Smoking and Biologics

My rheumy is adamant that the reason I failed my first biologic (Enbrel) and the reason I am not getting the full effects from my second (Humira) is because I am a smoker. She agreed to increase my injections to every 10 days but only for a couple months time because she believes it is too risky to stay on increased doses for longer than that in general, her reasoning has nothing to do with my personal response to it. This is obviously a habit that is not helping my health in many ways (duh) but I have trouble believing my failure to fully “recover” with bios is only because I smoke. I have tried multiple times to search studies that usually are only 100% useful for RA. Has anyone else found any info on this? I am going to start really working on this since I have not found the proper mix or dose of meds since diagnosis which is over a year and a half now. I am beyond frustrated with advocating everything to my rheumy, trying med after med, and trying to pretend I am where I should be after such a long time that if I have to quit I will. I guess I have just never seen this discussed and am sick of being told I feel this way because of something…weight…smoking… Diet…stress…Shoes…blah…blah…
Does everyone that failed a bio smoke?

I'm very sceptical about this alleged cause of failure. Smoking is bad news, we all know that, but I don't see how your rheumy can be so sure that this particular factor is responsible for failure to respond to these drugs.

If you can't give up the cigarettes perhaps a very nutritious diet and forcing fresh air into the lungs via exercise can offset the effects to some extent. Could you give up that rheumy, seeing as this isn't the only issue you have with her? I suspect that finding a better one might be quite difficult or you'd have done so already.

Oh Rachael, I'm so sorry you're having to do so much of your rheumy's job yourself (shakes head!).

To answer your principal question, I've never smoked a cigarette in my life and I failed a bio (Humira) nor have I ever read anything connecting smoking to the inefficacy of biologics. And I've read ALOT, although that's not to say I've read everything or the 'right' things. The only connection I ever recall reading about smoking was related to psoriasis.

I've also just re-checked what our 'expert' book authors say in case I didn't take in something crucial and the only indexed reference to smoking as an Environmental Factor reads: Smoking is less prevalent in PsA patients compared to patients with psoriasis without PsA. IL13 gene polymorphisms are associated with PsA, especially in non-smokers. So this doesn't tell us anything in the biologics context.

I feel pretty certain that if smoking or more precisely not smoking was so critical to the success of biologic therapy it would be pretty well known. And knowing the way our drugs are approved and rationed here in the UK there would be a big red banner on the guidelines document which said 'smokers need not apply'.

Stopping smoking (or cutting right down) I'm sure would be of general health benefit and so we're all here to support you.

Hopefully everyone else will weigh-in with their thoughts and experiences too.

It seems fairly reasonable to take the research on RA and biologic failure associated with smoking and apply it to PsA. I'm actually surprised that there is research supporting this, although with no clear understanding of why.

So, where does that leave you? Not in a really good position. It sounds as though you are more likely to fail biologics while you are still smoking, although nothing is guaranteed. Quitting smoking is really tough. There are more and more tools available to help, but persistence would be required. I'm sorry you find yourself in this position.

Shockingly, I found this -

There are research studies available on the web as well.

Sybil said:

I'm very sceptical about this alleged cause of failure. Smoking is bad news, we all know that, but I don't see how your rheumy can be so sure that this particular factor is responsible for failure to respond to these drugs.

If you can't give up the cigarettes perhaps a very nutritious diet and forcing fresh air into the lungs via exercise can offset the effects to some extent. Could you give up that rheumy, seeing as this isn't the only issue you have with her? I suspect that finding a better one might be quite difficult or you'd have done so already.

Thanks for replying such good feedback! I can’t seem to get past the fact that my rheumy is making me feel as if I am to blame or rather have control over how well I respond to bios. I fully understand that smoking is in no way healthy and that it sounds like I am reducing my ability to fully benefit from meds, but many people who do not smoke fail bios and there is no definitive reason for their response either. Stoney, you reaffirmed her exact point, smoking does seem to have an effect on the bodies ability to accept biologics but no one knows why, almost word for word what my rheumy said. I found a similar studies and all I can find is RA info but like you pointed out that has little relevance in respect to medication vs disease. I am going to try next week to start getting a game plan to tackle this but in all honesty I am not convinced that if I quit smoking I will see a huge difference. I do know that she only is willing to increase my humira to every 10 days for about the same amount of time it will take for me to know if it is worth staying on and for the amount of time it will take for me to quit (or seriously reduce) smoking and both will tell me what I need to know. Either way I guess it is hard to argue for cigarettes but like Jules said, if it was that big a deal then why is it not mentioned over and over and considered common knowledge?

