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Biologic DMARD (TNF-alpha inhibitor, monoclonal antibody) Pregnancy: Can be used if essential (lowest effective dose). Avoid in third trimester (risk of neonatal immunosuppression — no live vaccines to neonate for 6 months).

Adalimumab

Brand names: Humira, Amgevita, Hyrimoz (biosimilars)

Adult dose

Dose: RA: 40 mg every 2 weeks SC; Psoriatic arthritis/AS: 40 mg every 2 weeks SC; Crohn's/UC: different induction/maintenance protocols
Route: Subcutaneous injection
Frequency: Every 2 weeks (RA/PsA/AS); weekly if inadequate response (RA — with MTX)
Max: 40 mg per dose (standard); 40 mg weekly in some indications
RA: 40 mg SC every 2 weeks (with or without MTX). Can increase to weekly if inadequate response. Induction for IBD: 160 mg week 0, 80 mg week 2, then 40 mg every 2 weeks. Inject into thigh or abdomen (rotate sites). Refrigerate — allow to reach room temperature before injection.

Paediatric dose

Route: SC
Frequency: Every 2 weeks
Max: 20 mg per dose (<30 kg); 40 mg per dose (≥30 kg)
Concentration: 50 mg/ml
JIA (≥2 years): 24 mg/m² every 2 weeks (max 40 mg). Paediatric Crohn's (≥6 years): 160/80 mg induction then weight-based maintenance. Paediatric psoriasis (≥4 years): 0.8 mg/kg (max 40 mg) every 2 weeks.

Dose adjustments

Renal

No dose adjustment required.

Hepatic

Use with caution in moderate-severe hepatic impairment.

Clinical pearls

  • Screen for latent TB (IGRA and CXR) before starting — treat latent TB first
  • Screen for hepatitis B (HBsAg, HBcAb) before starting
  • Withdraw 3–5 half-lives before surgery (adalimumab ~2 weeks)
  • No live vaccines during treatment or within 3 months of stopping
  • Biosimilars (Amgevita, Hyrimoz) equally effective and significantly cheaper — prescribe by brand

Contraindications

  • Active infections (including TB, sepsis, opportunistic infections)
  • Moderate-severe heart failure (NYHA III-IV)
  • History of demyelinating disease
  • Untreated latent TB (treat first)
  • Live vaccines during treatment

Side effects

  • Injection site reactions
  • Increased infection risk (bacterial, TB reactivation, viral, fungal, opportunistic)
  • Demyelinating disease (rare)
  • Worsening heart failure
  • Lupus-like syndrome
  • Lymphoma and other malignancies (increased risk with prolonged use)
  • Hepatitis B reactivation

Interactions

  • Anakinra and abatacept — increased infection risk (avoid combination)
  • Live vaccines — contraindicated (do not give while on biologic)
  • Azathioprine/MTX — used in combination for IBD (adequate efficacy)

Monitoring

  • FBC, LFTs, U&E before each biological cycle
  • TB and hepatitis B screening at baseline
  • Annual CXR in endemic areas
  • Signs of infection

Reference: BNFc; BNF; NICE TA715/TA130; BSR Biologic DMARD Guidelines 2021. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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