What is the recommended treatment regimen for a patient with a history of autoimmune diseases, such as psoriasis or rheumatoid arthritis, using Adalimumab (adalimumab)?

Adalimumab Treatment Regimen for Autoimmune Diseases

For patients with moderate-to-severe psoriasis or psoriatic arthritis, initiate adalimumab with 80 mg subcutaneously at week 0, followed by 40 mg at week 1, then 40 mg every 2 weeks thereafter as the standard maintenance regimen. 1

Standard Dosing Protocol

Initial Loading and Maintenance

• Loading dose: Administer 80 mg subcutaneously (given as two 40-mg injections) at week 0 1, 2
• Second dose: 40 mg subcutaneously at week 1 1
• Maintenance: 40 mg subcutaneously every 2 weeks thereafter 1, 2

Dose Escalation for Inadequate Response

• For patients requiring better disease control: Increase maintenance dose to 40 mg weekly 1
• Consider weekly dosing particularly in: Obese patients or those experiencing disease relapse during the treatment cycle, though this carries a potentially increased infection risk 2

Pre-Treatment Screening Requirements

Mandatory Baseline Testing

• Tuberculosis screening: PPD (purified protein derivative) test is required before initiating therapy 1, 3
• Laboratory monitoring: Complete blood count (CBC) and liver function tests (LFT) 1, 3
• Hepatitis B screening: Required in appropriate clinical settings 3
• Cardiac evaluation: Assess for congestive heart failure; patients with class I/II CHF should undergo echocardiogram, and adalimumab should be avoided if ejection fraction is <50% 3
• Neurological assessment: Evaluate for demyelinating diseases including multiple sclerosis 3

Disease-Specific Indications

Psoriasis (Strength A Recommendations)

• Moderate-to-severe plaque psoriasis: Adalimumab is recommended as monotherapy 1
• Palmoplantar psoriasis: Recommended for moderate-to-severe disease affecting palms and soles 1
• Nail psoriasis: Recommended for moderate-to-severe nail involvement 1
• Scalp psoriasis: Can be recommended (Strength B) 1
• Pustular or erythrodermic psoriasis: Can be recommended (Strength B) 1

Psoriatic Arthritis

• With any severity of plaque psoriasis: Adalimumab is recommended as monotherapy (Strength A) 1
• Expected efficacy: 39% achieve ACR20 response at week 12 versus 16% with placebo 4

Combination Therapy Options

Recommended Combinations (Strength B)

• Topical corticosteroids with or without vitamin D analogue: Can be combined to augment efficacy 1
• Methotrexate: May be combined to increase efficacy, particularly beneficial in psoriatic arthritis where >50% of patients maintain prior systemic agents 1
• Narrowband ultraviolet phototherapy: May be combined 1

Possible Combinations (Strength C)

• Acitretin: May be combined, particularly for palmoplantar psoriasis, with negligible immunosuppressive effect 1
• Apremilast: May be combined 1
• Cyclosporine: May be combined 1

Ongoing Monitoring During Treatment

Regular Surveillance

• Clinical monitoring: Periodic history and physical examination throughout treatment 1, 3, 2
• Annual tuberculosis testing: Yearly PPD recommended 1, 3, 2
• Laboratory monitoring: Regular CBC and liver function tests 1, 3, 2

Therapeutic Drug Monitoring

• When to measure anti-adalimumab antibodies: Consider when patients experience loss of clinical response or primary non-response 5
• Concomitant DMARDs: Lower immunogenicity risk across inflammatory conditions 5

Expected Efficacy Outcomes

Short-Term Results (12-16 Weeks)

• PASI-75 achievement: 71-80% of patients with psoriasis 1, 2
• PASI-90 achievement: 45% of patients 1

Long-Term Results

• At 40 weeks: PASI-75 maintained in 67% and PASI-90 in 40% 1
• At 60 weeks: 68% maintain PASI-75 1, 2

Safety Profile and Contraindications

Absolute Contraindications

• Active serious infections: Adalimumab is contraindicated 3
• NYHA class III/IV congestive heart failure: Should not be used 3

Relative Contraindications and Cautions

• Multiple sclerosis or demyelinating diseases: Avoid use 3
• Live vaccines: Should not be administered concurrently 3

Common Adverse Events

• Injection site reactions: Most common side effect, generally mild to moderate 1, 3, 6
• Serious infections: Two-fold increased risk, including tuberculosis reactivation 6
• Rare complications: Drug-induced lupus (without renal or CNS involvement), cytopenia, MS exacerbation, and CHF worsening 1, 3, 6

Critical Clinical Pitfalls

Loss of Efficacy

• Small percentage lose efficacy with continued use: If this occurs at standard dosing, consider increasing to weekly dosing, adding combination therapy, or switching agents 1
• Rebound typically does not occur upon discontinuation: However, clearance is better maintained with continuous use 1

Pregnancy Considerations

• FDA pregnancy category B: Although classified as category B, careful risk-benefit consideration is warranted 1
• VACTERL syndrome: Rare association reported with TNF-α antagonists during pregnancy 1