Yes, TNF blockers increase infection risk. Now what?

September 10th, 2008

Yes, TNF blockers increase infection risk. Now what?

So the FDA has issued (another) warning about TNF (tumor necrosis factor) blockers and increased infection risk, this time focusing on fungal infections, in particular histoplasmosis. TNF blockers are used for treatment of rheumatoid arthritis, Crohn’s Disease, ankylosing spondylitis, psoriasis, and a wide range of other autoimmune diseases, both in approved and in off-label use.

ID/HIV specialists of a certain age can easily remember the first patients they had who, after starting PI-based combination therapy (note I don’t say “HAART”), literally got their life back. Went from imminent death to joining the living again. It was miraculous. A similar thing happened when TNF blockers entered clinical trials, then were approved by the FDA.

No, the TNF blockers don’t usually reverse a fatal illness like the antiretrovirals. But their effect, while perhaps not literally life-saving, is nearly as profound. It doesn’t much matter what the disease is; for patients with severe RA, or Crohn’s, or whatever, going from a life of chronic pain and disability to feeling normal again is, well, a miracle of almost comparable magnitude to the reversal of AIDS with antiretroviral therapy.

That’s why seeing patients with serious infectious complications from these drugs is so challenging. It’s not just about treating the infection. It’s also about managing the post-infection life.

And coming up with a sensible, compassionate answer to the inevitable question, “When can I start the Enbrel [or Remicade, or Humira, or Cimzia …] again?” — is certainly one of the hardest things I do.

HIV and ID Observations

An ongoing dialogue on HIV/AIDS, infectious diseases,
all matters medical, and some not so medical.

September 10th, 2008