 months. Review monthly until stable, then 3–6 monthly.

Methotrexate (MTX) — Gold Standard First-Line DMARD

Dosing & Administration

Start 7.5–10 mg once weekly; escalate to 25 mg/week
SC preferred over oral — better bioavailability, less GI side effects
Folic acid 5 mg weekly — NOT on the same day as MTX
Effect onset: 6–12 weeks; maximum effect 3–6 months

Monitoring (NICE / BSR)

Baseline: FBC, LFTs, U&E, CXR, eGFR
Weekly for 4 weeks, then monthly for 3 months, then 3-monthly
FIB-4 score for liver fibrosis monitoring (replaces routine biopsy)
Hold if WBC <3.5, neutrophils <2.0, platelets <150, or ALT >3× ULN

Toxicity & Red Flags

!Pneumonitis: New dyspnoea, dry cough, fever — STOP MTX immediately. CXR urgently. Do NOT rechallenge.

!Teratogenic: Avoid in pregnancy. Contraception required in both male and female patients. Stop 3 months before conception.

Key Drug Interactions

NSAIDs — reduce MTX renal clearance, increase toxicity
Trimethoprim / co-trimoxazole — folate antagonism, severe pancytopenia risk — CONTRAINDICATED
PPIs (e.g. omeprazole) — reduce MTX renal tubular secretion, increase levels
Alcohol — additive hepatotoxicity; advise <14 units/week

Hydroxychloroquine (HCQ)

Dose: 200–400 mg/day (max 5 mg/kg lean body weight)
Safe in pregnancy and breastfeeding — drug of choice in pregnant RA/lupus
Onset of action: 3–6 months
No routine blood monitoring required

⚠Retinal toxicity: Risk increases after 5 years / cumulative dose >1000g. Annual ophthalmology review from year 5. Humphrey visual field + spectral domain OCT.

Additional Points

Mild disease activity / as add-on to MTX
May reduce cardiovascular risk and lipid levels
QTc prolongation — check baseline ECG if on other QT drugs

Sulfasalazine (SSZ)

Dose: Start 500 mg daily, increase to 2–3 g/day in divided doses
Moderately effective; useful in combination
Slower onset: 8–12 weeks

Monitoring

FBC + LFTs: 2-weekly for first 3 months, then 3-monthly
Watch for: neutropenia, thrombocytopenia, hepatitis

⚠Sulfonamide allergy: Contraindicated. Also avoid in G6PD deficiency. Orange-yellow urine/tears — warn patients.

Cautions

Reduces male fertility (reversible oligospermia)
Folate deficiency — supplement folic acid
Safe in pregnancy (with folate); caution breastfeeding — check neonatal G6PD

Leflunomide (LEF)

Dose: Loading 100 mg for 3 days (often omitted to reduce toxicity), then 10–20 mg daily
Active metabolite: teriflunomide — inhibits DHODH (pyrimidine synthesis)
Efficacy comparable to MTX

Monitoring

FBC + LFTs monthly for 6 months, then 3-monthly
BP monitoring (can cause hypertension)
Peripheral neuropathy — monitor and consider stopping

!Teratogenic — both sexes. Long half-life (up to 2 years). Cholestyramine washout required before pregnancy: 8g TDS for 11 days — confirm teriflunomide level <0.02 mg/L on two samples 14 days apart.

Triple Therapy & Combination Strategy

★Triple therapy (MTX + HCQ + SSZ) — consider before escalating to bDMARDs. Evidence shows comparable efficacy to anti-TNF in some patients.

Combination Principles

MTX is the anchor drug — combine rather than switch
MTX + HCQ: well tolerated, safe additive option
MTX + LEF: effective but increased hepatotoxicity risk — monitor closely
If inadequate response to 2 csDMARDs at adequate dose and duration — consider biologic or JAKi

Dose Optimisation Before Switching

MTX must be at maximum tolerated dose (≥15 mg preferably 20–25 mg/week SC)
Duration ≥3 months at therapeutic dose before declaring failure
Assess adherence before labelling as treatment failure

★Pre-biologic screening is mandatory. Never start a biologic without completing TB, viral hepatitis, and cardiovascular/neurological risk assessment.

Pre-Biologic Screening Checklist

Latent TB (LTBI)

!IGRA (QuantiFERON) preferred in GCC — more sensitive than Mantoux; Mantoux unreliable post-BCG. CXR mandatory for all. Positive IGRA/Mantoux >5mm = LTBI → treat with isoniazid 6–9 months (or rifampicin 4 months). Start biologic ≥4–8 weeks into LTBI treatment.

