Infusions for RA (Rheumatoid Arthritis) may be recommended by your Rheumatologist when oral or injectable DMARD (Disease Modifying Anti Rheumatic Drugs) alone or in combination are no longer effective in controlling symptoms or the disease process has advanced aggressively. Infusions for RA are not prescribed lightly nor should they be. There are significant side effects that must be weighed when considering if these drugs are for you. Often they are not prescribed unless the disease is to the moderate/severe level simply because of the time frame it takes to determine if oral therapy is effective. When oral therapy fails, more often than not, injectable drugs are then tried in combination with oral therapy before infusable drugs are considered. This can delay infusion therapy considerably.
There are four drugs that are commonly infused for RA at present. They are all types of manufactured proteins but they all work differently. Your Rheumatologist will determine which is the best course of treatment for you based on your past response to oral and injectable therapies.
- Orencia -used to suppress T-cells.
- Actemra – used to block interleukin-6 (IL-6).
- Remicade – used to as a TNF Inhibitor.
- Rituxan – targets mature B-cells.
Now that you know about the main types of infusible drugs and their action, you can see that they don’t work the same which is why you might find yourself being prescribed a different infusion if another is not working to control symptoms well. Orencia and Actemra were originally available as infusion only but in recent years have been made available as a home injectable. Your doctor may still prescribe the infusible version for a variety of reasons some of which may be dictated by your insurance. Unfortunately payment often dictates where, when and how you will receive advanced treatment for RA.
All infusible drugs for RA are very expensive. A http://www.sciencedirect.com article from 7/14/17 gives an estimate that cost of these drugs per year are $36,000 to $47,000 on average. This estimate does not include the fee for administration which can double the cost in some cases. Due to rising costs, most infusions for RA are given at infusion labs on an outpatient basis.
Once the infusion has been ordered and prior authorization has been met by your healthcare coverage, the next step in infusion therapy is getting ready for the infusion which may include:
- Referral – Your Rheumatologist will refer you to a infusion lab for your treatment. This lab may be a stand alone clinic, it may be located in a physician office building, or it may be located within a hospital. The majority of infusion labs are set up with reclining chairs in a common area with multiple patients receiving treatment simultaneously.
- Immunizations – Carefully consider getting the flu and/or pneumonia vaccines prior to starting infusion therapy if your therapy starts during flu season between September 1st – February 28th. Infusions squelch immunity to the point that getting the flu and/or the complication of pneumonia can be life threatening.
- Consent – Your Rheumatologist may or may not ask you to sign consent forms for the infusion. This is an agreement between you and your doctor that you understand the therapy and possible side effects.
- Understand Frequency – Each of the infusion therapies have their own schedules (frequency in which they are given) which your doctor should review with you so you will know what to expect for purposes of time off work, scheduling child care, etc… For example, my Rituxan is given twice a year in a set 14 days apart. I just finished my June/July set and my next will be Dec/Jan. My best friend, who has advanced RA, receives Remicade every 8 weeks.
- Patient Education – many infusion labs are now requiring patients to take a education course about their therapy with a trained professional. If this is dictated by your insurance, it is not optional.
- Understand Adverse Reactions – Reactions to infusion therapy for RA do happen. Often times, the infusion rate only need be slowed down and perhaps additional medication given. In order to alert your infusion nurse of any signs of a infusion reaction, you need to be aware before the day of infusion what to expect.
On the day of the infusion:
- Positive attitude – Arriving with a positive attitude will make for a more pleasant experience for you and your infusion lab mates, lowers blood pressure, checks anxiety, and helps prevent stress induced flares.
- Hydrate – Arrive at the infusion center well hydrated for easy of placing the IV site. Dehydration causes veins to flatten making it difficult for the nursing staff to start the IV site which may lead to multiple, painful, unwanted needle sticks. Dehydration also causes nausea which may be compounded as a side effect of the drug therapy.
- Expect your blood to be drawn – As a precaution, simple blood tests are done prior to the infusion to make sure you are healthy enough for the infusion. (Being well hydrated the morning of the infusion aides with the lab draw too.) The infusion nurse will review the lab work and determine if it is safe to proceed with the infusion. If for any reason your infusion cannot be given because of your lab values, understand it is for your safety.
- Take your oral medications as prescribed – It is not wise to hold any of your medication or take medication not listed on your medical record on the day of infusion. Advise your infusion nurse of any change to your medication regimen prior to start of infusion. It is wise to bring a current list of medications including: name of medicine (both prescribed and over the counter), medication strength, and time of day you take the medication along with a list of allergies for your infusion nurse. If you need to take any home medication during the infusion, please have the medication on your person as most infusion labs do not dispense home meds; however, you do need to make your infusion nurse aware of what you are taking and why.
- Have a driver – Often anti-nausea meds and/or Benadryl are given prior to the infusion to counteract anticipated side effects. These may cause drowsiness making it unsafe to drive after the infusion. The infusion may cause you to be unexpectedly tired and having someone to drive you home is a blessing. Many infusion labs will not allow you to drive yourself home.
- Dress comfortably and in layers – Your infusion nurse will need to be able to raise your sleeves for placement of the IV site and may also need to monitor blood pressure or perhaps place heart monitor leads for your infusion. Some infusions take several hours so being comfortable is important. The temperature of the infusion lab may not be to your comfort level so be able to adjust your clothing by taking off or adding layers; however, chills should be reported to the infusion nurse right away.
- Be considerate of your infusion mates – Don’t wear perfume as many people are allergic and strong smells can cause those getting chemotherapy to become nauseated. Don’t talk on your cell phone and quiet the ringer – The infusion lab should be calm and quiet to allow the infusion nurses to observe patients for emergencies without distraction. Keep conversation pleasant, light and quiet as many patients nap. Controversial subjects should be avoided.
- Come prepared – Bring things to pass the time (electronic devices are okay as long as the sound is off and/or headphones are used), bring a pillow/blanket if these items not provided by the infusion lab, bring your own drinks/snacks (food is not encouraged as the smell can trigger nausea for some patients but dry snacks are okay). In most cases the infusion lab will have coffee, water, ice, snack crackers but check to be sure if your infusion is over meal times.
I hope you have found this series of articles on medication management helpful. This is the last entry in the series. Other articles in the series discussed management of prescriptions and refills, cost of medications and real resources for help, how to use a medication planner, and injections used in the treatment of RA.