TNF blockade in daily practice

Abstract

In conclusion, this thesis describes different clinical aspects on the use of anti-TNF. Initial combination treatment with infliximab and methotrexate seems very promising in early RA and may even alter the course of the disease. In patients with intolerance or inadequate response to infliximab, a second TNF-blocking agent can be successful, although, the introduction of new biologicals such as rituximab and abatacept provides other therapeutic options. Further research is needed to answer the question which drugs are indicated after failing a first TNF-blocking agent, or even as initial therapy. The use of intra-articular infliximab is inferior to intra-articular depomedrol in chronic and/or recurrent gonartrtitis and this expensive treatment should not have benefit of the doubt in these patients. In contrast, the use of infliximab in rheumatoid vasculitis seems promising in patients who have contra-indication for the recommended immunosupression. Influenza- and pneumococcal vaccinations result in less and lower antibody titers during treatment with anti-TNF, however, antibodies were formed and it remains unclear whether the lower laboratory outcomes are clinically relevant. To date, most guidelines recommend vaccination in patients using immunosuppressive therapy. During the use of anti-TNF neurological symptoms comparable to those of multiple sclerosis (MS) have been described and MR changes have been detected. The use of anti-TNF should be considered as contra-indicated in patients with signs and symptoms compatible with MS.