Biologic Medications

     These matters have to do with Disease Modifying Anti-Rheumatic Drugs.  Administration of them may be intravenously, orally, and subcutaneously (2).  These agents are beneficial for the management of rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS).  These are only a few of the illnesses which may occur from these conditions.  Without question, the presence of infection poses quite a serious situation in these clients.  For example, viral, fungal, and bacterial infections require close management in those who receive DMARDs.  Physicians have long screened patients for hepatitis B and C.  Tuberculin skin test is also necessary when there is no contraindication for it.  Obviously, these cases are quite serious, and subspecialists such as gastroenterologist, rheumatologist, or dermatologist are necessary.  In any event, DMARDs are immunosuppressive and immunomodulatory.  The National Cancer Institute defines immunomodulation as a change in the human body’s immune system.  Specifically, the result is from agents which may activate or suppress its function.  It is clear, however, that DMARDs may be conventional or biologic.  Examples of biologic agents are infliximab, adalimumab, and tofacitinib.  Conventional agents include methotrexate, sulfasalazine, and hydroxychloroquine.  There is considerable debate about hydroxychloroquine and its utility for management of Covid-19.  Researchers raise the question over its use as a post-exposure prophylaxis.  However, many resources do not verify its benefit in that regard.  Hydroxychloroquine has been beneficial for 75 years as an antimalarial agent when there is not a drug resistance problem in that community (Boulware et al, 2020; Centers for Disease Control, 2020, Arthritis Foundation, and Benjamin, O. et al).  Moreover, one must not take hydroxychloroquine when he or she concomitantly has psoriasis (4).

     It was during the 1990s that biologic agents became available, and conventional medications, in some instances, have been available for several decades.  

     Cutaneous reactions are not new to the field of medicine.  They take place when there has been an undesirable alteration in the structure or function of human skin.  There are also immunologic and nonimmunologic causes of drug reactions.  Examples of immunologic drug reactions encompass anaphylaxis from an antibiotic such as penicillin.  Another one would be morbilliform rash from sulfonamides.  In that instance, there is a specific T-cell activation which leads to an immunologic reaction.  On the other hand, nonimmunologic reactions can occur from hepatotoxicity from methotrexate therapy or from erythromycin in combination with theophylline and the development of seizures.  This would obviously be the result of drug toxicity.  The occurrence of seizures in clients who receive too much lidocaine is another example of nonimmunologic reaction.  In some of these cases, it is possible to measure the serum levels of these agents (5).

     Still there is the possibility of pseudo-allergic nonimmunologic reaction, and one example is anaphylactoid reaction after the administration of radiocontrast media.  Another well-known example is idiosyncratic nonimmunologic reaction in which there is hemolytic anemia in patients who have glucose-6-phosphate-dehydrogenase deficiency after he or she receives primaquine therapy.  Of course, one well-known use of that medication has been management of malaria (5).

     The occurrence of these cutaneous reactions has varied across the globe as well as with the passage of time, and new medications have surfaced.  The use of biologic medications has dramatically changed the outcome in many scenarios.  They have also altered the physician’s method of management.  The use of specialists will also continue to change as new approaches continue to have more importance than in the past (1).

     Skin problems in some of these clients include eczematoid dermatitis, lichenoid reactions, skin cancer, psoriasis, and cutaneous infections.  There may be injection site reactions or infusion issues.  The clinical situation will, of course, affect the appearance of these matters (Pasadyn, page 289).  There are several factors which will lead to cutaneous infection should one have TNF alpha inhibitor therapy.  Some of them are diabetes mellitus, organic brain disease, and chronic lung illness.  Alcoholism, malnutrition, and age may affect these issues (Pasadyn, page 290).  There is no question that these new agents have improved the management of these situations; however, there are many side effects.  In any event, there is discussion over human papillomavirus (HPV).  Specifically, it may lead to cervical dysplasia and anogenital warts.  In these patients who take TNF alpha inhibitors, there is some degree of relief.  Essentially, such an approach will likely lessen the presence of abnormal PAP smears (Pasadyn, page 290).

     The medical literature also describes psoriasis and its other connections.  For example, the use of infliximab in the presence of Crohn disease may occur with palmar abnormalities.

     There is significance between biologics from agents which one obtains traditionally.  Several well-known distinctions are clinical efficacy, cost, production, and administration.  It is obvious, however, that Western medicine rapidly changes.  Managed care has major roles.  Specifically, biologics are present in human growth hormone as well as red blood cells.  Genomics, proteomics, monoclonal antibody technologies, and other methods have importance for the development of biologics.  Specifically, proteomics is the study of proteomes, that is “the entire complement of proteins that is…expressed by a cell, tissue, or organism.” (Oxford, 2020).  Whereas genetics is the study of heredity, genomics is a branch of molecular biology, and it has to do with evolution, mapping, function, and structure (Oxford, 2020; World Health Organization, 2020).  In other words, there is value in treatment.  Examples are liver rejection and cancer (6).

     Without question, the research and development of biologics is quite costly.  There are so many of these agents.  It can become a challenge for researchers.  One item, however, is quite clear about extracts and the use of living organisms—they are well-established protocols for disease management.  Also, researchers know that variables such as temperature, light, and enzymatic action leave biologics in a sensitive situation.  One must understand that genes and proteins have  role of a biologic (6). 

     Medical practice has grown enormously over the last half century—and before.  These are challenging cases which sometimes do better than in the past, and biomedical sciences will likely develop further over the decades.  Despite their complexity, new approaches have clearly shown that medical personnel can in fact revolutionize such presentations—as has already taken place.

1. Pasadyn, S., Knabel, D., Fernandez, A., and Warren, C.  (2020).  Cutaneous adverse effects of biologic medications.  Cleveland Clinic Journal of Medicine, 87, 288-299.
2. Benjamin, O., Bansal, P., Goyal, A., and Lappin, S.  (2020).  Disease modifying anti-rheumatic drugs (DMARD).  Stat Pearls Publishing, LLC.  Treasury Island (FL):  Stat Pearls Publishing; 2020 Jan.
3. Boulware, D., Pullen, M., Bangdiwala, A. et al.  (2020).  A randomized trial of hydroxychloroquine as post-exposure prophylaxis for Covid-19.  New England Journal of Medicine
4. U.S. Centers for Disease Control and Prevention.  (2020).  Coronavirus disease.
5. Nayak, S. and Acharjya, B.  (2008).  Adverse cutaneous drug reaction.  Indian Journal of Dermatology, 53, 2-8.
6. Morrow, T. and Felione, L.  (2004).  Defining the difference:  What makes biologics unique.  Biotechnology Healthcare.  Medi Media, USA.
7. Arthritis Foundation.  (2020).    
8. Copyright 2020.  All rights reserved.  Michael Koger, Sr., M.D.

     The information contained in this article is for educational purposes only, and one should not use it for diagnosis or treatment without the opinion of a health professional. Any reader who is concerned about his or her health should contact their physician for advice.