Hepatitis B

Screen: HBsAg, Anti-HBc, Anti-HBs
Active HBV (HBsAg+): refer hepatology, antiviral treatment before biologic
Occult HBV (HBsAg–, Anti-HBc+): prophylactic entecavir/tenofovir during biologic + 12 months after
Monitor HBV DNA every 3–6 months

Hepatitis C

Screen anti-HCV; if positive: HCV RNA
Active HCV: liaise hepatology — DAA treatment may allow biologic use
Anti-TNF generally safer than rituximab in HCV

Absolute Contraindications to Anti-TNF

✕Demyelinating disease (MS, optic neuritis) — anti-TNF can worsen. Use non-TNF biologic.

✕NYHA Class III/IV Heart Failure — anti-TNF contraindicated. Caution class I/II — monitor closely.

Other Screens

Varicella zoster IgG — vaccinate if non-immune BEFORE starting (live vaccine)
Influenza & pneumococcal vaccines — give BEFORE biologic start
HIV screen
FBC, LFTs, U&E, eGFR
Skin cancer screening (lymphoma risk assessment)
Pregnancy test if applicable
Dental review (infection risk)

⚠Live vaccines CONTRAINDICATED on biologics: BCG, yellow fever, MMR, varicella, oral typhoid, rotavirus.

Anti-TNF Agents — Overview

Drug	Type	Route / Frequency	Notable Features
Etanercept	TNF receptor fusion protein (p75-Fc)	SC 50 mg weekly or 25 mg twice weekly	Does NOT bind lymphotoxin-α; possibly lower TB risk vs. mAbs; no live vaccines; biosimilars available
Adalimumab	Fully human anti-TNF mAb (IgG1)	SC 40 mg every 2 weeks	Most widely used anti-TNF; biosimilars available; injection site reactions common
Certolizumab pegol	PEGylated Fab fragment anti-TNF	SC 400 mg at 0/2/4 weeks, then 200 mg every 2 weeks	No Fc region — less placental transfer; can be used in pregnancy (limited data); minimal in breast milk
Golimumab	Human anti-TNF mAb (IgG1)	SC 50 mg monthly (IV formulation also available for RA)	Once-monthly dosing — good adherence; also licensed for UC, PsA, AS
Infliximab	Chimeric (human/mouse) anti-TNF mAb	IV infusion 3 mg/kg at 0, 2, 6 weeks then every 8 weeks	Higher immunogenicity — always use with MTX; biosimilars widely used; infusion reactions; trough level monitoring available

Infection Management on Anti-TNF

!Serious infection rule: Any infection requiring hospitalisation or IV antibiotics — STOP anti-TNF. Resume only after full recovery and on oral antibiotics (if applicable).

Infection Risk Profile

2–3× increased risk of serious infection vs. general population
Bacterial: skin & soft tissue, RTI, UTI, bone/joint
Opportunistic: TB reactivation (especially first 3–6 months), Listeria, Pneumocystis jirovecii (PCP) in high-risk
Fungal: histoplasma, coccidioides in endemic areas
Herpes zoster risk increased — ensure vaccination pre-treatment

Patient Advice

Carry biologic alert card at all times
Contact helpline for fever >38°C, rigors, unusual infection
Avoid contact with active TB / chickenpox if non-immune
Safe food handling — avoid unpasteurised dairy, undercooked meat (Listeria)

Monitoring on Anti-TNF

Routine Monitoring

DAS28 at 3 months — response required for continuation (NICE: DAS28 improvement ≥1.2)
FBC, LFTs, CRP, ESR — 3–6 monthly
Renal function annually
Lipid profile — particularly with IL-6 inhibitors (see Tab 4)

TB Surveillance

Annual IGRA if ongoing high-risk exposure (healthcare workers, contacts)
Any new respiratory symptoms — investigate urgently for TB

Switching Anti-TNF

Primary failure (<3 months): switch to different mechanism (abatacept/rituximab)
Secondary failure (lost response): can trial second anti-TNF or switch class
Washout: generally 2× half-life minimum between biologics

Infliximab trough levels: target 1–3 mg/L (remission). If low trough + high disease activity = underdosing. If low trough + ADA+ = immunogenic failure — switch class.

