Infections related to TNF-α inhibitors

The tumor necrosis factor (TNF)-α inhibitors etanercept, infliximab and adalimumab represent a major therapeutic advance in the treatment of immunologically mediated inflammatory diseases. These agents are already approved for the treatment of Crohn’s disease, rheumatoid arthritis, ankylosing spondylitis, psoriasis and psoriatic arthritis and have been used ‘off-label’ in numerous other inflammatory diseases that have been difficult to treat with conventional therapies. Aside from their cost, the principal downside of these agents has been concern regarding infectious complications. Although there are numerous case reports of adverse infectious events, most controlled trials of TNF-inhibitors in rheumatic, cutaneous and gastrointestinal diseases failed to show an increase in the frequency of serious infectious complications beyond that seen with the usual immunosuppressive regimens. Recently, more data have become available from patient cohorts receiving these agents in clinical practice, which have allowed better risk categorization and the development of preventive strategies. This article will review the epidemiology of infectious complications in TNF-inhibitor treated populations, review current guidelines for infection prevention and management and present opportunities for future research in this field.