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Anti-TNF Contraindication — SCE Rheumatology MCQ

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ModerateRheumatology PharmacologyAnti-TNF ContraindicationSCE Rheumatology

A 55-year-old woman with rheumatoid arthritis has been receiving adalimumab. She develops progressive exertional dyspnoea, orthopnoea and bilateral ankle oedema. Echocardiography demonstrates new left ventricular systolic dysfunction with an ejection fraction of 35%. What is the most appropriate action regarding her biologic therapy?

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Correct answer: E — Discontinue adalimumab and arrange assessment and treatment of the heart failure

Adalimumab should be discontinued because she has developed new symptomatic congestive heart failure during treatment. The UK SmPC mandates discontinuation when new or worsening heart-failure symptoms occur. It separately advises caution in NYHA class I–II disease and lists NYHA class III–IV heart failure as a contraindication; an ejection fraction of 35% alone does not establish NYHA class. Continuing treatment or increasing the dose therefore conflicts with the prescribing information. Infliximab is also a TNF inhibitor, so switching directly to it does not avoid the relevant class concern. Adding abatacept while continuing adalimumab would expose her to dual biologic therapy, which is not recommended because of increased toxicity, particularly serious infection. Subsequent non-TNF rheumatoid arthritis therapy should be selected after cardiac assessment.

Reference: AbbVie Ltd. Humira 40 mg solution for injection in pre-filled pen, Summary of Product Characteristics, sections 4.3 and 4.4: Congestive heart failure. Revised February 2026. https://www.medicines.org.uk/emc/product/7986/smpc