Abatacept — T-Cell Co-stimulation Blocker

Mechanism: CTLA-4-Ig fusion — blocks CD80/CD86:CD28 co-stimulation → T-cell anergy
Route: IV infusion (weight-based: <60 kg = 500 mg, 60–100 kg = 750 mg, >100 kg = 1000 mg) at 0, 2, 4 weeks then monthly; SC 125 mg weekly
Can be used as first biologic or after anti-TNF failure
Good safety profile in patients with previous malignancy
May be preferred in patients with ILD associated with RA

✓Lower infection risk compared to anti-TNF; does not increase TB risk significantly. Still requires pre-biologic screening. Do NOT combine with other biologics.

Monitoring

FBC, LFTs, CRP every 3–6 months
DAS28 response at 3 months

Rituximab — Anti-CD20 B-Cell Depletion

Preferred In:

Seronegative RA (may be less effective — note)
Previous malignancy (lymphoma — anti-TNF avoided)
RA-associated ILD — may be safer than anti-TNF
Failed or contraindicated anti-TNF
Active hepatitis B? — avoid (B-cell depletion risk)

Dosing

2 × 1000 mg IV infusions 2 weeks apart
Repeat cycles every 6 months (B-cell count guided)
Pre-medicate: methylprednisolone 100 mg IV + antihistamine + paracetamol

!PML (Progressive Multifocal Leukoencephalopathy) — rare but fatal JC virus reactivation. Screen for JC virus antibodies. Monitor for cognitive/neurological changes.

Monitoring

Immunoglobulins (IgG) before each cycle — if IgG <5 g/L, withhold; refer immunology
FBC — cytopenias post-infusion; late-onset neutropenia
B-cell counts (CD19) — guide retreatment timing
Hepatitis B reactivation — mandatory prophylaxis if anti-HBc positive

IL-6 Inhibitors — Tocilizumab & Sarilumab

Mechanism

Tocilizumab: Anti-IL-6 receptor mAb — IV (8 mg/kg monthly) or SC (162 mg every 1–2 weeks)
Sarilumab: Anti-IL-6 receptor mAb — SC 200 mg every 2 weeks
Can be used as monotherapy (without MTX) — important advantage
Effective for systemic features (fatigue, anaemia)

Uses

Active RA with inadequate response to csDMARD or anti-TNF
Large vessel vasculitis (GCA) — tocilizumab licensed
CAR-T cytokine release syndrome — tocilizumab licensed

!Silent infection risk: IL-6 blockade masks fever and suppresses CRP. A patient on tocilizumab/sarilumab with sepsis may present with NORMAL temperature and NORMAL CRP. High index of suspicion required.

⚠Bowel perforation risk: Screen for history of diverticulitis, prior bowel perforation, or concurrent NSAID/steroids. Avoid in active diverticular disease.

Monitoring

FBC — neutropenia common (dose-dependent), platelets
LFTs — transaminase elevation common
Lipid profile — IL-6 blockade raises LDL/HDL; cardiovascular risk assessment
CRP unreliable as infection marker — use PCT, clinical exam, WBC

JAK Inhibitors (JAKi) — Oral Targeted Synthetic DMARDs

!Black box warning (FDA/EMA): Increased risk of VTE (pulmonary embolism, DVT), major adverse cardiovascular events (MACE), malignancy (including lymphoma and lung cancer), and serious infections. Use after anti-TNF failure in patients ≥65 or with CV/malignancy risk factors — use lowest effective dose.

Tofacitinib (JAK1/3)

5 mg BD or 11 mg extended-release once daily
First JAKi approved for RA
Oral — no injection required
Herpes zoster risk significantly increased vs. biologics

Baricitinib (JAK1/2)

4 mg once daily (2 mg if renal impairment)
JAK2 inhibition — potential anaemia
Licensed for moderate-severe RA
Used in COVID-19 hospitalised patients

Upadacitinib (JAK1 selective)

15 mg once daily
More selective JAK1 — potentially fewer off-target effects
Licensed for RA, PsA, AS, atopic dermatitis
Higher efficacy data vs. adalimumab in head-to-head trials

JAKi Monitoring Requirements

Parameter	Frequency	Action Threshold
FBC	Baseline, 4–8 weeks, then 3-monthly	Hb <8 g/dL, neutrophils <1.0, lymphocytes <0.5 — withhold
Renal function (eGFR)	Baseline & 3-monthly	Dose reduce baricitinib eGFR 30–60; avoid <30
Lipids (LDL/HDL)	Baseline & 12 weeks, then annually	Statin initiation if significant rise in LDL
LFTs	Baseline & 3-monthly	ALT >3× ULN — withhold and investigate
VTE risk assessment	Baseline & ongoing	Avoid if high VTE risk (prior DVT/PE, immobility, thrombophilia)
Skin cancer surveillance	Annual dermatology review	Avoid in active malignancy

Treat-to-Target (T2T) Strategy

★ACR/EULAR T2T recommendation: Target = remission (DAS28 <2.6) or at minimum low disease activity (DAS28 <3.2) within 6 months. Monthly DAS28 assessment until target achieved.

