Rheumatoid Arthritis - My Doctor Says I Need Remicade

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Author: William C. Shiel Jr., MD, FACP, FACR

Your rheumatoid arthritis is causing you daily pain and stiffness in your fingers, wrists, and knees. It is difficult for you to dress and care for yourself. You've tried numerous traditional medications, which have failed to improve your conditions and the threat of permanent joint damage is lurking.

So, your doctor recommends a new treatment for your aggressive rheumatoid arthritis. The treatment is given directly into your veins (intravenously or IV). The treatment is extremely expensive, but side effects are uncommon. The treatment is Remicade (generic name is infliximab).

What is Remicade?

Remicade is an antibody that blocks the effects of tumor necrosis factor alpha (TNF-alpha). TNF- alpha is a substance that is produced by cells of the body and that has an important role in promoting inflammation. Basically, TNF-alpha acts like a messenger that summons the immune cells of inflammation to participate in the inflammation.

By blocking the action of TNF-alpha, Remicade reduces the inflammation and its accompanying signs and symptoms. Remicade does not cure rheumatoid arthritis. However, studies have demonstrated that Remicade can inhibit the progress of joint destruction from rheumatoid arthritis.

Remicade can either be used alone or is often combined with methotrexate for treating rheumatoid arthritis in patients who have not adequately responded to methotrexate alone. In these patients, the drug is used to prevent joint damage that is caused by the rheumatoid arthritis.

What does the doctor mean that Remicade treatment is expensive?

A single dose of Remicade can cost from $1,300 to $2,500. The first step is determining insurance coverage for the infusion. Medicare does cover Remicade infusions. Most insurance companies require "pre-approval" for coverage. Therefore, the doctor's office must explain to the insurance company what drug is being given, what other treatments have been tried, and why the new treatment is recommended (typically via a standard form). HMO coverage depends on the individual HMO and the particular agreement with the treating doctor. Any balance of the charges and/or co-pays should be understood prior to beginning treatment.

What actually happens during a Remicade treatment?

Remicade is typically given in the outpatient setting of the doctor's office.

A nurse or assistant mixes the powdered form of the Remicade with sterile water. The solution is injected into a large bag of sterile clear water for the infusion. Tubing is connected to the bag and the bag is attached atop an IV pole. The nurse then applies a tourniquet over an arm that has a visible vein. The vein is rubbed with alcohol and a fine needle catheter is inserted into the vein. (A catheter is a plastic tube with an attachment on one end into which tubing can be attached. This poke into the vein to insert the catheter is very similar to the feeling of having blood drawn.)

The IV tubing is attached to the catheter, the tourniquet is released, and the stop-clamp is opened to allow the fluid to drain from the bag into the vein.

The infusion is dripped in slowly, usually over about 2 hours. Because of the long infusion time, it is best for patients to use the restroom prior to the infusion. It is also convenient for patients to bring reading materials to occupy them during the infusion. (I have business people who bring in their laptops and actually work on their computers during the infusion!)

During the infusion, the nurse record blood pressure readings that are taken at several intervals and any symptoms.

After the IV bag is empty, the nurse removes the tape that was securing the catheter and then slip out the catheter and that's it! (This is painless.)

What is the dose of a Remicade treatment?

The recommended dose of Remicade for the treatment of rheumatoid arthritis is 3 mg/kg as a single dose. This means that the amount of each dose is based on the weight of the patient. Therefore, infusions can be more expensive for heavier persons because more Remicade is used. The initial dose should be followed by additional 3 mg/kg doses two and six weeks after the first dose. Thereafter, the maintenance dose is 3 mg/kg every eight weeks.

What are the side effects of Remicade treatment?

The most common side effects of Remicade are upper respiratory tract infections, urinary tract infections, cough, rash, back pain, nausea, vomiting, abdominal pain, headache, weakness, and fever. (While this is the generally reported list, in my experience, rash and headaches have been the more common side effects. Nevertheless, other side effects can occur and more are listed below.)

Side effects such as low or high blood pressure, chest pain, difficulty breathing, rash, itching, fever and chills may occur during or shortly after the infusion. These reactions could indicate an allergy to the drug. They are more common among patients who develop antibodies to Remicade and are less likely to occur in patients who are taking drugs that suppress the immune system, such as methotrexate. Remicade is discontinued if serious reactions occur.

Serious infections have been reported with other drugs that block TNF- alpha and infections have been reported during treatment with Remicade. Therefore, Remicade should not be used in patients with serious infections. Moreover, Remicade treatments should be discontinued if a serious infection develops during treatment.