One of the major concerns with biologics is the increased risk of infection due to immune suppression. It is always preferable to risk stratify patients for potential infections. Despite all precautions, prolonged infections, opportunistic infections, or herpes zoster flare- ups may still occur. In such events, it is advisable to stop the biologic therapy, wait for the patient to recover from the infection, and then reassess the risk. Based on this assessment, one may consider switching to a biologic with a lower risk profile or permanently discontinuing the biologic.

The adjusted hazard ratio (aHR) for serious infections associated with tofacitinib was 1.41 (95% CI 1.15–1.73) compared to etanercept, 1.20 (0.97–1.49) compared to abatacept, 1.23 (0.94–1.62) compared to golimumab, and 1.17 (0.89–1.53) compared to tocilizumab. The risk of serious infection with tofacitinib was similar to adalimumab (1.06, 0.87–1.30) and certolizumab (1.02, 0.80–1.29), but lower than infliximab (0.81, 0.65–1.00). However, tofacitinib was associated with a twofold higher risk of herpes zoster compared to all other bDMARDs (Pawar et al. 2020). This information should guide the selection of an alternative biologic if needed.

REFERENCE

1. Pawar A, Desai RJ, Gautam N, Kim Risk of admission to hospital for serious infection after initiating tofacitinib versus biologic DMARDs in patients with rheumatoid arthritis: a multidatabase cohort study. The Lancet Rheumatology. 2020 Feb 1;2(2):e84–98.