Principles of immunomodulatory drug use - what is covered in this topic

This topic includes practical information on a range of immunomodulatory drugs used to treat autoimmune or autoinflammatory disorders, but does not apply to the use of these drugs for other indications (eg as cancer therapy or to prevent transplant rejection). Within this topic, the immunomodulatory drugs are described using the terminology of the Rheumatology guidelines, which is described in Classification of immunomodulatory drugs. However, other names (eg biological medicine, immunosuppressant) are used by other specialties.

The advice in this topic applies to people of all ages. Additional considerations apply when immunomodulatory drugs are used for children and adolescents; see Additional considerations for immunomodulatory drug use in children and adolescents.

Table 1. Classification of immunomodulatory drugs
Immunomodulatory drug class	Drug subclass	Drugs
corticosteroid [NB1]		hydrocortisone methylprednisolone prednisolone (or prednisone)
conventional synthetic DMARD (csDMARD)	PDE-4 inhibitor	apremilast
conventional synthetic DMARD (csDMARD)		azathioprine ciclosporin cyclophosphamide hydroxychloroquine leflunomide mercaptopurine methotrexate mycophenolate sulfasalazine tacrolimus tioguanine
biological or targeted-synthetic DMARD (b/tsDMARD)	B-cell activating factor inhibitors	belimumab
	B-cell antigen CD20 inhibitors	crelizumab rituximab
	CTLA-4 immunoglobulin fusion protein	abatacept
	JAK inhibitors	baricitinib tofacitinib upadacitinib
	IL-1 inhibitors	anakinra canakinumab
	IL-6 inhibitors	tocilizumab
	IL-12 and -23 inhibitors	ustekinumab
	IL-17 inhibitors	bimekizumab ixekizumab secukinumab
	IL-23 inhibitors	guselkumab risankizumab tildrakizumab
	TNF inhibitors	adalimumab certolizumab pegol etanercept golimumab infliximab
	type-1 interferon inhibitor	anifrolumab
Note: CTLA = cytotoxic T-lymphocyte-associated protein; DMARD = disease-modifying antirheumatic drug; JAK = Janus kinase; IL = interleukin; PDE = phosphodiesterase; TNF = tumour necrosis factor NB1: This table lists only those corticosteroids most commonly used to treat autoimmune and autoinflammatory disorders.

Advice includes:

a general approach to managing people taking immunomodulatory drugs, as well as drug-specific considerations for
managing intercurrent infection
preventing infection through screening, antimicrobial prophylaxis and vaccination
reproductive health
perioperative use of immunomodulatory drugs.

For comprehensive drug information, including precautions, contraindications, adverse effects and drug interactions, consult an appropriate drug information resource. Patient medicine information sheets for many of the drugs used in rheumatology can be accessed from the Australian Rheumatology Association website.