T2T Protocol

Baseline DAS28 — document and set target
Monthly DAS28 while active or changing treatment
If DAS28 not improving significantly at 3 months — escalate/change DMARD
If target not reached at 6 months — mandatory treatment change
Once in sustained remission (≥6 months) — consider tapering (not stopping) biologics
Tapering: reduce frequency before stopping; monitor closely for flare

Biologic Continuation Criteria (NICE)

DAS28 improvement ≥1.2 at 3 months
If inadequate response at 6 months — stop and switch
Document DAS28 at every biologic review

Nurse-Led Monitoring Clinics

Routine Clinic Components

DAS28 calculation — joint counts (TJC28 + SJC28) + CRP/ESR + patient global
FBC, LFTs, ESR, CRP — per DMARD protocol
Biologic trough levels where applicable (infliximab)
HAQ-DI score — 3–6 monthly
Adverse effect review and drug interactions check
Injection technique assessment for SC biologic users
Biologic alert card and patient record update

Patient Helpline Role

Same-day access for: fever, suspected infection, unusual symptoms
Guidance on withholding biologic for surgery/illness
Flare management advice — steroid rescue protocol
Injection site problems / pen technique support

✓Early nurse contact for infection/flare reduces hospitalisation and improves safety on biologics. Document every patient contact.

Patient Education — Core Topics

Joint Protection

Avoid excessive grip and pinch forces
Use larger joints for tasks (e.g. push with palm not fingers)
OT referral for splints, adaptive equipment
Ergonomic assessment — workplace, kitchen

Fatigue Management

Pacing activities — energy conservation
Planned rest periods (not bed rest)
Sleep hygiene — pain and fatigue cycle
CBT referral for fatigue/depression

Lifestyle Modification

Smoking cessation — smoking worsens RA disease activity, reduces biologic response, increases cardiovascular risk and nodule formation
Mediterranean diet — anti-inflammatory
Maintain healthy BMI — excess weight worsens outcomes
Hydrotherapy / aerobic exercise — improves function without worsening joints

Pregnancy & RA

RA often improves in pregnancy (2nd trimester)
Flare common postpartum
Safe drugs in pregnancy: HCQ, SSZ (+ folate), certolizumab, steroids
Avoid: MTX, LEF, most biologics (except certolizumab)

Foot Care & Podiatry

MTP joint involvement — metatarsalgia, hallux valgus, claw toes
Podiatry referral for: offloading insoles, nail care, callus
Appropriate footwear education — extra-depth shoes
Annual foot assessment in established RA

Hand Exercises

Daily range-of-motion exercises — maintain PIPJ/MCPJ mobility
Strengthening exercises — grip/pinch
Physiotherapy hand therapy programmes
Wax bath / warm soaks for morning stiffness

Osteoporosis Prevention (GIOP)

⚠Glucocorticoid-Induced Osteoporosis (GIOP): Any patient on prednisolone ≥7.5 mg/day for ≥3 months should receive bone protection.

GIOP Protocol

Baseline DEXA scan — T-score assessment
Bisphosphonate: alendronate 70 mg weekly (first-line) or risedronate 35 mg weekly
Calcium + vitamin D supplementation — all patients on steroids
Annual DEXA — monitoring response
Use minimum effective steroid dose; consider steroid-sparing agents
Fracture risk assessment: FRAX tool (with BMD)

Perioperative Management

Surgery & DMARDs

MTX: Continue perioperatively (evidence shows no increased wound infection)
HCQ & SSZ: Continue perioperatively
LEF: Consider stopping 2 weeks pre-op (washout) for major surgery
Anti-TNF / bDMARDs: Stop 1 dosing interval before elective surgery; restart once wound healed (~2 weeks post-op if no infection)
JAKi: Stop 3–7 days pre-op; restart when wound healed

Anaesthesia Considerations

Cervical spine X-ray / MRI — C1-C2 subluxation in long-standing RA
Inform anaesthetist of biologic use (infection risk)
Cricoarytenoid joint involvement — intubation difficulty

