Common side-effects:

• Infection (colds, sinusitis, urinary tract infections and skin infections)
• Injection site reactions (bleeding, bruising, redness, itching, pain and swelling)
• Infusion reactions of infliximab: Flushing, Chills, chest tightness,  shortness of breath, hypotension or hypertension (pre-medication given to prevent infusion reactions)
• Headache
• Rash

Uncommon side-effects:

• Severe infections (pneumonia, joint infection, activation of tuberculosis)
• Low blood platelet count
• Localized swelling of the skin or hives
• Lung inflammation 

Rare side-effects:

• Combined low platelet, red and white blood cell count
• Severe muscle weakness
• Seizures

Long term use of anti-TNF may increase the risk of lymphoma and other cancers. You may be more at risk if you are also taking immunosuppressant such as methotrexate and azathioprine.

Patient should be tested for tuberculosis before starting anti-TNF therapy.

Hepatitis B and C testing may be done. Hepatitis B and C infection may get worse during the anti-TNF therapy.

If you have heart problems, as anti-TNF could make your symptoms worse, therefore your heart will need to be monitored closely before and after the treatment.

Come back to the hospital for regular blood test as instructed by your doctor.

Because adverse effects can happen at any time during the course of treatment and some side effects may not cause symptoms, it is really important that you have your regular blood test. This can monitor the side-effects of anti-TNF.

Move the injection site where you give the shot each time.

It may be given by injection under the skin, e.g.: Adalimumab, Etanercept, Certolizumab and Golimumab (administer at home) or by infusion, e.g.: Infliximab (administer in hospital up to 2-4 hours)

Injection under the skin can be injected into the abdomen or thigh.

Starting, maintenance dose and time to effect :

Drug	Usual Dosing Regimen	Time to Effect
Infliximab	Initial: 3-5 mg/kg (Week 0, 2, 6) Maintain: 5-10mg/kg every 4-8 w	2-3 weeks
Adalimumab	40mg every other week	2-3 weeks
Etanercept	50mg once a week	1-2 weeks
Certolizumab	Initial: 400mg (Week 0, 2, 4) Maintain: 200mg every other week	1-2 weeks
Golimumab	50mg once a month	1-2 weeks

Take the missed dose as soon as you remember.

Then take your next injection as you would have on your originally scheduled day.

If it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule.

Do not take a double dose to make up a missed dose.

Keep away from children;#Keep in a cool, dry place, away from direct sunlight;#Store in the refrigerator. Do not freeze.;#After injection, dispose needles in a sharp disposal box. When the box is full, return it to pharmacy or clinic.

Do I skip dose if I am sick?

• Seek prompt advice from your doctor when you develop any of the serious symptoms described above or is being treated with antibiotics for an infection.
• Your doctor will decide whether to stop anti-TNF on a case-by case basis.

When do I seek medical attention IMMEDIATELY?

• Allergic reactions: Rash, hives, blistered, wheezing, chest tightness, trouble breathing, swelling of mouth, face, lips, tongue
• High fever (38°C), chills and very bad sore throat
• Chest pain or pressure
• Shortness of breath or swelling of feet or ankles
• Unusual bruising or bleeding
• Yellow skin or eyes, dark urine, stomach pain

Can I take other MEDICINES or SUPPLEMENTS?

• DMARDs such as methotrexate, hydroxychloroquine, sulfasalazine or leflunomide can be used in combination with anti-TNF.
• Do not start a new drug, over the counter medicines and herbal supplements without informing your doctor.
• You should avoid live vaccine such as live polio, yellow fever, rubella (German measles), MMR (measles, mumps and rubella), typhoid and BCG (tuberculosis).
• Killed vaccines for pneumococcal, influenza, hepatitis B and human papillomavirus should be given to patients receiving anti-TNF therapy.

Can I get PREGNANT or BREASTFEED?

• The evidence about the safety of anti-TNF in pregnancy is still fairly limited.
• Therefore, the use of anti-TNF in pregnant women is not recommended.
• If you are considering having a child, it is important to discuss with your doctor before taking this drug.
• Recent studies have suggested infliximab is usually not detected in breast milk and absorption is unlikely in infants. However, in view of limited evidence, it was suggested not to breastfeed while receiving Infliximab.
• Limited evidence on the drug excretion in breast milk or lack of long term follow up data on infant breastfed while receiving other anti-TNF.

In SUMMARY… what you need to know about anti-TNF?

• Inject anti-TNF following the scheduled interval at home.
• Infliximab infusion is administered in hospital at scheduled interval.
• Always come for your BLOOD TESTS on the scheduled date.
• Beware of the SIDE EFFECTS and when to seek immediate medical attention.
• Never take medicines, supplements or herbal medicines OVER-THE-COUNTER without checking with your doctor or pharmacist first.
• If you intent to start a family, please inform your doctor as anti-TNF may not be appropriate in pregnancy.
• If you have further questions about Anti-TNF, please call ______________________ (office number) to discuss with your doctor / pharmacist / specialty nurse (please circle as appropriate).