TNF Blockers for Rheumatic Diseases: Laboratory Support of Management

TNF Blockers for Rheumatic Diseases: Laboratory Support of Management

This Clinical Focus provides information about laboratory tests related to TNF blockers when used to treat rheumatic diseases.

See also 8 related tests 0 related guides Test Guide List

TNF Blockers for Rheumatic Diseases, Drug and Anti-drug Antibody Levels: Laboratory Support of Management

Clinical Focus

 

TNF Blockers for Rheumatic Diseases

Laboratory Support of Management

Contents:

Clinical background

Individuals suitable for testing

Test availability

Test selection

Test interpretation

References

Clinical background [return to contents]

Tumor necrosis factor (TNF) blockers, such as adalimumab (Humira®), infliximab (Remicade®), and the infliximab biosimilar infliximab-dyyb (Inflectra®), are therapeutic antibody drugs used to treat rheumatic diseases (eg, rheumatoid arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis) and inflammatory bowel disease (ie, Crohn disease, ulcerative colitis).1–3 TNF blockers work by reducing the TNF-mediated inflammation typical of these diseases.1 However, they do not work for all patients. In rheumatoid arthritis, for example, only 50% to 70% of TNF blocker–treated patients achieve an ACR20 response (≥20% improvement as defined by the American College of Rheumatology), and fewer achieve ACR50 (30%-40%) and ACR70 (15%-25%) responses.4

When patients do not respond (primary failure) or lose their initial response (secondary failure) to TNF blocker treatment, laboratory tests can help identify the cause of failure and guide changes in treatment. Laboratory tests are also useful for patients with rheumatic diseases who are starting or being considered for treatment with TNF blocker treatment to (1) help identify infections that may pose risks for patients using TNF blockers and (2) help identify patients unlikely to respond to TNF blockers.

This Clinical Focus provides an overview of laboratory tests useful in the management of rheumatic diseases with TNF blockers. This material is provided for educational purposes only and is not intended as medical advice. Test selection and interpretation, diagnosis, and patient management decisions should be based on the physician’s education, clinical expertise, and assessment of the patient.

Individuals suitable for testing [return to contents]

  • Individuals with a rheumatic disease who are starting or being considered for treatment with a TNF blocker
  • Individuals with a rheumatic disease who have experienced treatment failure with adalimumab, infliximab, or the infliximab biosimilar infliximab-dyyb

Test availability [return to contents]

Quest Diagnostics offers tests that are useful before and during TNF blocker treatment for patients with rheumatic diseases (Table 1).

Table 1. Tests Available for Management of Rheumatic Diseases With TNF Blockers [return to contents]

Test code

Test name

Clinical use

36295

Adalimumab Anti-drug Antibody for Rheumatic Diseasesa

Determine presence of antibodies to adalimumab

36297

Adalimumab Level and Anti-drug Antibody for Rheumatic Diseasesa

Determine adalimumab levels and presence of antibodies to adalimumab

36299

Adalimumab Level for Rheumatic Diseasesa

Determine adalimumab levels

36301

Infliximab Anti-drug Antibodya,b

Determine presence of antibodies to infliximab and infliximab-dyyb (Inflectra®)

36311

Infliximab Level and Anti-drug Antibodya,b

Determine infliximab and infliximab-dyyb levels and presence of antibodies to infliximab and infliximab-dyyb (Inflectra®)

36303

Infliximab Levela,b

Determine infliximab and infliximab-dyyb (Inflectra®) levels

37616

Pre-biologic/biosimilar Screen Panel, HCV/HBV with Reflexes and QFT 1 Tubec,d

Includes HBV surface antigen with reflex confirmation (test code 498); HBV surface antibody immunity, quantitative (test code 8475); HBV core antibody, total, with reflex to IgM (test code 37676); HCV antibody with reflex to HCV RNA, PCR, with reflex to genotype, LiPA® (test code 94345); and QuantiFERON®-TB Gold Plus, 1 tube (test code 36970)

Detect HBV, HCV, and TB infections prior to starting biologic therapy

37620

Pre-biologic/biosimilar Screen Panel, HCV/HBV with Reflexes and QFT 4 Tubesc,d

Includes HBV surface antigen with reflex confirmation (test code 498); HBV surface antibody immunity, quantitative (test code 8475); HBV core antibody, total, with reflex to IgM (test code 37676); HCV antibody with reflex to HCV RNA, PCR, with reflex to genotype, LiPA® (test code 94345); and QuantiFERON®-TB Gold Plus, 4 tubes, draw-site incubated (test code 36971)

