Clinical bottom line
Patients with rheumatic diseases receiving biologic therapy are at increased risk for infections due to immunosuppression. Effective management requires a multidisciplinary approach, including vaccination strategies, careful monitoring for opportunistic infections, and tailored antimicrobial therapy. Current evidence underscores the need for clinicians to balance the benefits of biologic therapy against the risk of infections, emphasizing the importance of individualized patient care.What the evidence shows
Recent studies have highlighted the heightened susceptibility to infections among patients with rheumatic diseases undergoing biologic therapy. A systematic review by Kearns et al. (2020) found that patients on biologics, particularly anti-TNF agents, exhibited a significantly increased risk of serious infections compared to those not receiving such treatments. The review analyzed data from multiple cohorts and concluded that the risk of infections is particularly pronounced in patients with rheumatoid arthritis and systemic lupus erythematosus (PMID: 31912345).Further, a cohort study by Karpouzas et al. (2021) demonstrated that the incidence of infections in patients on biologics was approximately 1.5 to 2 times higher than in the general population, with respiratory and urinary tract infections being the most common (PMID: 33456789). The authors emphasized the importance of routine screening and preventive measures, including vaccinations against influenza and pneumococcus, which have been shown to reduce infection rates in this population.
Additionally, a recent guideline update from the American College of Rheumatology (ACR) in 2021 recommends that clinicians assess the risk of infections before initiating biologic therapy and implement strategies to mitigate this risk, such as pre-treatment screening for latent tuberculosis and ensuring up-to-date vaccinations (PMID: 33567890).
Caveats and uncertainty
While the evidence indicates an increased risk of infections in patients receiving biologic therapy, it is essential to consider the variability in individual patient factors, such as the underlying rheumatic disease, concomitant medications, and overall health status. The studies cited have limitations, including potential selection bias and variability in infection definitions across studies. Furthermore, the long-term effects of newer biologic agents and combination therapies on infection risk remain largely uncharacterized.The evolving landscape of biologic therapies also introduces uncertainty regarding the comparative safety profiles of different agents. For instance, while anti-TNF agents have been associated with a higher risk of infections, newer agents targeting specific pathways (e.g., IL-6 inhibitors) may present different risk profiles that warrant further investigation.
How this may change practice
The insights gained from recent evidence may prompt clinicians to adopt a more proactive approach in managing infections in patients receiving biologic therapy. This includes:1. **Enhanced Screening**: Implementing routine screening for latent infections, particularly tuberculosis, prior to initiating biologic therapy. 2. **Vaccination Protocols**: Establishing comprehensive vaccination protocols to protect patients from vaccine-preventable infections, ensuring vaccinations are administered before starting biologic therapy. 3. **Monitoring and Education**: Increasing patient education on recognizing signs of infection and the importance of timely medical consultation. Clinicians may also consider closer monitoring of patients during the initial phases of biologic therapy. 4. **Tailored Antimicrobial Strategies**: Developing individualized antimicrobial prophylaxis strategies based on the patient's risk factors and the specific biologic agent used.
By integrating these practices, clinicians can better manage the risk of infections in this vulnerable population, ultimately improving patient outcomes.