Adalimumab Dosing and Treatment Regimen
For psoriasis, adalimumab should be administered at 80 mg subcutaneously the first week, followed by 40 mg the second week, and then 40 mg every other week thereafter. 1 This dosing regimen has demonstrated high efficacy with 80% of patients achieving PASI-75 at 12 weeks and 68% maintaining this response at 60 weeks.
Indication-Specific Dosing
Psoriasis
- Initial dose: 80 mg subcutaneously at week 0
- Second dose: 40 mg subcutaneously at week 1
- Maintenance: 40 mg subcutaneously every other week 1
Psoriatic Arthritis
- Standard dose: 40 mg subcutaneously every other week 1
- No loading dose is required for psoriatic arthritis alone
Other FDA-Approved Indications
- Rheumatoid arthritis: 40 mg subcutaneously every other week
- Crohn's disease: 160 mg at week 0 (given as four 40 mg injections in one day or as two 40 mg injections per day for two consecutive days), 80 mg at week 2, then 40 mg every other week starting at week 4
- Juvenile rheumatoid arthritis: Weight-based dosing (approved for children as young as 4 years)
- Ankylosing spondylitis: 40 mg every other week 1
Efficacy Data
Adalimumab has demonstrated significant efficacy across multiple conditions:
- Psoriasis: 80% of patients achieve PASI-75 at 12 weeks; 68% maintain PASI-75 at 60 weeks 1
- Psoriatic arthritis: 58% of patients achieve ACR20 response at 12 weeks compared to 14% with placebo 2
- Radiographic progression: Adalimumab significantly inhibits structural joint damage with mean change in modified Sharp score of -0.2 compared to 1.0 with placebo (p<0.001) 2
Administration Considerations
- Adalimumab is administered via subcutaneous injection
- Continuous therapy is recommended as interrupted therapy may result in loss of efficacy 1
- Clearance is better maintained with continuous use, and there is potential loss of efficacy after restart 1
- The British Association of Dermatologists notes that interrupted therapy should be avoided due to poorer disease control 1
Monitoring Requirements
Baseline Screening
- PPD (purified protein derivative) test for tuberculosis is required
- Liver function tests (LFT)
- Complete blood count (CBC)
- Hepatitis profile 1
Ongoing Monitoring
- Periodic history and physical examination while on treatment
- Consider yearly PPD testing
- Periodic CBC and LFT 1
Safety Considerations
- Infections: Serious infections including tuberculosis and opportunistic infections have been reported
- Malignancies: Rare reports have been documented
- Autoimmune reactions: Rare reports of drug-induced lupus without renal or CNS complications
- Neurological concerns: Association with demyelinating diseases; should not be used in patients with multiple sclerosis or other demyelinating diseases
- Cardiovascular: Potential exacerbation or new onset of congestive heart failure
- Injection site reactions: Moderately painful injection site reactions may occur 1
Combination Therapy
Adalimumab can be combined with other treatments to enhance efficacy:
- Topical therapies: Can be combined with topical steroids and vitamin D analogues 1
- Methotrexate: Often combined for psoriatic arthritis; may reduce immunogenicity and increase effectiveness 1
- Acitretin: Can be added in palmoplantar psoriasis to increase efficacy without increasing immunosuppression 1
Common Pitfalls to Avoid
- Inadequate screening: Failure to screen for tuberculosis before initiating therapy
- Premature discontinuation: Discontinuing therapy too early before adequate assessment of response (minimum 12 weeks)
- Inappropriate use in contraindicated conditions: Using in patients with active serious infections, multiple sclerosis, or NYHA class III/IV heart failure
- Inadequate monitoring: Failure to perform periodic monitoring for adverse effects
- Live vaccines: Administering live vaccines during treatment
Adalimumab has a pregnancy category B rating, indicating it may be safer than some other biologics during pregnancy, though careful risk-benefit assessment is still required 1.