Rheumatology Question 26 Instructor

There are five tumor necrosis factor-a (TNF-a) inhibitors currently used in Canada in the treatment of rheumatic diseases. These are:

  • infliximab (Remicade)
  • etanercept (Enbrel)
  • adalimumab (Humira)
  • golimumab (Simponi)
  • certolizumab pegol (Cimzia)

List 4 potential side effects of these drugs.

Tuberculosis is of particular concern. All patients starting anti-TNF therapy should be screened for latent TB with a chest x-ray and PPD. Patients on these medications are also at increased risk of certain other unusual infections, including histoplasmosis. These drugs should be held in the event of any febrile illness or unusual infection.

TNF-a is known to have anti-tumor effects in laboratory settings, leading to concern that TNF blockade may increase cancer risk. To date, it is not clear whether TNF blockers increase the risk of lymphoma or solid tumors in patients on TNF inhibitors and the relationship between TNF-inhibitor use and malignancy is still being investigated. These medications are contraindicated in patients with a history of malignancy.

Congestive heart failure
Anti-TNF therapy should be avoided in patients with Class III or IV heart failure due to a trend toward increased hospitalizations and greater mortality.

Demyelinating disorders
These have been described in post-marketing surveillance. These agents should be avoided in patients with any history of prior demyelinating conditions.

Infusion reactions
Approximately 10% of patients receiving infliximab infusions will have mild infusion reactions necessitating a decreased rate of infusion or pretreatment with an H1 receptor antagonist and/or corticosteroids. Less than 2% of patients have severe reactions including bronchspasm, hypotension and anaphylaxis.

Injection site reactions occur in many patients receiving these medications subcutaneously, but they are generally minor.

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