GCC-Specific Clinical Context

Epidemiology in GCC

RA prevalence ~0.5–1% — similar to global rates; Arab populations not disproportionately affected
High RF seropositivity reported in Gulf populations — may reflect high inflammatory burden
Smoking — major modifiable risk factor; high rates in Gulf male populations; significantly worsens RA activity, reduces biologic response, associated with ACPA positivity
Vitamin D deficiency highly prevalent — contributes to musculoskeletal burden
Obesity rates increasing in GCC — associated with worse RA outcomes and reduced biologic efficacy

TB Screening in GCC

!Critical: GCC has large South Asian expat workforce with higher TB prevalence rates. IGRA (QuantiFERON-TB Gold) preferred over Mantoux — BCG vaccination history prevalent, causing false-positive Mantoux. Screen ALL patients before biologic initiation.

Treat LTBI: isoniazid 300 mg daily + pyridoxine (B6) for 6–9 months
Alternative: rifampicin 600 mg daily for 4 months
Start biologic minimum 4–8 weeks after LTBI treatment commenced
Annual IGRA surveillance for high-risk patients (healthcare workers, new TB contacts)

Biologic Access in GCC

Improving access through national formularies (DHA, DOH, MOHAP, MOH Saudi)
Biosimilars increasingly available and encouraged — cost-effective
Step therapy requirements: 2 csDMARDs failure before biologic approval (varies by emirate/country)
HAAD/DOH Abu Dhabi arthritis pathway — structured referral and monitoring
DHA (Dubai Health Authority) — biologic prescribing requires rheumatologist specialist approval

Ramadan & RA Management

★Methotrexate weekly dose: Take at consistent time during Ramadan — either with suhoor (pre-dawn meal) or iftar (breaking fast). Do NOT skip doses. Ensure adequate hydration.

SC biologic self-injection training — advise patients to inject at iftar or post-iftar during Ramadan (easier to manage hydration)
IV biologic infusions (infliximab, rituximab) — can be scheduled during daytime; fasting does not affect infusion safety
NSAIDs — take with suhoor and iftar to minimise GI side effects
Steroids — consider single dose at suhoor to minimise disruption
Adequate rest — encourage protection of prayer time from heavy activity

SCFHS / DHA / DOH Nursing Competencies

Assessment Skills

28-joint count (tender + swollen) — correct technique
DAS28 calculation — ESR and CRP versions
HAQ-DI administration & scoring
Functional assessment & documentation
Recognising extra-articular features

Medicines Management

DMARD monitoring protocols — timing and parameters
Biologic pre-screening — TB, hepatitis, vaccines
SC injection technique — training and assessment
IV biologic infusion preparation & monitoring
Recognising drug toxicity and adverse effects

Patient Education & Safety

Biologic alert card education
Infection recognition and action plan
Contraception counselling (MTX/LEF)
Vaccine counselling — live vaccine contraindication
Pregnancy safety counselling

GCC Exam Prep — High-Yield Topics

DAS28 Scoring

Remission = <2.6 | Low = 2.6–3.2 | Moderate = 3.2–5.1 | High = >5.1
Components: TJC28 + SJC28 + ESR or CRP + patient global (0–100 VAS)
DAS28-ESR and DAS28-CRP have different formulae — CRP generally gives slightly lower score
NICE biologic continuation: DAS28 improvement ≥1.2 at 3 months

MTX Monitoring — Key Points

FBC + LFTs: 2-weekly × 4, monthly × 3, then 3-monthly
Trimethoprim is CONTRAINDICATED with MTX
Pneumonitis: stop immediately, urgent CXR, do not rechallenge
Folic acid 5 mg weekly — NOT same day as MTX
Avoid pregnancy both sexes — stop 3 months before

Pre-Biologic TB Screening

IGRA preferred (especially post-BCG) + CXR for all
Positive IGRA → treat LTBI → start biologic after ≥4 weeks on treatment
Active TB: TREAT FIRST, defer biologic
Annual re-screening for high-risk patients

Infection on Biologics

Hospital admission / IV antibiotics → STOP biologic
Resume after full clinical recovery
IL-6 inhibitors: CRP and fever may be absent even with severe sepsis
Live vaccines contraindicated on all biologics and JAKi
VTE black box warning — all JAK inhibitors

Rituximab Key Facts

2 × 1000 mg IV, 2 weeks apart, every 6 months
Check IgG before each cycle — withhold if <5 g/L
PML — rare JC virus; monitor neurological symptoms
HBV prophylaxis mandatory if anti-HBc positive