A recent review provides some helpful advice: “A Practical Guide to the Safety and Monitoring of New IBD Therapies” (B Click, M Regueiro. Inflamm Bowel Dis 209; 25: 831-42).
This review discusses infection risk, malignancy risk, immunologic issues and other complications.
In terms of infection risk assessment, the authors describe a pyramid in which they stratify the risks of medications. The safest to least safe in their assessment: vedolizumab –>ustekinumab–>anti-TNF monotherapy–>thiopurine or tofacintinib–>thiopurine/anti-TNF combination–>steroids.
- Table 1 lists potential infections and vaccination recommendations
- Table 2 suggests management of active infections by IBD Medication Class
- For anti-TNF agents and for IL12/23 agents: the authors recommend continuation of agent if viral (eg EBV, VZV, HSV) or bacterial (eg. Strep/Staph)/C difficile infections (unless severe) but holding for opportunistic infections.
- For integrin agents, the authors recommend continuation of medications in the face of infections except “consider holding dose” during active C difficile infection
- For JAK agents, the authors recommend stopping during viral infections and with opportunistic infections. They recommend continuing with bacterial infections (hold if severe) and continuing with C difficile infection
- Table 3 suggests management in the setting of active malignancy
- Table 4 lists recommendations in the setting of immunologic complications. Theses categories include antidrug antibodies,lupus-like reactions, demyelinating conditions, and psoriasis.
- One of the points alluding to in this chart is that addition of methotrexate may help in patients receiving anti-TNF therapy with psoriasis.
- No psoriatic reactions have been reported with vedolizumab, ustekinumab or tofacitinib; ustekinumab is FDA-approved for use in psoriasis and tofacitinib is FDA-approved for psoriatic arthritis.
- Table 5 suggests recommendations in the setting of altered liver enzymes and altered lipids/creatine kinase
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- Safer Than You Think: Biologic Therapies for IBD and Risk of Infection and Malignancy | gutsandgrowth
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