Immunosuppressive therapy
From IDWiki
Screening
Before starting immunosuppressive therapy, consider the following investigations:
- Tuberculin skin test
- Strongyloides serology, if from endemic country
- Hep B and C serology
- Cytomegalovirus serology
- HIV serology
Management
- Latent TB infection: start treatment at least 4 weeks prior to starting the biologic
Specific Medications
Medications | Target | Type | Indications | Specific Risks |
---|---|---|---|---|
Eculizumab | C5 complement | meningococcus (very high risk; needs MCV4 + MenB + pen prophylaxis) | ||
Rituximab | CD20 | specific risk of PML and HBV; serious bacterial infections, PML, parvovirus, CMV, HSV, and disseminated VZV infections, HBV and HCV reactivation | ||
Ocrelizumab | CD20 | |||
Natalizumab | α4-integrin | humanized IgG4 | specific risk of PML; herpesvirus infections, influenza, Cryptosporidium diarrhea, bacterial pneumonias and UTIs, PCP, Mycobacterium avium-intracellulare infection, Aspergillus and Burkholderia cepacia infections | |
Ibrutinib | Bruton's tyrosine kinase (BTK), on B cells | Invasive aspergillosis and other fungal infections | ||
Steroids | ||||
Cyclosphosphamide | Antimetabolite | |||
Leflunomide | Antimetabolite | |||
Methotrexate | Antimetabolite | |||
Azathioprine | Antimetabolite | |||
6-mercaptopurine | Antimetabolite | |||
Mycophenolic acid | Antimetabolite | |||
Mycophenolate mofetil | Antimetabolite | |||
Tacrolimus | Calcineurin inhibitor | |||
Cyclosporine | Calcineurin inhibitor | |||
Sirolimus | Calcineurin inhibitor | |||
Baricitinib | JAK inhibitor | |||
Tofacitinib | JAK inhibitor | |||
Upadacitinib | JAK inhibitor | |||
Adalimumab | TNF-α | human IgG1 | serious pulmonary bacterial infections, TB, candidiasis, CMV infection, toxoplasmosis, and nocardiosis | |
Certolizumab pegol | TNF-α | humanized Fab' fragment | serious pulmonary bacterial infections, TB, viral and fungal infections | |
Golimumab | TNF-α | |||
Certolizumab pegol | TNF-α | |||
Etanercept | TNF-α | human dimeric fusion protein | serious bacterial infections, TB, infections with MOTT, listeriosis, histoplasmosis, candidiasis, aspergillosis, cryptococcosis, nocardiasis, protozoal and VZV infection | |
Infliximab | TNF-α | chimeric IgG1 | pneumonia, sepsis, TB, infections with MOTT, listeriosis, histoplasmosis, candidiasis, aspergillosis, cryptococcosis, salmonellosis, toxoplasmosis, brucellosis, bartonellosis, leishmaniasis, coccidiomycoses, leprosy, CMV infection, HBV reactivation | |
Sulfasalazine | Anti-inflammatory | |||
5-aminosalicylic acid and mesalamine | Anti-inflammatory | |||
Anakinra | IL-1 | non-glycosylated IL-1 receptor | pneumonia, cellulitis, TB, unspecified mycobacterial and fungal infections | |
Rilonacept | IL-1 | dimeric fusion protein IL-1 inhibitor | meningitis, MOTT infection, severe bronchitis | |
Canakinumab | IL-1 | |||
Tocilizumab | Anti-IL6 | |||
Sarilumab | Anti-IL6 | |||
Ustekinumab | Anti-IL12/IL23 | |||
Secukinumab | Anti-IL17 | human IgG1κ monoclonal antibody | psoriasis, ankylosing spondylitis, and psoriatic arthritis | |
Ixekizumab | Anti-IL17 | |||
Brodalumab | Anti-IL17 receptor | |||
Belimumab | Anti-BLyS | |||
Guselkumab | Anti-IL23 | |||
Risankizumab | Anti-IL23 | |||
Abatacept | T-cell costimulation inhibitor | fusion protein | pneumonia, sepsis, aspergillosis, sinusitis, candidiasis, bronchitis, skin and soft tissue infections, viral infections with HSV and VZV | |
