Medication | Effect on immune system | Associated infections* | Pre-treatment testing¶ | Pre-treatment vaccinationsΔ | Comments |
IL-1 inhibitors | |||||
Anakinra | Inhibits IL-1 and prevents activation of proinflammatory cytokine pathways | Bacterial:
Viral:
Fungal:
| Test for:
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Canakinumab | |||||
Rilonacept | |||||
IL-6 inhibitors | |||||
Sarilumab | Inhibits IL-6 and prevents proinflammatory cytokine release | Bacterial:
Viral:
Fungal:
| Test for:
|
| |
Tocilizumab | |||||
IL-17 inhibitors | |||||
Secukinumab (IL-17) | Inhibits IL-17 and prevents release of proinflammatory cytokines | Bacterial:
Fungal:
| Test for:
|
| |
Ixekizumab (IL-17) | |||||
Brodalumab (IL-17) Bimekizumab (IL-17) | |||||
IL-12 and IL-23 inhibitors | |||||
Ustekinumab (IL-12, IL-23) | Inhibits IL-12 and IL23 and interferes with NK cell activation and CD4 T cell differentiation | Fungal:
| Test for:◊
|
| |
Guselkumab (IL-23) | Inhibits IL-23 and prevents proinflammatory cytokine release | ||||
Risankizumab (IL-23) | Binds to the p19 subunit of IL-23 and inhibits its interaction with the IL-23 receptor | Bacterial:
Fungal:
| Test for:§
|
HBV: hepatitis B virus; HCV: hepatitis C virus; HIV: human immunodeficiency virus; IL: interleukin; NK cells: natural killer cells; RZV: recombinant (non-live) zoster vaccine (Shingrix); TBI: latent tuberculosis infection.
* 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.
◊ Although the drug labels for these agents warns that the risk of TBI and HBV reactivation may be increased, post-marketing data has not shown a significantly increased risk of infection with these agents. Nevertheless, we continue to test for these infections because the benefit of testing outweighs the harms.
§ Risankizumab (an IL-23 inhibitor) appears to have a lower risk for HBV and HCV reactivation compared with guselkumab or ustekinumab, thus we do not test for HBV or HCV in patients starting risankizumab.Do you want to add Medilib to your home screen?