Immunosuppressive therapy

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	Specific Risks
Eculizumab	C5 complement	Meningococcus (very high risk), needs MCV4 + MenB + pen prophylaxis
Rituximab	Anti-CD20 antibody, on B cells	Long-term B cell depletion
Ocrelizumab	Anti-CD20 antibody
Natalizumab	α4-integrin, on all leukocytes except neutrophils	JC virus
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	Anti-TNF antibody
Golimumab	Anti-TNF antibody
Certolizumab pegol	Anti-TNF antibody
Etanercept	Anti-TNF
Infliximab	Anti-TNF antibody
Sulfasalazine	Anti-inflammatory
5-aminosalicylic acid and mesalamine	Anti-inflammatory
Anakinra	IL-1 receptor antagonist
Canakinumab	IL-1 receptor antagonist
Tocilizumab	Anti-IL6
Sarilumab	Anti-IL6
Ustekinumab	Anti-IL12/IL23
Secukinumab	Anti-IL17
Ixekizumab	Anti-IL17
Brodalumab	Anti-IL17 receptor
Belimumab	Anti-BLyS
Guselkumab	Anti-IL23
Risankizumab	Anti-IL23
Abatacept	Selective T-cell costimulation blocker
Fingolimod	Selective T-cell costimulation blocker
Siponimod	S1PR agonist
Ozanimod	S1PR agonist
Apremilast	Phosphodiesterase inhibitor
Vedolizumab	Anti-integrin