Detect HBV, HCV, and TB infections prior to starting biologic therapy

12943

PrismRA® (Performed/Billed by Scipher Medicine, Orderable Through Quest)

Determine likelihood of inadequate response to TNF blocker treatment for patients with rheumatoid arthritise
HBV, hepatitis B virus; HCV, hepatitis C virus; LiPA, line probe assay; PCR, polymerase chain reaction; QFT, QuantiFERON-TB; TB, tuberculosis.
a This test was developed and its analytical performance characteristics have been determined by Quest Diagnostics. It has not been cleared or approved by the US Food and Drug Administration. This assay has been validated pursuant to the CLIA regulations and is used for clinical purposes.
b Infliximab assays are validated for the infliximab biosimilar infliximab-dyyb with no analytical differences between these drugs.
c Reflex tests are performed at an additional charge and are associated with an additional CPT code.
d Panel components may be ordered separately.
e For more information about PrismRA®, see the Quest Diagnostics Test Directory.

 

Test selection [return to contents]

Pre-biologic/biosimilar screen panels

TNF blockers can suppress immunity and increase the risk of new or reactivated infections, most notably tuberculosis and hepatitis B and C. Before starting treatment with a TNF blocker, screening patients for these infections (test codes 37616, 37620) is recommended.5–7

Drug and drug antibody tests

When TNF blocker treatment fails, a physician may need to consider adjusting the dose or dosing interval, switching to a different TNF blocker, or switching to a non–TNF blocker. Strategies for addressing treatment failure include

  • Empiric dose escalation: increasing the dose as a first response to failure
  • Testing-based strategy: using drug and/or drug antibody levels to guide therapy changes

American clinical practice guidelines have not recommended one strategy over the other, but recent guidance from the European League Against Rheumatism states that a testing-based strategy should be considered in the event of TNF blocker treatment failure.8 Additionally, a meta-analysis found that testing-based strategies are associated with lower costs and the same or better clinical outcomes as empiric strategies.9

In a testing-based strategy, drug level testing indicates drug bioavailability and antidrug antibody (ADA) testing can help differentiate causes of insufficient bioavailability. Drug levels are typically measured just before administration of the next dose to determine whether the trough level is therapeutic or subtherapeutic.10 ADA levels are measured when ADAs are suspected to cause subtherapeutic drug levels.11 ADAs are reported to form in up to 69% of TNF blocker–treated patients. They can reduce drug levels (and thus, treatment effectiveness) by forming ADA-drug complexes that accelerate drug clearance or by directly preventing the drug from binding TNF.10,12

Quest offers the following options for drug and ADA level testing:

  • Testing drug levels only (test codes 36299, 36303), which may be appropriate if sequential testing is preferred to concurrent testing
  • Testing ADA levels only (test codes 36295, 36301), which may be appropriate if insufficient bioavailability has already been established
  • Testing drug and ADA levels together (test codes 36297, 36311), which may help identify the cause of treatment failure more quickly

Tests for drug and ADA levels are enzyme-linked immunosorbent assays (ELISA). Quest assays test for total (ie, free and bound) ADA, which makes them less prone to interference by the active drug than assays that can only detect free ADA.11 Some ELISA-based assays for adalimumab or infliximab ADAs are susceptible to cross-reactivity with rheumatoid factor, which can lead to inaccurate results, but the ADA ELISAs developed by Quest appear not to be affected by the presence of rheumatoid factor.

Test interpretation [return to contents]

Pre-biologic/biosimilar screen panels

Positive test results for tuberculosis or hepatitis B or C indicate the presence of an infection, which may need treatment before starting TNF blocker therapy.5–7

Drug and drug antibody tests

Higher trough drug levels correlate with better therapeutic response, but optimal drug levels for patients with rheumatic diseases have not yet been established.8 ADA levels ≥10 AU indicate detectable serum levels, whereas levels <10 AU are reported as “not detected.”

