Patient assessment before using tumour necrosis factor alpha blockers in inflammatory bowel disease

Abstract

Blokatori tumor-nekrotizirajućeg faktora alfa (TNF-α) biološki su agensi kojima se blokira ključni proupalni citokin u upalnim bolestima crijeva, stoga je biološka terapija postala jedna od najznačajnijih u liječenju tih bolesti. U Hrvatskoj su registrirana dva blokatora TNF-α: infliksimab (RemicadeR) i adalimumab (HumiraR). U radu su navedeni postupci koje je potrebno učiniti prije uporabe biološke terapije. Ti postupci uključuju iscrpne anamnestičke podatke o ranijim infektivnim bolestima i cijepljenju te detaljan klinički pregled radi isključivanja infekcije. Prisustvo apscesa te pogoršanje kolitisa uzrokovano Clostridium difficile toksinom ili Cytomegalovirus (CMV) infekcijom predstavljaju apsolutnu kontraindikaciju za uporabu blokatora TNF-α. Njihova je uporaba također kontraindicirana u bolesnika s popuštanjem srca NYCHA III ili IV. Oprez je potreban u bolesnika s kroničnim bolestima jetre, neurološkom patologijom te u bolesnika s ranijim malignim bolestima, posebno limfomima. Od laboratorijskih nalaza potrebno je učiniti: leukogram, diferencijalni leukogram, CD4 stanice u slučaju leukopenije, transaminaze, C-reaktivni protein (CRP), analizu urina, serologiju za hepatitis C virus (HCV), hepatitis B virus (HBV) i virus humane imunodeficijencije (HIV). Ovisno o anamnestičkim podacima potrebna je i serologija za varicella zoster virus (VZV). Broj eozinofila, pregled stolice i serologija na strongiloidijazu potrebni su u slučaju boravka u tropima. Nadalje je potrebno učiniti radiogram pluća, PPD i radioimunoesej za interferon gama (IGRA) (od engl. interferon gamma release assay) prema nacionalnim smjernicama, a radi isključivanja aktivne i latentne tuberkuloze. Cijepljenje živim cjepivom kontraindicirano je za vrijeme terapije blokatorima TNF-α. Prije započinjanja terapije potrebno je, u seronegativnih, cijepljenje protiv hepatitisa B, dok se cijepljenje protiv humanog papiloma virusa (HPV) i VZV-a provodi samo u specifičnim slučajevima. Neživo cjepivo za sezonsku gripu potrebno je bolesnicima aplicirati jednom godišnje, a pneumokokno cjepivo jednom u pet godina.Tumour necrosis factor alpha (TNF-α) blockers are biological agents that specifically target the key cytokine in the inflammatory bowel process and became almost the mainsty in the therapy of inflammatory bowel disease. Currently, there are two TNF-α blockers available for clinical use in Croatia: infliximab (RemicadeR), and adalimumab (HumiraR). This paper reviews the necessary investigations before using this drugs. Before using TNF-α blockers detailed interview with the history of previous infective diseases and vaccination is necessary. Clinical examination in order to exclude any infection is mandatory. In patients with abscess and with Clostridium difficile or Cytomegalovirus (CMV) superinfection, biological therapy is contraindicated. This therapy is also contraindicated in NYCHA III or IV cardiac insufficiency. It must be used with caution in patients with chronic liver disease, neurological pathology or history of malignancies, especially lymphoma. Laboratory tests include neutrophil and lymphocyte count, in the case of lymphopenia, CD4 lymphocyte count, transaminases, C-reactive protein (CRP), urine analysis, hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus (HIV) serology, varicella zoster virus (VZV) serology (in patients without a clear history of varicella immunisation). Eosinophil count, stool examination and strongyloidiasis serology for patients having lived in a tropical area. Furthermore, before treatment with anti TNF-α all patients should be checked both for active and for latent tuberculosis infection. This check include: chest X-ray, tuberculin skin test and interferon gamma release assay (IGRA), according to country-specific guidelines. Vaccination with live vaccines is contraindicated during treatment with biological agents. Hepatitis B vaccination should be administered in naive patients. Other vaccinations (varicella, human papilloma virus) should be proposed to specific patients. Influenza vaccine should be given annually and 23-valent pneumococcal vaccine every 5 years