Management Strategies for Patients With Rheumatoid Arthritis Who Develop Infections While on Anti–Tumor Necrosis Factor Medication
As with many of the biologics and the targeted synthetic agents used to treat rheumatoid arthritis (RA), anti–tumor necrosis factor (anti-TNF) medications are associated with a small but significant increased risk of infection, including activation of tuberculosis. The benefits of controlling RA far outweigh the risks of therapy when used appropriately.
Instructor in Medicine
"We are extremely careful about monitoring patients who are on these therapies; we aim to detect infections early and treat them aggressively.”
When I counsel patients with RA about the risk of infection with anti-TNF medications, I tell them that these therapies decrease their ability to fight infections and increase their risk for developing serious infections. Additionally, I inform them that colds can be more common or can last longer than normal while they are taking these drugs. Fortunately, most patients on these medications do not develop serious bacterial infections. We are extremely careful about monitoring patients who are on these therapies; we aim to detect infections early and treat them aggressively. For those with a cold who have typical upper respiratory symptoms and no fever, an evaluation by a physician is typically not necessary. However, if patients develop a fever, I recommend that he or she be seen by a health care provider. If fever and cough are present, a chest x-ray and a complete blood count may be appropriate. I would be more likely to initiate antibiotic therapy empirically in patients on anti-TNF drugs and suspected pneumonia than in patients who are not on these drugs because missing an infection may prove to be very serious. It is important to explain the risks and benefits of biologic therapy to patients prior to starting these treatments. Although there is a small risk of infection with these agents, untreated or poorly treated RA leads to outcomes that include disability, an increased risk of heart disease, and even an increased risk of infection. In active RA, the benefits of biologic therapy typically greatly outweigh the potential harms. Some patients who are receiving steroids for short-term control are very hesitant to initiate anti-TNF therapy and would prefer the continued use of steroids, but steroids are some of the worst culprits for inducing infection (among many other side effects). In fact, a patient on both methotrexate and steroids is likely at as great a risk of infection as a patient on methotrexate and anti-TNF therapy.
Prior to initiating anti-TNF therapy, we try to ensure that vaccinations are up to date and screen for latent tuberculosis and viral hepatitis. Infectious disease specialists become involved in my patients with latent tuberculosis, hepatitis C, or latent hepatitis B. I also ask for their assistance when I have patients on anti-TNF agents who develop serious infections, as these individuals are more likely to harbor atypical organisms and/or will require more aggressive therapy. For patients who develop a single bacterial infection while on anti-TNF therapy, I will often restart them on their treatment once the infection has been controlled. However, for those who develop frequent infections while on anti-TNF therapy, I will consider switching them to an agent that may be less immunosuppressive.
Accortt NA, Lesperance T, Liu M, et al. Impact of sustained remission on the risk of serious infection in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2018;70(5):679-684.
Galloway JB, Hyrich KL, Mercer LK, et al; BSRBR Control Centre Consortium; British Society for Rheumatology Biologics Register. Anti-TNF therapy is associated with an increased risk of serious infections in patients with rheumatoid arthritis especially in the first 6 months of treatment: updated results from the British Society for Rheumatology Biologics Register with special emphasis on risks in the elderly. Rheumatology (Oxford). 2011;50(1):124-131.
Rutherford AI, Patarata E , Subesinghe S, Hyrich KL, Galloway JB. Opportunistic infections in rheumatoid arthritis patients exposed to biologic therapy: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Rheumatology (Oxford). 2018;57(6):997-1001.