Therapeutic drug levels in the context of treatment failure usually suggest that a patient’s disease is not driven by TNF, in which case, switching to a treatment with a different mechanism of action may be appropriate10,11 (Table 2). Subtherapeutic drug levels, on the other hand, can indicate different types of issues depending on whether ADAs are detected.11 Subtherapeutic trough levels in the absence of ADAs may indicate nonimmune or pharmacokinetic (ie, adherence, distribution, metabolism, and excretion) issues, including poor adherence to treatment or accelerated drug clearance caused by nonimmune mechanisms.10,11 These issues can therefore be managed by addressing adherence issues, increasing the dose, or shortening the dosing interval.10,11 Subtherapeutic trough levels in the presence of ADAs may indicate that immunogenicity is causing treatment failure, in which case, switching to a different TNF blocker may be appropriate.10,11

Table 2. Interpretation of Results in Patients With TNF Blocker Treatment Failurea [return to contents]

 

ADAs not detected (absent)

ADAs detected (present)

Drug levels subtherapeutic10,11

  • Suggests insufficient bioavailability caused by nonimmune pharmacokinetic or adherence issues
  • Consider increasing the dose or addressing adherence issues
  • Suggests insufficient bioavailability caused by immunogenicity
  • Consider switching to a different TNF blocker

Drug levels therapeutic
  • Suggests pharmacodynamic issue caused by TNF-independent disease
  • Consider switching to a non-TNF treatment
  • Rare situation that may be caused by a false-positive result or nonfunctional ADAs
  • Consider retesting or testing for neutralizing antibody by cell-based assay
ADA, antidrug antibody; TNF, tumor necrosis factor.
a Test interpretation for infliximab assays applies to both infliximab and infliximab-dyyb.

References [return to contents]

  1. HUMIRA® (adalimumab). Prescribing information. AbbVie Inc; 2024. Accessed March 18, 2024. https://www.rxabbvie.com/pdf/humira.pdf
  2. Remicade® (infliximab). Prescribing information. Janssen Inc; 2021. Accessed April 2, 2024. https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/REMICADE-pi.pdf
  3. Inflectra® (infliximab-dyyb). Prescribing information. Pfizer Inc; 2023. Accessed April 2, 2024. https://labeling.pfizer.com/ShowLabeling.aspx?format=PDF&id=9271
  4. Cohen S, Wells AF, Curtis JR, et al. A molecular signature response classifier to predict inadequate response to tumor necrosis factor-α inhibitors: the NETWORK-004 prospective observational study. Rheumatol Ther. 2021;8(3):1159-1176. doi:10.1007/s40744-021-00330-y
  5. Conley B, Bunzli S, Bullen J, et al. What are the core recommendations for rheumatoid arthritis care? systematic review of clinical practice guidelines. Clin Rheumatol. 2023;42(9):2267-2278. doi:10.1007/s10067-023-06654-0
  6. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924-939. doi:10.1002/acr.24596
  7. Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2016;68(1):1-25. doi:10.1002/acr.22783
  8. Krieckaert CL, van Tubergen A, Gehin JE, et al. EULAR points to consider for therapeutic drug monitoring of biopharmaceuticals in inflammatory rheumatic and musculoskeletal diseases. Ann Rheum Dis. 2023;82(1):65-73. doi:10.1136/annrheumdis-2022-222155
  9. Dong W, Hu X, Wu C, et al. Efficacy, safety, and cost-effectiveness of therapeutic drug monitoring (TDM) for TNF inhibitor therapy in rheumatic disease: a systematic review and meta-analysis. Semin Arthritis Rheum. 2023;63:152302. doi:10.1016/j.semarthrit.2023.152302
  10. Strand V, Goncalves J, Isaacs JD. Immunogenicity of biologic agents in rheumatology. Nat Rev Rheumatol. 2021;17(2):81-97. doi:10.1038/s41584-020-00540-8
  11. Mehta P, Manson JJ. What is the clinical relevance of TNF inhibitor immunogenicity in the management of patients with rheumatoid arthritis? Front Immunol. 2020;11:589. doi:10.3389/fimmu.2020.00589
  12. Pizano-Martinez O, Mendieta-Condado E, Vázquez-Del Mercado M, et al. Anti-drug antibodies in the biological therapy of autoimmune rheumatic diseases. J Clin Med. 2023;12(9):3271. doi:10.3390/jcm12093271
     

Content reviewed 07/2024

top of page

This Clinical Focus provides information about laboratory tests related to TNF blockers when used to treat rheumatic diseases.

