Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Serious infection during biologic therapy
Sepsis, pneumonia, opportunistic infection, disseminated zoster, tuberculosis or hepatitis reactivation may progress with muted fever and inflammatory markers; tocilizumab can suppress CRP particularly strongly.
Action: Withhold the biologic, arrange urgent syndrome-directed cultures, imaging and antimicrobial treatment, involve rheumatology and infection specialists, and do not restart until infection control, organ recovery and a documented risk-benefit decision are complete.
Synopsis
Select, start and monitor biologic DMARDs through the relevant disease and NICE pathway, matching molecular target to phenotype while preventing serious infection, reactivation, organ-specific toxicity and reproductive harm.
A biologic DMARD is a protein therapeutic targeting a cytokine, receptor or immune cell; choice follows diagnosis, prior DMARD response, NICE eligibility, dominant disease domain, comorbidity and patient preference.
Do not start during active serious infection. Before treatment, screen for tuberculosis, hepatitis B with HBsAg, anti-HBc and anti-HBs, hepatitis C and HIV, and update vaccination.
TNF inhibitors treat rheumatoid, psoriatic and axial spondyloarthritis but need special caution with latent TB, demyelination and heart failure; adalimumab is contraindicated in NYHA class III or IV heart failure.
Key red flags
Fever, rigors, hypotension, confusion, hypoxaemia, focal neurological change or rapidly progressive infection requires immediate biologic interruption and emergency sepsis assessment.
Serious or opportunistic infection
Focal symptoms, weight loss, zoster, dyspnoea, confusion or functional decline may be more informative than fever or CRP during biologic immunosuppression.
Investigation priorities
01
First-line baseline infection screenFirst stepFirst line
Exclude active infection and identify reactivation risks before the first biologic dose.
Management branches
Eligibility and selectionConfirm target, then choose class
Active rheumatic disease remains above target after the required conventional therapy or has a pathway-specific indication.
Verify diagnosis, inflammatory activity, adherence and NICE criteria and document peripheral, axial, skin, eye and bowel domains plus the patient's priority.
Compare classes against TB and hepatitis risk, recurrent infection, heart failure, demyelination, IBD, uveitis, malignancy, pregnancy, route and monitoring burden.
Key medicines
AdalimumabGive 40 mg subcutaneously every other week for adult rheumatoid arthritis, psoriatic arthritis or axial spondyloarthritis; some licensed skin and bowel indications use loading or weekly regimens and must follow their own product schedule.
TocilizumabFor adult rheumatoid arthritis, give 162 mg subcutaneously once weekly; giant-cell-arteritis treatment can be 162 mg weekly or every other week according to the product and clinical need, while intravenous regimens differ.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.