What is the recommended regimen for Adalimumab?

Adalimumab Recommended Regimen

The recommended regimen for adalimumab is 80 mg subcutaneously at week 0 (initial dose), followed by 40 mg at week 1, and then 40 mg every other week thereafter as maintenance therapy. 1, 2

Standard Dosing Protocol

Initial Loading Dose

• 80 mg subcutaneously at week 0 (administered as two 40 mg injections)
• 40 mg subcutaneously at week 1

Maintenance Dose

• 40 mg subcutaneously every other week

Disease-Specific Dosing Considerations

Plaque Psoriasis

• Standard regimen as above
• For better disease control in some patients, a maintenance dose of 40 mg weekly may be considered 1
• Particularly effective for:
  • Moderate-to-severe plaque psoriasis (80% achieve PASI 75 by week 16) 1
  • Palmoplantar psoriasis
  • Nail psoriasis
  • Scalp psoriasis

Rheumatoid Arthritis

• Standard regimen: 40 mg every other week 2, 3
• May be combined with methotrexate for:
  • Reduced immunogenicity
  • Increased effectiveness
  • Reduced clearance of adalimumab 1, 3

Crohn's Disease

• Initial dose: 160 mg at week 0 (four 40 mg injections)
• Second dose: 80 mg at week 2 (two 40 mg injections)
• Maintenance: 40 mg every other week starting at week 4 2, 3

Combination Therapy Options

Adalimumab efficacy can be enhanced through combination therapy:

• With topical therapies: High-potency corticosteroids with/without vitamin D analogues (Strength of recommendation B) 1
• With methotrexate: Particularly beneficial for:
  • Reducing immunogenicity (lower rate of anti-adalimumab antibody formation)
  • Increasing effectiveness
  • Reducing clearance of adalimumab
  • Managing associated psoriatic arthritis (Strength of recommendation B) 1, 2
• With acitretin: May augment efficacy for moderate-to-severe plaque psoriasis (Strength of recommendation C) 1
• With narrowband ultraviolet phototherapy: Can enhance efficacy (Strength of recommendation B) 1

Monitoring Requirements

• Tuberculosis screening before initiation (PPD test)
• Baseline laboratory tests:
  • Complete blood count
  • Liver function tests
  • Hepatitis profile
• Periodic monitoring during treatment:
  • Clinical assessment
  • Consider yearly TB testing
  • Periodic CBC and LFT 2

Dose Adjustment Considerations

• For patients with inadequate response to standard dosing, increasing to 40 mg weekly may improve disease control 1
• This higher frequency dosing has strong evidence (Strength of recommendation A) but may not be approved by all insurance providers 1
• Pharmacokinetic studies show that a loading dose significantly reduces time to reach efficacy 4

Common Pitfalls and Caveats

1. Interrupted therapy: Should be avoided as it may result in:

   • Loss of efficacy
   • Lower response rate upon restarting therapy
   • Poorer disease control 1, 2

2. Immunogenicity concerns:

   • Development of anti-adalimumab antibodies can reduce efficacy
   • Consider methotrexate co-administration to reduce antibody formation 1

3. Safety considerations:

   • Most common side effect: injection site reactions
   • Serious infections (including tuberculosis) can occur
   • Should not be used during periods of active infection 5
   • Rare but serious adverse events include congestive heart failure exacerbation, lupus-like syndrome, and demyelinating disorders 5

The evidence strongly supports the standard regimen of adalimumab with an 80 mg loading dose followed by 40 mg at week 1 and then 40 mg every other week, with consideration for dose escalation to weekly administration in patients with inadequate response.