Test Guide List

TNF Blockers for Rheumatic Diseases, Drug and Anti-drug Antibody Levels: Laboratory Support of Management

Clinical Focus

 

TNF Blockers for Rheumatic Diseases

Laboratory Support of Management

Contents:

Clinical background

Individuals suitable for testing

Test availability

Test selection

Test interpretation

References

Clinical background [return to contents]

Tumor necrosis factor (TNF) blockers, such as adalimumab (Humira®), infliximab (Remicade®), and the infliximab biosimilar infliximab-dyyb (Inflectra®), are therapeutic antibody drugs used to treat rheumatic diseases (eg, rheumatoid arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis) and inflammatory bowel disease (ie, Crohn disease, ulcerative colitis).1–3 TNF blockers work by reducing the TNF-mediated inflammation typical of these diseases.1 However, they do not work for all patients. In rheumatoid arthritis, for example, only 50% to 70% of TNF blocker–treated patients achieve an ACR20 response (≥20% improvement as defined by the American College of Rheumatology), and fewer achieve ACR50 (30%-40%) and ACR70 (15%-25%) responses.4

When patients do not respond (primary failure) or lose their initial response (secondary failure) to TNF blocker treatment, laboratory tests can help identify the cause of failure and guide changes in treatment. Laboratory tests are also useful for patients with rheumatic diseases who are starting or being considered for treatment with TNF blocker treatment to (1) help identify infections that may pose risks for patients using TNF blockers and (2) help identify patients unlikely to respond to TNF blockers.

This Clinical Focus provides an overview of laboratory tests useful in the management of rheumatic diseases with TNF blockers. This material is provided for educational purposes only and is not intended as medical advice. Test selection and interpretation, diagnosis, and patient management decisions should be based on the physician’s education, clinical expertise, and assessment of the patient.

Individuals suitable for testing [return to contents]

  • Individuals with a rheumatic disease who are starting or being considered for treatment with a TNF blocker
  • Individuals with a rheumatic disease who have experienced treatment failure with adalimumab, infliximab, or the infliximab biosimilar infliximab-dyyb

Test availability [return to contents]

Quest Diagnostics offers tests that are useful before and during TNF blocker treatment for patients with rheumatic diseases (Table 1).

Table 1. Tests Available for Management of Rheumatic Diseases With TNF Blockers [return to contents]

Test code

Test name

Clinical use

36295

Adalimumab Anti-drug Antibody for Rheumatic Diseasesa

Determine presence of antibodies to adalimumab

36297

Adalimumab Level and Anti-drug Antibody for Rheumatic Diseasesa

Determine adalimumab levels and presence of antibodies to adalimumab

36299

Adalimumab Level for Rheumatic Diseasesa

Determine adalimumab levels

36301

Infliximab Anti-drug Antibodya,b

Determine presence of antibodies to infliximab and infliximab-dyyb (Inflectra®)

36311

Infliximab Level and Anti-drug Antibodya,b

Determine infliximab and infliximab-dyyb levels and presence of antibodies to infliximab and infliximab-dyyb (Inflectra®)

36303

Infliximab Levela,b

Determine infliximab and infliximab-dyyb (Inflectra®) levels

37616

Pre-biologic/biosimilar Screen Panel, HCV/HBV with Reflexes and QFT 1 Tubec,d

Includes HBV surface antigen with reflex confirmation (test code 498); HBV surface antibody immunity, quantitative (test code 8475); HBV core antibody, total, with reflex to IgM (test code 37676); HCV antibody with reflex to HCV RNA, PCR, with reflex to genotype, LiPA® (test code 94345); and QuantiFERON®-TB Gold Plus, 1 tube (test code 36970)

Detect HBV, HCV, and TB infections prior to starting biologic therapy

37620

Pre-biologic/biosimilar Screen Panel, HCV/HBV with Reflexes and QFT 4 Tubesc,d

Includes HBV surface antigen with reflex confirmation (test code 498); HBV surface antibody immunity, quantitative (test code 8475); HBV core antibody, total, with reflex to IgM (test code 37676); HCV antibody with reflex to HCV RNA, PCR, with reflex to genotype, LiPA® (test code 94345); and QuantiFERON®-TB Gold Plus, 4 tubes, draw-site incubated (test code 36971)