Okay I'll come clean, it's about time! And 'fess up that I still smoke. Oh my, I wish I could quit. Every day I berate myself for it, it's my Achilles Heel 'cos in other respects I'm a bit of a fitness freak. There was a time when I couldn't smoke for 6 months or more .... the disease stopped me, it was really quite strange. But I am doing really well on Humira, hence my scepticism about how categorically your rheumy seems to link smoking with failing bios.

I do know that I can get down to about 3 cigarettes a day relatively easy and need to maintain that as the maximum level at the very, very least. Perhaps we should have a smokers' group, a giving up group rather than an 'enjoying a cigarette' group that is!

I think rheumys need to lay it on the line with us rather than pussy-footing around the obvious issues. But at the same time they have to work with who we are. Otherwise there's going to be a very substantial group of people excluded from biologics for being overweight, leading a sedentary lifestyle, eating junk food, having a defeatist attitude, excessive alcohol consumption ... hey, maybe even over-work.

Thanks for the honest support, Sybil! It’s been a long journey for me and cigarettes but I have managed to quit for 9 months once but I did not make an emergency plan and I am an extremely patterned person. When ml little sister ended up in a hospital the first thing I did was buy a pack on the way there and blew off such a great effort. After things calmed down I felt like such a failure I have never really tried since. Not only do I half live by routine (production workers lifestyle) but I am also definitely addicted as well. I have been steady pack a day, no more no less, since about 20 yrs old. Ouch! Time flies so that means 21 yrs now. I could and have given up coffee before them in the past so this is a big sacrifice to me, MTX and alcohol seems like fluffing pillows in comparison. It is doable though and I I know I can do it if I can muster the willpower with the pain that comes with bad days. I even filled a welbutrin script less than a year ago fully believing that with biologics I would soon be in remission and on to a life others have seem to have found when properly medicated. You know the one we all remember that we used to take for granted? Fully expecting to quit and enjoy life, take a plane for hours without nicotine withdrawal, be a good example for my kids but here I am feeling sorry for myself because the reason I am not in "that place"may very well be my fault. I still think there should have be a whole lot more conversation if smoking inhibits the ability to accept biologics to a large extent because if I had paid full price vs insurance copay I would be p*ss**off!

I think the stress of quitting would be difficult, too.....I always thought my psoriasis started because I quit smoking! It was very stressful for me for several months (in my early 20s) and within months of quitting I got psoriasis! I quit cold turkey.

I know a few people who used Chantix to quit and it worked really well for them. One is my son, who quit about 7 years ago and has no desire to ever smoke again. Our daughter (34) still smokes and keeps making and breaking plans to quit....I'd be the happiest mom in the whole USA if she did manage to quit.

Good luck, Rachael! I know how hard it is to quit. I don't agree with your doctor, but nevertheless, it's not a healthy habit. I've never regretted quitting and wouldn't smoke a cigarette for $1,000,000!!! I'd be afraid I'd get addicted again if I took one puff!

Hi Rachael - I’m a smoker - nobody has ever suggested to me that my psa or lack of response to medications is associated with this. Currently I have 24/7 pain, take no pain killers and am not even remotely ready to consider quitting … Cutting my feet off - yes!

I smoked like a forest fire when I started on humira and while on Remicade. I was on each for 2 years a piece, and I think that’s a pretty good run. I quit smoking anyway. It’ll be 2 years in May! I used a vape. Honestly, it saved me. I noticed some shortness of breath and it scared me straight! The vape has helped a ton, especially since I’m the kind of smoker that really likes smoking and didn’t really want to quit, but knew I needed to. COPD is a nightmare and not something I ever want to deal with.

Also, I totally disagree with your doc. Smoking can exacerbate autoimmune diseases like PsA and psoriasis, but I’ve never read anything about it inhibiting or conflicting with the biologic drugs, and I’ve read a lot.

