Etanercept. Drug information Etanercept. This leaflet provides information on etanercept and will answer any questions you have about the treatment.

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1 Drug information Etanercept Etanercept This leaflet provides information on etanercept and will answer any questions you have about the treatment. Arthritis Research UK produce and print our booklets entirely from charitable donations.

2 What is etanercept? Etanercept (trade name Enbrel) is a type of drug known as anti-tnf (anti-tumour necrosis factor). In people with rheumatoid arthritis and some other inflammatory diseases a protein called TNF is overproduced in the body, causing inflammation and damage to bones, cartilage and tissue. Anti-TNF drugs block the action of TNF proteins and so reduce this inflammation.

3 At a glance What type of drug is etanercept (trade name Enbrel)? Etanercept is an anti-tnf (antitumour necrosis factor) drug. What does it do? It blocks the action of TNF proteins and so reduces inflammation. What is it used for? Etanercept is available for people with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis, and for young people with juvenile idiopathic arthritis (JIA). How is it taken? It s usually given as a subcutaneous injection once or twice a week. Are there any side-effects? The most common side-effects are reactions at the injection site (usually redness and sometimes itching), a blocked or runny nose, nausea, mild fever, headaches, dizziness, a rash and stomach problems. It can also make you more likely to develop infections.

4 Why is etanercept prescribed? Etanercept is available for people with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis, and for young people with juvenile idiopathic arthritis (JIA). Etanercept will only be prescribed if your arthritis is active. If you have rheumatoid arthritis it ll only be used if you ve already tried methotrexate and another disease-modifying anti-inflammatory drug (DMARD) such as sulfasalazine or hydroxychloroquine, or if you can t use these drugs for any reason. Slightly different restrictions may apply in the case of the other conditions, so you should discuss this with your doctor or rheumatology nurse. Is there any reason I won t be prescribed etanercept? Etanercept won t be prescribed if: your rheumatoid arthritis isn t active you haven t tried standard treatments first you have an infection. Your doctor may decide not to prescribe etanercept if: you ve had tuberculosis (TB) in the past you ve had other repeated/serious infections you have or have had multiple sclerosis (MS) you ve had cancer you have or have had a serious heart condition you have lung fibrosis you re pregnant or breastfeeding. When and how do I take etanercept? Etanercept is only available on prescription from a consultant rheumatologist. It s given once or twice a week by subcutaneous injection (an injection under the skin) and comes in a pre-filled pen device or syringe. You, your partner, or another member of your family can learn to give the injections. If this isn t possible, you may be able to arrange for the injections to be given by your rheumatology nurse specialist or district nurse. How long does etanercept take to work? If you respond to etanercept you ll probably feel better in 2 12 weeks. What are the possible side-effects? The most common side-effects of etanercept are: a blocked or runny nose nausea (feeling sick) Record your dosage here to help you manage your treatment: How many? What dosage/strength? How often? When?

5 a mild fever headaches dizziness a rash stomach pain or indigestion inflammation around the injection site. Taking etanercept can sometimes affect your blood count (the number of blood cells present in your blood) and can make you more likely to develop infections. You should tell your doctor or rheumatology nurse straight away if you develop any of the following after starting etanercept: a sore throat a fever any other symptoms of infection unexplained bruising, bleeding or paleness any other new symptoms or anything else that concerns you. You should stop etanercept and see your doctor immediately if: any of the symptoms listed above are severe you haven t had chickenpox and you come into contact with someone who has chickenpox or shingles you develop chickenpox or shingles. Chickenpox and shingles can be severe in people who are on treatments that affect the immune system. You may need antiviral treatment, which your doctor will be able to prescribe. Your etanercept will be stopped if you do develop chickenpox or shingles and restarted when you re better. The long-term side-effects of etanercept aren t yet fully understood because it s a relatively new drug. Etanercept helps to reduce inflammation. It usually takes 2 12 weeks to take effect. What are the risks? There may be a slightly increased risk of some cancers in patients using anti-tnf drugs like etanercept which interfere with the immune system. Such a link hasn t been proven and is still being researched. Please discuss this with your doctor if you re worried. Anti-TNF drugs have been associated with certain types of skin cancer these can be readily treated when diagnosed early. Very rarely, people taking etanercept may develop a condition called drug-induced lupus. This is usually mild and can be diagnosed by a blood test. Symptoms include a rash, fever and increased joint pain. If you develop drug-induced lupus, etanercept will be stopped and the condition then usually disappears. How can I reduce the risk of infection? Because of its effects on the immune system, etanercept may make you more likely to pick up infections. You should avoid close contact with people who