Detect HBV, HCV, and TB infections prior to starting biologic therapy

12943

PrismRA® (Performed/Billed by Scipher Medicine, Orderable Through Quest)

Determine likelihood of inadequate response to TNF blocker treatment for patients with rheumatoid arthritise
HBV, hepatitis B virus; HCV, hepatitis C virus; LiPA, line probe assay; PCR, polymerase chain reaction; QFT, QuantiFERON-TB; TB, tuberculosis.
a This test was developed and its analytical performance characteristics have been determined by Quest Diagnostics. It has not been cleared or approved by the US Food and Drug Administration. This assay has been validated pursuant to the CLIA regulations and is used for clinical purposes.
b Infliximab assays are validated for the infliximab biosimilar infliximab-dyyb with no analytical differences between these drugs.
c Reflex tests are performed at an additional charge and are associated with an additional CPT code.
d Panel components may be ordered separately.
e For more information about PrismRA®, see the Quest Diagnostics Test Directory.

 

Test selection [return to contents]

Pre-biologic/biosimilar screen panels

TNF blockers can suppress immunity and increase the risk of new or reactivated infections, most notably tuberculosis and hepatitis B and C. Before starting treatment with a TNF blocker, screening patients for these infections (test codes 37616, 37620) is recommended.5–7

Drug and drug antibody tests

When TNF blocker treatment fails, a physician may need to consider adjusting the dose or dosing interval, switching to a different TNF blocker, or switching to a non–TNF blocker. Strategies for addressing treatment failure include

  • Empiric dose escalation: increasing the dose as a first response to failure
  • Testing-based strategy: using drug and/or drug antibody levels to guide therapy changes

American clinical practice guidelines have not recommended one strategy over the other, but recent guidance from the European League Against Rheumatism states that a testing-based strategy should be considered in the event of TNF blocker treatment failure.8 Additionally, a meta-analysis found that testing-based strategies are associated with lower costs and the same or better clinical outcomes as empiric strategies.9

In a testing-based strategy, drug level testing indicates drug bioavailability and antidrug antibody (ADA) testing can help differentiate causes of insufficient bioavailability. Drug levels are typically measured just before administration of the next dose to determine whether the trough level is therapeutic or subtherapeutic.10 ADA levels are measured when ADAs are suspected to cause subtherapeutic drug levels.11 ADAs are reported to form in up to 69% of TNF blocker–treated patients. They can reduce drug levels (and thus, treatment effectiveness) by forming ADA-drug complexes that accelerate drug clearance or by directly preventing the drug from binding TNF.10,12

Quest offers the following options for drug and ADA level testing:

  • Testing drug levels only (test codes 36299, 36303), which may be appropriate if sequential testing is preferred to concurrent testing
  • Testing ADA levels only (test codes 36295, 36301), which may be appropriate if insufficient bioavailability has already been established
  • Testing drug and ADA levels together (test codes 36297, 36311), which may help identify the cause of treatment failure more quickly

Tests for drug and ADA levels are enzyme-linked immunosorbent assays (ELISA). Quest assays test for total (ie, free and bound) ADA, which makes them less prone to interference by the active drug than assays that can only detect free ADA.11 Some ELISA-based assays for adalimumab or infliximab ADAs are susceptible to cross-reactivity with rheumatoid factor, which can lead to inaccurate results, but the ADA ELISAs developed by Quest appear not to be affected by the presence of rheumatoid factor.

Test interpretation [return to contents]

Pre-biologic/biosimilar screen panels

Positive test results for tuberculosis or hepatitis B or C indicate the presence of an infection, which may need treatment before starting TNF blocker therapy.5–7

Drug and drug antibody tests

Higher trough drug levels correlate with better therapeutic response, but optimal drug levels for patients with rheumatic diseases have not yet been established.8 ADA levels ≥10 AU indicate detectable serum levels, whereas levels <10 AU are reported as “not detected.”

