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 | 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 | ||
| 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
