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Review article

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

Brankica Mijandrušić Sinčić ; Department for gastroenterology, Clinics for internal medicine, Clinical hospital centre Rijeka, Rijeka, Croatia

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page 29-36

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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.


adalimumab; infliximab; opportunistic infection; screening; vaccination

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