TNF inhibitors and infections

An increased risk of infection is associated with tumor necrosis factor (TNF) inhibitors; it may vary among the specific agents. These risks predominantly involve intracellular pathogens, Mycobacterium tuberculosis, and the endemic fungi. Although these risks are small, clinicians and patients need to be vigilant for these complications until we are better able to discern predictors of risk. At present, the most effective measures to reduce infectious complications include screening for tuberculosis, age- and disease-appropriate immunization, and rapid and aggressive diagnostic evaluation and prompt institution of antimicrobial therapy when indicated. Many practical questions remain unanswered, including the most appropriate screening, optimal timing of vaccines, need for discontinuation of TNF inhibitors, and role of monitoring and prophylaxis.