Anti-TNF medicines, such as adalimumab, etanercept and infliximab, act against a protein in the blood called Tissue Necrosis Factor Alpha (TNFα). This protein can cause inflammation when it is present in large amounts in the blood.
Anti-TNF medicines remove this protein from the blood circulation, which in turn, should reduce inflammation. An added benefit of these medicines is that they appear to stimulate the body to repair the damage that has happened previously.
At Great Ormond Street Hospital (GOSH), these are supplied as a single-dose prefilled syringe under the brand name Humira®. We will teach you how to give the injections at GOSH but this information page should act as a reminder.
What is a subcutaneous injection?
A subcutaneous injection is given into the subcutaneous fat under the skin. The skin is made up of different layers. Underneath the epidermis and dermis, which contain sweat glands and hair follicles, is a layer of fat. This is the area into which subcutaneous injections are given.
Preparing the syringe
1. On a clean, flat area, collect together all the equipment you will need:
pre-filled syringe of adalimumab
cotton wool or gauze
site rotation chart
2. Holding the syringe upright with the needle facing downwards, confirm that:
the dosage tray and syringe are labelled Humira®
the expiry date has not passed
the liquid in the syringe is clear and colourless
the liquid in the syringe is the same or close to the 0.8ml line for the 40mg pre-filled syringe
3. Wash your hands thoroughly with soap and water.
4. Choose the injection site for this dose and clean it with the alcohol wipe.
5. Remove the needle cover without touching the needle with your fingers or on any surface.
6. Holding the needle upwards, tap the syringe gently to move any air bubbles towards the needle.
7. Push the plunger gently to remove the air bubble and squirt a small amount of the medicine into the air.
Giving the injection
1. Lift the skin in the chosen injection site between your thumb and index finger.
2. Holding the needle at a 45° angle, insert the needle into the skin fold quickly using a dartlike motion.
3. Once the needle has been inserted, let go of the skin.
4. Pull back slightly on the syringe plunger.
If you see blood, remove the needle from the skin and start again at a new site.
If you do not see blood, push the syringe plunger to inject all of the medicine.
5. Remove the needle from the skin at the same angle it was inserted.
6. Put a piece of cotton wool or gauze over the injection site and press for 10 seconds.
7. Do not rub the injection site. The area may bleed a little but this is normal.
8. Throw the syringe away in the sharps container as you have been taught.
9. Mark the injection site on your site rotation chart.
You should call your healthcare provider
If you have any questions about this information, any of the common side effects occur or if your child’s symptoms do not improve after taking this medicine.
If you suspect an overdose, take your child to the nearest Accident and Emergency department immediately.
If your child shows any signs of a life-threatening reaction, call for an ambulance immediately. Signs include wheezing, chest tightness, fever, itching, bad cough, blue skin colour, fits, swelling of face, lips, tongue or throat or if your child shows any other unusual behaviour.
If your child shows any signs of infection, including a fever of 39°C or more, chills, severe sore throat, ear or sinus pain, cough, increased sputum or different coloured sputum, painful urination, mouth sores, wound healing problems or anal itching or pain.
If your child has difficulty breathing, a severe headache or develops a rash.
What do I do when the sharps container is full?
When we taught you how to give subcutaneous injections, we will have explained about disposal of the syringes. We will give you a sharps container to take home with you but when it is full, please call your community team to ask them to dispose of it and give you a new one. All other packaging, such as the syringe package and cotton wool can be disposed of with your normal household rubbish.
What are the side effects of adalimumab?
If any of these side effects are severe or carry on for a long time, please tell your doctor.
skin reactions affecting the injection site
headache or tummy ache
mild viral infection
Rarely, children develop eye inflammation (uveitis) or a temporary form of lupus (an auto-immune disorder, where the immune system attacks healthy tissue instead of foreign invaders such as bacteria and viruses).
If your child develops a rash or has a severe allergic reaction to the injection, please contact your doctor immediately and do not give any further doses.
Important information about anti-TNF medicines
Chicken pox or tuberculosis
If your child has not had chicken pox or tuberculosis and is in direct contact with a child who has it or develops it within 48 hours, you must contact the hospital immediately. Chicken pox and tuberculosis can be more severe in children who are taking anti- TNF medicines. A blood test will be arranged to check your child’s antibodies to chicken pox and tuberculosis. Your child may need an injection to protect him or her. Your doctor or nurse will discuss this with you. If your child has chicken pox, it may be necessary to stop your child’s treatment for a short while. Your doctor will discuss this with you.
As anti-TNF medicines affect your child’s immune system, children and young people taking these medicines should not be given any ‘live’ vaccines. However, children may be very ill if they catch one of the vaccine preventable diseases, so it is important that they are up to date with the other vaccines.
Your other children should be immunised according to the usual schedule and although chicken pox vaccine is not routinely given to all children, it may be advisable for the siblings or other close family members of a child who is receiving anti-TNF medicines. If you have any questions about immunisations, please ask your doctor.
Anti-TNF medicines can leave your child more prone to developing food-borne infections, such as listeria and salmonella. It is important to follow a few simple rules to reduce this risk. Your child should not eat: raw or undercooked eggs, rare or undercooked poultry, meat or fish and unpasteurised milk and cheeses.
We recommend that your child carries a biological therapy alert card at all times. This could be important if your child needs emergency treatment for any reason.
Risk to the unborn child
Biologic medicines may harm the unborn child. If your daughter is ten years old or older, we will ask her about her periods and any possibility that she could be pregnant before starting the course. Once she has started and for three months after finishing the course, she must use reliable precautions against becoming pregnant, like condoms, the Pill or other barrier methods. Boys must also use reliable precautions, such as condoms, while taking these medicines.
Please read this information sheet from GOSH alongside the patient information leaflet (PIL) provided by the manufacturer. If you do not have a copy of the manufacturer’s patient information leaflet please talk to your pharmacist. A few products do not have a marketing authorisation (licence) as a medicine and therefore there is no PIL.
For children in particular, there may be conflicts of information between the manufacturer’s patient information leaflet (PIL) and guidance provided by GOSH and other healthcare providers. For example, some manufacturers may recommend, in the patient information leaflet, that a medicine is not given to children aged under 12 years. In most cases, this is because the manufacturer will recruit adults to clinical trials in the first instance and therefore the initial marketing authorisation (licence) only covers adults and older children.
For new medicines, the manufacturer then has to recruit children and newborns into trials (unless the medicine is not going to be used in children and newborns) and subsequently amend the PIL with the approved information. Older medicines may have been used effectively for many years in children without problems but the manufacturer has not been required to collect data and amend the licence. This does not mean that it is unsafe for children and young people to be prescribed such a medicine ‘off-licence/off-label’. However, if you are concerned about any conflicts of information, please discuss with your doctor, nurse or pharmacist.