Choice of Biologic Therapy for Patients with Rheumatoid Arthritis: The Infection Perspective

Filip De Keyser

doi:10.2174/157339711794474620

Abstract

Biologicals revolutionized the treatment of Rheumatoid Arthritis (RA). The targeted suppression of key inflammatory pathways involved in joint inflammation and destruction allows better disease control, which, however, comes at the price of an elevated infection risk due to relative immunosuppression. The disease-related infection risk and the infection risk associated with the use of TNF-α inhibitors (infliximab, adalimumab, etanercept, golimumab and certolizumab pegol), rituximab, abatacept and tocilizumab are discussed. Risk factors clinicians need to take into account when selecting the most appropriate biologic therapy for RA patients, as well as precautions and screening concerning a number of specific infections, such as tuberculosis, intracellular bacterial infections, reactivation of chronic viral infections and HIV are reviewed.

Highlights

The introduction of biological therapies targeting specific inflammatory mediators revolutionized the treatment of rheumatoid arthritis (RA)
Screening for latent TB is recommended for all biological agents, except rituximab, where clinical vigilance would suffice in view of the paucity of arguments pointing towards an elevated tuberculosis risk with this drug [59]
HIV screening prior to biological therapy is recommended in patients with risk behavior

Summary

Introduction

The introduction of biological therapies targeting specific inflammatory mediators revolutionized the treatment of rheumatoid arthritis (RA). As flip side of the coin, treatment with biologicals leaves the patient more susceptible to infection by inducing a certain extent of immunosuppression. Much remains to be discovered about the precise mechanisms of increased infection risk under biologic therapy, it is clear that clinical differences with respect to type and frequency of infectious complications exist between the different compounds. This article aims to summarize literature data on compound-related and disease-related infection risk factors that clinicians need to take into account when selecting the most appropriate biologic therapy for their RA patients. The risk of serious infections associated with different biologicals is discussed, followed by risks and precautions needed under biological therapy with respect to a number of specific infections, such as tuberculosis, intracellular bacterial infections, reactivation of chronic viral infections and HIV

Objectives

Findings

Conclusion