What is abatacept?

Abatacept (Orencia™) is a type of drug called a biological therapy. It works by interfering with the function of particular cells (T-cells) in the immune system. This action modifies the inflammation and immune activity which cause the symptoms of rheumatoid arthritis.

It's a long-term treatment, so it may be 6–12 weeks before you start to notice the benefits.

Uses

Abatacept can be prescribed by a rheumatologist for rheumatoid arthritis. It may be the first biological therapy you receive, or you may have tried others first such as an anti-TNF drug or rituximab. It's almost always used in combination with methotrexate.

Are there any reasons why I won't be prescribed abatacept?

Abatacept won't be started if:

Doctors sometimes use a score known as DAS28 to work out how active your arthritis is. This counts how many of 28 specific joints are tender and swollen, and looks at inflammation levels in a blood test. You'll also be asked to score how well you feel on a scale of 0 to 10.

Your doctor may decide not to prescribe abatacept if you're pregnant or breastfeeding, or if:

  • you have an infection or have had repeated infections
  • you're currently taking an anti-TNF drug
  • you've had cancer.

You'll probably have blood tests before treatment starts to assess whether the drug will be suitable for you. Your doctor will need to check if you've previously been exposed to tuberculosis (TB). You may need a course of treatment for latent (asymptomatic) TB.

If you've previously had hepatitis you may need regular checks for this as abatacept may increase the risk of hepatitis being reactivated.

If you're taking other drugs alongside abatacept you'll also need to continue any blood tests required for these.

How is it taken?

Abatacept may be given:

  • either through a drip into a vein (intravenous infusion) which takes 1–2 hours once a month, in hospital or at a special clinic
  • or as an injection under the skin (subcutaneous injection) once a week using a pre-filled syringe or pen. You, your partner, or another family member can learn to give these injections at home.

Speak to your rheumatology team if you're already having abatacept by infusion and wish to switch to injections – you'll probably start your injections when your next infusion is due.

If you're more than three days late taking a dose, ask your rheumatology team for advice on when to take your next dose.

How long does it take to work?

It may be 6–12 weeks before you start to notice the benefits of abatacept. Because it's a long-term treatment, it's important to keep taking abatacept (unless you have severe side-effects):

  • even if it doesn't seem to be working at first
  • even when your symptoms improve (to help keep the disease under control).

Side-effects and risks

Some side-effects can happen around the time of the infusion or injection. The most common are dizziness, headaches and feeling sick (nausea). These aren't usually serious.

Because abatacept affects your immune system (the body's own defence system) you may be more likely to pick up infections. It can also make them harder to spot. The most common are chest and urinary infections, rhinitis and conjunctivitis. Tell your doctor or rheumatology nurse straight away if you develop any of the following symptoms after starting abatacept:

  • a sore throat, fever or persistent cough
  • unexpected weight loss
  • any other new symptoms that concern you.

You should also tell your rheumatology team if you have any of these symptoms before having an infusion or injection. They may advise you to delay the treatment.

You should also see your doctor if you develop chickenpox or shingles or come into contact with someone who has chickenpox or shingles. These illnesses can be severe if you're on abatacept. You may need antiviral treatment and your abatacept may be stopped until you're better.

Some people have an allergic reaction with sudden swelling, a rash or breathlessness. This is very rare, but if you do develop these symptoms, or any other severe symptoms, during or soon after a dose of abatacept you should seek medical advice immediately.

There may be a slightly increased risk of some cancers when using drugs like abatacept which interfere with the immune system, though research hasn't so far confirmed this.

Reducing the risk of infection

Effects on other treatments

You'll probably be taking methotrexate alongside abatacept.

Check with your doctor before starting any new medications, and remember to mention you're on abatacept if you're treated by anyone other than your usual rheumatology team.

It's recommended that you carry a biological therapy alert card, so anyone treating you will know you're on abatacept – ask your rheumatology team for a card.

Vaccinations

It's usually recommended that people on abatacept avoid live vaccines such as yellow fever. However, sometimes a live vaccine may be necessary (for example, rubella vaccination for women of childbearing age).

If you're offered shingles vaccination (Zostavax) it's best if you can have this before starting abatacept. Shingles vaccination isn't recommended for people who are already on abatacept.

Pneumococcal vaccine (which protects against the commonest cause of pneumonia) and yearly flu vaccines are safe and recommended.

Having an operation

Talk this over with your specialists. It's likely you'll be advised to stop abatacept for a time before and after surgery.

Alcohol

There's no known interaction between abatacept and alcohol.

However, if you're also taking methotrexate, this can interact with alcohol and damage your liver – so you should keep within the recommended limits (14 units of alcohol per week for adults). In some circumstances, your doctor may advise a lower limit.

Fertility, pregnancy and breastfeeding

If you're planning to try for a baby, if you become pregnant or if you're thinking of breastfeeding we suggest you discuss your medications with your rheumatologist.

We don't yet know how abatacept might affect an unborn baby but it does not cross the placenta until 16 weeks of pregnancy so it's unlikely to be harmful if taken in the first three months of pregnancy. To be on the safe side, however, women of childbearing age are advised to use contraception while on abatacept. If you're planning to become pregnant, you should continue to use contraception for three months after stopping abatacept. If you're also on methotrexate this should also be stopped at least three months before trying for a baby.

It's also unknown whether abatacept affects men who are trying to father a baby. There's no evidence to suggest that it's harmful but it's probably a good idea for men to take contraceptive precautions for at least three months after stopping treatment. For men who are also taking methotrexate, current guidelines state that this drug doesn't need to be stopped when trying to father a child.

Breastfeeding isn't recommended if you're on abatacept because the effects are unknown. You shouldn't re-start your abatacept until you've stopped breastfeeding.