Article

Preventing and treating biologic-associated opportunistic infections.

Oregon Health & Science University, Portland, OR, USA.
Nature Reviews Rheumatology (Impact Factor: 10.25). 08/2009; 5(7):405-10. DOI: 10.1038/nrrheum.2009.105
Source: PubMed

ABSTRACT A variety of opportunistic pathogens have been reported to infect patients receiving tumor necrosis factor (TNF) antagonists for the treatment of autoimmune diseases. These pathogens are numerous, and include coccidioides, histoplasma, nontuberculous mycobacteria, Mycobacteria tuberculosis, and others of public health concern. Accordingly, TNF antagonists should be used with caution in patients at risk for tuberculosis, and screening for latent tuberculosis infection should be undertaken before anti-TNF therapy is initiated. Although screening and prevention efforts have decreased the risk of tuberculosis in this setting, optimal screening methods represent an area of evolving controversy. This article discusses the latest developments in screening methodologies for latent tuberculosis infection, as well as potential preventive and therapeutic considerations for opportunistic infections associated with anti-TNF agents and other biologic therapies.

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    • "Screening for TB exposure with PPD skin testing or newer interferon-based serum tests (although their optimal use in this setting is not yet clear) should be performed before beginning therapy with anti-TNF agents (Winthrop and Chiller 2009). Anergy is known to occur in patients with RA or Crohn's disease, and the possibility of false-negative skin tests should be taken into consideration. "
    Insights and Perspectives in Rheumatology, 01/2012; , ISBN: 978-953-307-846-5
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    ABSTRACT: High therapeutic efficacy of inhibitors of tumor necrosis factor-a (iTNF-a) in the treatment of rheumatoid arthritis (RA), ankylosing spondylitis (AS)–spondyloarthritides (SpA), and several other inflammatory rheumatic diseases (IRDs) has been well established over the past decade. Large registries on the use of these biologicals and extensive experience with their use worldwide have shown that overall these agents have a good safety profile with a highly favorable risk–benefit ratio with the exception of the problem of reactivation of tuberculosis infection (TBI) among patients with latent tuberculosis infection (LTBI) with their use. Observational studies have established that the risk of developing TB is several fold higher with monoclonal antibodies against TNF-a than with soluble TNF-a receptor fusion protein. It has also been observed that almost all the TB flare seen with iTNF-a is reactivation of LTBI. Therefore, key to the prevention of TB flare associated with the use of iTNF-a is detection of LTBI among prospective users of these agents. There is, however, no ''gold standard'' for the diagnosis of LTBI. Therefore, different strategies for the screening of LTBI and its treatment have been recommended in different regions of the world. This review discusses the problems related to TB screening especially among patients with IRDs who may have an inherent immunocompromised state, outlining the pros and cons of different strategies and the issues related to the treatment of LTBI prior to the use of iTNF-a agents. The review focuses especially on TB preventive strategies in high-burden TB regions of the world.
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