6 have severe active infections, and visit the NHS Choices website nhs.uk/livewell/homehygiene/pages/ Homehygienehub.aspx for information on reducing your risk of infection from foods. Will it affect vaccinations? If you re on etanercept it s recommended that you avoid live vaccines such as yellow fever. However, in certain situations a live vaccine may be necessary (for example rubella immunisation in women of childbearing age), in which case your doctor will discuss the possible risks and benefits of the immunisation with you. If you re in your 70s and are offered shingles vaccination (Zostavax), you should discuss this with your rheumatology team. You may be advised to have the shingles vaccine before starting etanercept. Shingles vaccination isn t recommended for people who are already on etanercept. If possible, children should be brought up to date with their immunisations before starting etanercept therapy. Alternatively, children who require measles, mumps and rubella (MMR) immunisation may need to defer this while having treatment with etanercept. Pneumovax (which gives protection against the most common cause of pneumonia) and yearly flu vaccines are safe and recommended. Can I drink alcohol while on etanercept? You can drink alcohol while on etanercept but should not exceed recommended amounts (2 3 units per day for women and 3 4 units per day for men). If you have psoriasis and you re also taking methotrexate, your doctor may advise lower limits (no more than 4 units per week) because methotrexate and alcohol can interact and damage your liver. Does etanercept affect fertility or pregnancy? At present there is limited information on the use of etanercept during pregnancy and on how it might affect an unborn baby. Similarly, the effects of etanercept on men trying to father a child are uncertain. Generally, it s recommended that men and women use contraception while on this drug. However, some women have used etanercept successfully during pregnancy and guidelines may change as more evidence becomes available. If you re thinking of having a baby or if you become pregnant, you should discuss this with your rheumatologist. There may be an increased risk of infections in babies born to mothers using etanercept, particularly if it s taken during the third trimester of pregnancy. If you are also taking methotrexate this drug should be stopped three months before you try for a baby. Does it affect breastfeeding? Generally, it s recommended that you don t breastfeed if you want to re-start etanercept after pregnancy. However, limited information has shown that only small amounts of etanercept may pass into your breast milk, so you should discuss with your doctor whether to take etanercept whilst breastfeeding. There may be an increased risk of infections in your baby if you use etanercept while breastfeeding and your baby then receives a live vaccine.

7 What else should I know about etanercept? If you re being prescribed etanercept it s recommended that you carry a biological therapy alert card, which you can get from your doctor or rheumatology nurse. Then if you become unwell, anyone treating you will know that you re on etanercept and that you re therefore at risk of its side-effects, including infections. The pre-filled syringes and pens should be stored in a fridge at 2 8ºC and kept in the outer carton to protect from light. Are there any alternatives? A number of other drugs are used in the treatment of rheumatoid arthritis and related conditions. Your doctor will discuss these other options with you. Will I need any special checks while on etanercept? You ll have a chest x-ray, blood tests and a screening to check whether you ve ever been exposed to tuberculosis (TB) or hepatitis. Some patients may need a course of treatment for latent (asymptomatic) TB before starting etanercept. You may also have further blood tests while you re on etanercept to monitor its effects. Etanercept may increase the risk of the hepatitis infection being reactivated in people who carry the virus. If your doctor decides that you may be at risk from a previous hepatitis infection, they may test your blood for the presence of hepatitis. You should discuss any new medications with your doctor before starting them, and you should always tell any other doctor treating you that you re on etanercept. You should also be aware of the following points: Etanercept isn t a painkiller. If you re already on a non-steroidal antiinflammatory drug (NSAID) or painkillers you can carry on taking these as well as etanercept, unless your doctor advises otherwise. If etanercept works for you, you may be able to reduce your NSAIDs or painkillers after a time. Don t take over-the-counter preparations or herbal remedies without discussing this first with your doctor, rheumatology nurse or pharmacist. Can I continue with etanercept if I m going to have an operation? If you re going to have an operation please discuss this with your doctor, as you may be advised to stop the etanercept temporarily before and after surgery. It s important to remember to restart the drug after surgery otherwise you might suffer a flare-up of your arthritis. Notes Can I take other medicines alongside etanercept? Etanercept may be prescribed along with other drugs, including methotrexate.

8 Where can I get more information? Arthritis Research UK is the charity leading the fight against arthritis. We do this by funding high-quality research, providing information and campaigning. We publish over 60 information booklets which help people to understand more about their condition, its treatment, therapies and how to help themselves. If you would like any further information about etanercept, or if you have any concerns about your treatment, you should discuss this with your doctor, rheumatology nurse or pharmacist. Get involved! You can help to take the pain away from millions of people in the UK. To get more actively involved, please call us on or us at enquiries@arthritisresearchuk.org or go to A team of people contributed to this booklet. It was written by Dr Elizabeth Rankin and updated by Dr Alison Jordan, who have expertise in the subject. It was assessed at draft stage by consultant rheumatologist Dr Ben Thompson and rheumatology nurse specialist Elizabeth Meecham. An Arthritis Research UK editor revised the text to make it easy to read, and a non-medical panel, including interested societies, checked it for understanding. An Arthritis Research UK medical advisor, Dr Ian Giles, is responsible for the content overall. Please note: We have made every effort to ensure that this content is correct at time of publication, but remember that information about drugs may change. This information sheet is for general education only and does not list all the uses and side-effects associated with this drug. For full details please see the drug information leaflet that comes with your medicine. Your doctor will assess your medical circumstances and draw your attention to any information or side-effects that may be relevant in your particular case. Arthritis Research UK Copeman House, St Mary s Court, St Mary s Gate, Chesterfield, Derbyshire S41 7TD Tel calls charged at standard rate Registered Charity England and Wales No , Scotland No SC Arthritis Research UK 2014 Published May /D-ETAN/14-1 This leaflet has been produced, funded and independently verified by Arthritis Research UK.