Fingolimod | Selective T-cell costimulation blocker | |||
Siponimod | S1PR agonist | |||
Ozanimod | S1PR agonist | |||
Apremilast | Phosphodiesterase inhibitor | |||
Vedolizumab | Anti-integrin | |||
Efalizumab | CD11a | humanized IgG1 | generally mild; pneumonia, cellulitis, abscess, sepsis, Legionella pneumonia, necrotizing fasciitis, TB, PML | |
Alefacept | T-cell activation | fusion protein | cellulitis, abscess, wound infections, toxic shock, pneumonia, appendicitis, cholecystitis, gastroenteritis, MOTT infection, influenza virus, HCV, and herpesvirus infections | |
Alemtuzumab | CD52 | humanized IgG1 | causes prolonged lymphopenia; overwhelming bacteremia, pneumonia, meningitis, CMV, VZV, and HSV infections, PCP, PML, adenovirus infection, acanthamebiasis, toxoplasmosis, histoplasmosis, cryptococcosis, aspergillosis, Fusarium infection, Scedosporium infection, BK virus infection, HHV-6 infection, candidiasis, parvovirus infection, mucormycosis, TB, Balamuthia mandrillaris infection, MOTT infection, BCGosis, Rhodococcus infection, HBV reactivation | |
90Y-ibritumomab tiuxetan | CD20 | radioconjugated murine IgG1 | pneumonia, sepsis, cellulitis, colitis, diarrhea, empyema, osteomyelitis, pericarditis, viral pneumonia and viral hepatitis | |
131I-tositumomab | CD20 | radioconjugated murine IgG2 | pneumonia, septicemia, bronchitis, skin infections, viral infections | |
Gemtuzumab ozogamicin | CD33 | humanized IgG4 conjugated to calichaemicin | causes prolonged neutropenia; sepsis, pneumonia, HSV infection, usual opportunistic infections with neutropenia, unusual pathogens include Staphylococcus hominis, Agrobacterium radiobacter, Acinetobacter lwoffii, Rhodococcus, and Pantoea agglomerans | |
Bevacizumab | VEGF | humanized IgG1 | severe neutropenia; sepsis, anaerobic liver abscess with Bacteroides fragilis, Fusarium nasal septal infection, endophthalmitis, intraocular injection including Bacillus cereus and coagulase-negative Staphylococcus | |
Cetuximab | ErbB1 | chimeric human-murine IgG1 | paronychia caused by Staphylococcus aureus, abscess, sepsis | |
Panitumumab | ErbB1 | human IgG2 | paronychia, abscess, sepsis | |
Trastuzumab | HER2 | human IgG1 | febrile neutropenia | |
Basiliximab | CD25 | chimeric human-murine IgG1 | bacterial, CMV, and HSV infections, aspergillosis, nocardiosis, candidiasis, and protozoal infections | |
Daclizumab | CD25 | humanized IgG1 | nocardiosis, legionellosis, MOTT infection, TB, viral infection with CMV, BK virus, adenovirus, HSV, RSV, or influenza virus, fungal infections with Aspergillus, Scedosporium, Cunninghamella, and Candida | |
Muromonab | CD3 | murine IgG2 | bacterial infections, including Listeria, Nocardia, and MOTT infections; infections with Aspergillus, Candida, Cryptococcus, or dermatophytes; PCP; infections with Toxoplasma gondii, CMV, EBV, HSV, hepatitis viruses, VZV, adenovirus, enterovirus, RSV, and parainfluenza virus | |
Abciximab | GPIIb/IIIa | Fab' fragment of chimeric human-murine IgG1 | pneumonia | |
Omalizumab | IgE | humanized IgG1 | none | |
Palivizumab | F protein of RSV | humanized IgG1 | otitis media |
Further Reading
- Infectious complications associated with monoclonal antibodies and related small molecules. Clin Microbiol Rev. 2009 Apr;22(2):274-90. doi: 10.1128/CMR.00040-08