Update upon the infection risk in patients receiving TNF alpha inhibitors

ABSTRACT

Introduction: TNF-α inhibitors can be administered either as monotherapy or in combination with other anti-inflammatory drugs or DMARDs in the treatment of chronic immune-mediated diseases.

Areas covered: Patients receiving TNF-α inhibitors are at high risk of infections. An update is made on the risk of infection in patients receiving TNF-α inhibitors and the strategies for mitigating against the development of these serious adverse events.

Expert opinion: Infliximab than etanercept appears to be responsible for the increased risk of infections. Re-activation of latent tuberculosis infection and the overall risk of opportunistic infections should be considered before beginning a course of TNF-α inhibitors. A careful medical history, Mantoux test/quantiferon-TB Gold In-tube Test and chest-X-ray should always be performed before starting TNF-α inhibitors. Particular attention should be paid to risk factors for Pneumocystis jirovecii infection. Hepatitis B and C virological follow-up should be considered during TNF-α inhibitors treatment. Finally, appropriate vaccinations for influenza, S. pneumoniae, and HBV should be administered to decrease the risk of infection, and patients who are at high risk of herpes zoster reactivation would benefit from a second vaccination in adulthood.

KEYWORDS:

• TNF-α inhibitors
• infections
• TB
• HBV
• HCV

Article highlights

• TNF-α inhibitors have demonstrated efficacy in large, randomized controlled clinical trials either as monotherapy or in combination with other anti-inflammatory or DMARDs in the treatment of chronic immune-mediated diseases.

• Monoclonal antibody as infliximab than anti-receptor fusion protein as etanercept appear to be responsible for the increased risk of infections.

• Absolute lymphocyte count below 500 lymphocytes/μL virtually increases the risk for severe infections.

• Appropriate screening with Mantoux test/quantiferon-TB Gold In-tube Test and chest-X-ray should be performed before starting treatment.

• Physicians should pay particular attention to the risk factors for PCP (use of corticosteroids/DMARDs, advance age, lung disease or fibrosis, CD4+ T-lymphocyte count <100 cells/μl).

• HBV and HCV virological follow-up should be considered during TNF-α inhibitors treatment

• Appropriate vaccinations for influenza, S. pneumoniae, and HBV should be administered to decrease the risk of infection.

• Patients who are at high risk of for HZ reactivation would benefit from a second vaccination in adulthood when receiving TNF-α inhibitors.

This box summarizes the key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.