Adalimumab (Humira)
Adalimumab is a protein that targets a protein involved in inflammation, TNFα (Zouboulis, et al., 2015).
It can be self-injected by patients at home (Hidradenitis Suppurativa Foundation, Inc.).
Adalimumab is a human monoclonal antibody corresponding to the human immunoglobulin IgG1, which binds to TNFα and neutralizes its inflammatory activity (Zouboulis, et al., 2015).
Infliximab (Remicade, Renflexis)
Infliximab is administered intravenously (Hidradenitis Suppurativa Foundation, Inc.) and may be used as an alternative TNFα inhibitor to adalimumab (Saunte & Jemec, 2017). The contraindications, side effects, and monitoring parameters listed above for adalimumab are similar to those for infliximab.
Etanercept (Enbrel)
Limited conflicting data does not support its use in HS patients.
Golimumab (Simponi, Simponi Aria)
Golimumab can be administered subcutaneously or intravenously.
Anakinra (Kineret)
Anakinra is a protein that binds to and blocks interleukin-type I (IL-1) receptors involved in inflammation (Lee & Eisen, 2015). It is self-injected daily by patients at home (Hidradenitis Suppurativa Foundation, Inc.). Consider only after failing to respond to treatment with TNFα inhibitors (Alikhan, et al., 2019).
Ustekinumab (Stelara)
Ustekinumab is a human antibody that blocks the effects of two proteins involved in inflammation, interleukin-12 (IL-12) and interleukin-23 (IL-23). It may be self-injected at home or the dermatologist’s office (Hidradenitis Suppurativa Foundation, Inc.).
Those with moderate to severe HS (Zouboulis, et al., 2015).
Those with allergies to adalimumab; with severe infections, multiple sclerosis, or heart failure (Lexicomp).
Those younger than 2 years (Drugs.com).
Caution should be taken in those:
Level of Evidence: Level I
Strength of recommendation: “A” rating
Two 12-week phase 3 trials (N=307 in PIONEER 1 and N=326 in PIONEER 2) showed better response to adalimumab vs. placebo (42% vs. 26% in PIONEER 1 and 59% vs. 28% in PIONEER 2) (Kimball, et al., 2016).
Infliximab (Remicade, Renflexis)
Level of Evidence: Level II
Strength of recommendation: “B” rating
At week 8, greater improvement was observed in moderate to severe HS patients randomized to infliximab (N=15) vs. placebo (N=18).
Placebo patients who crossed over to the infliximab group from weeks 8 to 16 improved similarly to those treated with infliximab from weeks 0 to 8 (Grant, Gonzalez, Montgomery, Cardenas, & Kerdel, 2010).
Etanercept (Enbrel)
Level of Evidence: Level II
Strength of recommendation: “C” rating
Moderate to severe HS patients were randomized to etanercept (N=10) or placebo (N=10) for 12 weeks. All received etanercept for another 12 weeks. No significant improvement between groups was reported at 12 or 24 weeks (Adams, Yankura, Fogelberg, & Anderson, 2010). Other studies reported mixed results.
Golimumab (Simponi, Simponi Aria)
Level of Evidence: Level III
Strength of recommendation: “C” rating
A case reported that HS deteriorated in a female treated with golimumab for 8 months, while lesions disappeared within two months in another case (van der Zee & Prens, 2013; Tursi, 2016).
Anakinra (Kineret)
Level of Evidence: Level II
Strength of recommendation: “B” rating
Hurley stage II or III HS patients were randomized to anakinra or placebo for 12 weeks. Better responses were observed in a larger proportion of those treated with anakinra (7 of 10) vs. placebo (3 of 10) (Tzanetakou, et al., 2016). Other studies reported mixed results.
Ustekinumab (Stelara)
Level of Evidence: Level II
Strength of recommendation: “B” rating
47% of 17 Hurley stage II or III HS patients who received ustekinumab at weeks 0, 4, 16, and 28 improved (Blok, Li, Brodmerkel, Horvátovich, Jonkman, & Horváth, 2016). Other studies reported mixed results.
Serious: Severe infections, cancers, liver damage, immune system disorders, nerve problems (Lexicomp). The use of adalimumab has also been associated with specific cancers in those with Crohn’s disease or ulcerative colitis (Lexicomp).
Other: Headache, nausea, abdominal pain, allergic reaction(s) at the injection/infusion site (Lexicomp).
Pregnancy risk according to the U.S. Food and Drug Administration (FDA):
A blood draw will need to be performed to test for Hepatitis B virus (HBV) and tuberculosis before starting the medication (epocrates).
Skin examinations should be performed, especially in those with increased risk of skin cancer (epocrates).
Adalimumab users should avoid receiving “live” vaccines, as serious infections may develop (Lexicomp).
All recommended vaccines should be current before taking adalimumab (Lexicomp). Non-live influenza vaccination is still recommended annually while on biologics.