Medication | Effect on immune system | Associated infections* | Pre-treatment testing¶ | Pre-treatment vaccinationsΔ | Comments |
Anti-integrin monoclonal antibody | |||||
Vedolizumab | Inhibits alpha-4-beta-7 integrin and prevents its binding to MAdCAM-1, leading to impaired migration of memory T cells to the gut mucosal endothelium. | Bacterial:
Viral:
| Test for:
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Natalizumab | Inhibits alpha-4-beta-1 integrins, preventing it from binding to VCAM, leading to the inhibition of leukocyte migration to site of infection (including the CNS). | Bacterial:
Viral:
Fungal:
| Test for:
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Sphingosine-1-phosphate (S1P) receptor modulator | |||||
Fingolimod§ | Inhibits S1P and prevents T cell migration from lymph nodes. | Bacterial:
Viral:
Fungal:
| Test for¥:
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CMV: cytomegalovirus; CNS: central nervous system; EBV: Epstein-Barr virus; HBV: hepatitis B virus; HCV: hepatitis C virus; HHV-8: human herpesvirus 8; HIV: human immunodeficiency virus; HSV: herpes simplex virus; JCV: John Cunningham virus; LTBI: latent tuberculosis infection; MAdCAM-1: mucosal vascular addressin cell adhesion molecule 1; PML: progressive multifocal leukoencephalopathy; RZV: recombinant (non-live) zoster vaccine (Shingrix); S1P: sphingosine-1-phosphate; TBI: tuberculosis infection; VCAM: vascular cell adhesion protein.
* In addition to the infections listed, typical, common bacterial and viral infections should also be considered in the differential when infection is suspected in a patient taking the specified agent.
¶ For patients who do not have a negative HIV test documented in their records or are at increased risk of acquiring HIV (eg, men who have sex with men, engagement in sex work), the pre-treatment infectious testing process is a good opportunity to provide routine HIV screening prior to the initiation of immunosuppression. Treat any latent or active infections found on pre treatment testing. Control of infection should be demonstrated prior to initiating immunosuppressive therapy.
Δ Live and non-live vaccines should be administered no later than 4 and 2 weeks, respectively, prior to initiating therapy. Vaccine responses may be attenuated while on therapy.
◊ We also obtain baseline magnetic resonance imaging of the brain prior to initiating therapy with natalizumab.
§ Other S1P receptor modulators (eg, siponimod, ozanimod) should be managed like fingolimod.
¥ Some clinicians opt to test for JCV similar to the approach used for patients starting natalizumab; however, this is not routine among all clinicians.Do you want to add Medilib to your home screen?