Thanks Grandmaj, Golfnut and Grumpy for the responses! I lost my last reply earlier lets hope this does it justice. Golfnut you said exactly what I have told rheumy and primary for a year now. If only my pain was managed properly or at least at a predictable level ( I am past believing in pain free life now which is a step I needed to make) that I would quit. Still being in a gap this adds stress which makes something I am not confident nor truly wanting to do sooo much harder. I smoke heavier in pain and use it as a coping mechanism not to mention I may not be able to do much but can make it outside to the porch.
I also have a big problem with the fact that I feel like she’s using bogus reasoning , doesn’t have a clue why I am not just getting better and dangling proper care steps like a carrot over my head. Now I am toying with deciding if I should confront her on it. I can not find much info so I am going to call Humira and directly ask them if it is addressed anywhere in their info. I will still try and hopefully succeed for myself but not for her personal agenda. If I do quit and there is zero change in health or med plans I most definitely will be looking for a new rheumy that isn’t grabbing for excuses or blame.

Rachael, you have a way of saying things that gets to the heart of the matter. No doctor should casually accept that their patient smokes, but neither should they use that fact for as a bogus reason for something happening or not happening. A more considered approach is required. I think calling Humira is a very good idea. Let us know what happens.

Incidentally, I saw a very kind and thorough GP today. She wants me to access their 'quit smoking' programme without worrying that I will fail, she says that may happen again & again before I succeed.

I smoke and failed enebrel (strong injection site reactions that lingered for weeks to a month) and don’t have full remission of symptoms with humira but def. Better than I was. However, my rheum has never pointed to my smoking as cause. I’m like you - I know I need to quit, but I also realize I need to be in the right mindset for it to happen. Might be time to consider a new doc if that’s an option for you (sometimes it’s just not the right fit). It’s your treatment, so I don’t feel like you or anyone should feel like they have to stick to a particular doctor if it’s not working.

Hi Rachel!

Are you feeling any better today? Are you still taking extra injections of Humira? I was thinking maybe your doctor said that to try to scare you into quitting smoking! Cuz I doubt she really believes smoking would make a biologic not work. Especially as you say having a cigarette helps you cope with the pain--even if it's psychological--it's doing something for you. Not that I'm OK with smoking, but geez it's so hard to quit!

Grumpy mentioned the vape and I've heard of that working for other people. Yes, you do not want to have COPD, whether or not your PsA is under control. Now that's a good reason to eventually quit.

You need your own reasons for quitting, tho, and when you come up with enough of them and you're ready, it's good to write them down and post them on your bathroom mirror or some place you'll see them often to have a frequent reminder of why you're quitting. That really helped me, along with lemon drops and finding other 'bad' habits to replace the smoking urge!

Thank you all for such great encouragement! You know I really expected a lecture or testimonial from at least one person and almost didn’t post this discussion for that reason but you guys surprised me! Just goes to show the amazing point of view we all have.
Well I discussed my nasty habit (working on psych verbiage) to my primary on Friday. She said my rheumy’s reasoning was probably based on tissue reformation. Bios prevent the immune system from attacking healthy tissue allowing our bodies the opportunity to regrow or repair tissue. Smoking has been proven to prevent this process to the point most surgeons required smokers to quit for surgery and heart patients have to quit to repair the tissue damage after events. This makes sense to me and she said most bios are new enough that studied have likely not been done drug specific. Wow, what a better answer than "I don’t know why it just does"
That leaves me with the full problem now of committing to quitting. Taking the weekend to let it sink in and devise a plan because after so many years of coping with nicotine and enjoying smoking I need to wrap my head around reality. More soon…

That is a GREAT explanation from your primary, Rachel. I think this knowledge that there is likely a sound reason for doing so will help you with the decision and committment to quit smoking. Did your primary offer any cessation support? I know here in the UK there often clinics/support available from the primary practice.

And it goes without saying you have our total support here for when you're ready to put your plan in to action.

Last week I went for my 'Help to Quit' appointment at GP's surgery & got a prescription for inhalators. That may not be the right spelling as I admit I've not exactly studied the box or its contents yet! We're up to our necks in house selling / buying, it's not pretty & stress levels are high. Astronomical in fact. However I am mentally preparing for the experience of standing outside in the garden - or wherever we end up - puffing on a plastic stick as opposed to a cigarette. My plan is to start the inhalators next week regardless of how homeless we look like being etc. I know the nurse who runs the Quit programme fairly well, she usually does my bloods. She was quite jovial about the depths of my depravity, which is probably the right approach for me. She took my CO2 levels so will know if I'm cheating, interesting that they weren't brilliant even tho' I'd only had one cigarette that day .... Anyway it seems doable, just got to open the box ....

And Rachel, I think most regular contributors here are likely to be those for whom knowledge makes a difference. But knowledge plus lecture plus added BS is so diluted as to be useless. So I can see that your primary doc's approach might actually help, unlike the approach your rheumy took.