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.

Their Tables:

• 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

Related posts:

• Anti-TNF Agents in Pediatrics Have NOT Been Shown to Cause Lymphoma | gutsandgrowth
• Safer Than You Think: Biologic Therapies for IBD and Risk of Infection and Malignancy | gutsandgrowth
• TNF-α antagonists and infections
• Disease modifying treatment in IBD
• Only one chance to make first impression
• More on IBD Medicine Risks