Infections associated with the use of biologic response modifiers in rheumatic diseases: a critical appraisal

Patients with autoimmune inflammatory rheumatic disorders have a higher incidence of infections indicative of inherent immunosuppressed state related to the disease activity. The latter is made worse by DMARD, including steroids that are universally used to treat these disorders. The problem has been compounded further with increasing worldwide use of biological response modifiers (BRMs or biologies) for the treatment of systemic inflammatory rheumatic diseases, especially rheumatoid arthritis (RA). To some extent, this was predicted considering that most BRM used in rheumatology practice specifically target molecules involved in the functioning of innate or adaptive immune system of the host defense system. The adverse effects of BRM, however, need to be balanced against their remarkable efficacy in disease control. BRM are highly effective drugs that have revolutionized the treatment of these diseases. In this paper the current status of infection with the use of BRM in rheumatic diseases is discussed.On balance, biologies seem to be safe drugs with acceptable range of drug-related infections. The preponderance of data indicates that TNF inhibitors (iTNF) are associated with a small increased risk of serious bacterial infections. The most common associated infections are urinary tract infection, pneumonia, upper respiratory infection, and soft-tissue/skin infections. Available data strongly suggest an increased risk of tuberculosis-flare with iTNF medications, especially the monoclonal drugs and has been discussed separately.Though sparse and grossly limited, the Indian data has been reviewed. Stringent screening is required for TB and other community infections prior to initiating BRM.