Therapeutic drug levels in the context of treatment failure usually suggest that a patient’s disease is not driven by TNF, in which case, switching to a treatment with a different mechanism of action may be appropriate10,11 (Table 2). Subtherapeutic drug levels, on the other hand, can indicate different types of issues depending on whether ADAs are detected.11 Subtherapeutic trough levels in the absence of ADAs may indicate nonimmune or pharmacokinetic (ie, adherence, distribution, metabolism, and excretion) issues, including poor adherence to treatment or accelerated drug clearance caused by nonimmune mechanisms.10,11 These issues can therefore be managed by addressing adherence issues, increasing the dose, or shortening the dosing interval.10,11 Subtherapeutic trough levels in the presence of ADAs may indicate that immunogenicity is causing treatment failure, in which case, switching to a different TNF blocker may be appropriate.10,11

Table 2. Interpretation of Results in Patients With TNF Blocker Treatment Failurea [return to contents]

 

ADAs not detected (absent)

ADAs detected (present)

Drug levels subtherapeutic10,11

  • Suggests insufficient bioavailability caused by nonimmune pharmacokinetic or adherence issues
  • Consider increasing the dose or addressing adherence issues
  • Suggests insufficient bioavailability caused by immunogenicity
  • Consider switching to a different TNF blocker

Drug levels therapeutic
  • Suggests pharmacodynamic issue caused by TNF-independent disease
  • Consider switching to a non-TNF treatment
  • Rare situation that may be caused by a false-positive result or nonfunctional ADAs
  • Consider retesting or testing for neutralizing antibody by cell-based assay
ADA, antidrug antibody; TNF, tumor necrosis factor.
a Test interpretation for infliximab assays applies to both infliximab and infliximab-dyyb.

References [return to contents]

  1. HUMIRA® (adalimumab). Prescribing information. AbbVie Inc; 2024. Accessed March 18, 2024. https://www.rxabbvie.com/pdf/humira.pdf
  2. Remicade® (infliximab). Prescribing information. Janssen Inc; 2021. Accessed April 2, 2024. https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/REMICADE-pi.pdf
  3. Inflectra® (infliximab-dyyb). Prescribing information. Pfizer Inc; 2023. Accessed April 2, 2024. https://labeling.pfizer.com/ShowLabeling.aspx?format=PDF&id=9271
  4. Cohen S, Wells AF, Curtis JR, et al. A molecular signature response classifier to predict inadequate response to tumor necrosis factor-α inhibitors: the NETWORK-004 prospective observational study. Rheumatol Ther. 2021;8(3):1159-1176. doi:10.1007/s40744-021-00330-y
  5. Conley B, Bunzli S, Bullen J, et al. What are the core recommendations for rheumatoid arthritis care? systematic review of clinical practice guidelines. Clin Rheumatol. 2023;42(9):2267-2278. doi:10.1007/s10067-023-06654-0
  6. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924-939. doi:10.1002/acr.24596
  7. Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2016;68(1):1-25. doi:10.1002/acr.22783
  8. Krieckaert CL, van Tubergen A, Gehin JE, et al. EULAR points to consider for therapeutic drug monitoring of biopharmaceuticals in inflammatory rheumatic and musculoskeletal diseases. Ann Rheum Dis. 2023;82(1):65-73. doi:10.1136/annrheumdis-2022-222155
  9. Dong W, Hu X, Wu C, et al. Efficacy, safety, and cost-effectiveness of therapeutic drug monitoring (TDM) for TNF inhibitor therapy in rheumatic disease: a systematic review and meta-analysis. Semin Arthritis Rheum. 2023;63:152302. doi:10.1016/j.semarthrit.2023.152302
  10. Strand V, Goncalves J, Isaacs JD. Immunogenicity of biologic agents in rheumatology. Nat Rev Rheumatol. 2021;17(2):81-97. doi:10.1038/s41584-020-00540-8
  11. Mehta P, Manson JJ. What is the clinical relevance of TNF inhibitor immunogenicity in the management of patients with rheumatoid arthritis? Front Immunol. 2020;11:589. doi:10.3389/fimmu.2020.00589
  12. Pizano-Martinez O, Mendieta-Condado E, Vázquez-Del Mercado M, et al. Anti-drug antibodies in the biological therapy of autoimmune rheumatic diseases. J Clin Med. 2023;12(9):3271. doi:10.3390/jcm12093271
     

Content reviewed 07/2024

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Reference ranges are provided as general guidance only. To interpret test results use the reference range in the laboratory report.

The tests listed by specialty and category are a select group of tests offered. For a complete list of Quest Diagnostics tests, please adjust the filter options chosen, or refer to our Directory of Services.