Updated: 12/22/2017

TNF-alpha Inhibitors

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Questions
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Evidence
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Topic
Overview

Snapshot
  • A 40-year-old woman presents to her physician’s office for management of her newly diagnosed rheumatoid arthritis. She reports that she has not tried any long-term medication for this disease and seeks advice. She is counseled on the immunosuppressive effects of this class of medications and is tested for latent tuberculosis prior to starting therapy.
Introduction
  • Tumor necrosis factor (TNF)-α inhibitors
    • categories
      • fusion proteins
      • monoclonal antibodies
  • Mechanism of action
    • inhibits physiologic response to TNFα, an important component of inflammation
  • Toxicity
    • immunosuppression
      •  risk of infections
      •  risk of lymphomas
    • reactivation of latent tuberculosis
      • TNF-α plays a key role in granuloma formation and stabilization
      • must always test for tuberculosis prior to starting TNF-α inhibitors
Fusion Proteins
  • Medications
    • etanercept
  • Mechanism of action
    • fusion protein of the receptor for TNFα and immunoglobulin (Ig) G1 Fc
      • produced by recombinant DNA
    • acts as a decoy TNFα receptor
  • Clinical use
    • ankylosing spondylitis
    • psoriasis
    • rheumatoid arthritis
  • Toxicity
    • immunosuppression
    • lupus-like syndrome
Monoclonal Antibodies
  • Medications
    • infliximab
    • adalimumab
    • certolizumab
    • golimumab
  • Mechanism of action
    • anti-TNFα monoclonal antibody
  • Clinical use
    • ankylosing spondylitis
    • hidradenitis suppurativa
    • inflammatory bowel disease
    • psoriasis
    • rheumatoid arthritis
  • Toxicity
    • immunosuppression
    • gastrointestinal irritation

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Questions (3)
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(M1.MK.15.75) A 43-year-old female presents with several years of pain and stiffness in her wrists and hands. Her symptoms have been getting progressively worse. She reports that her hands feel stiff for an hour or more after awaking in the morning. She undergoes subsequent testing, and is found to have anti-citrullinated protein antibodies. Her physician is concerned for rheumatoid arthritis, and discusses treatment with a biologic disease-modifying anti-rheumatic agent.

Which of the following must be done before beginning treatment with a TNF inhibitor?

QID: 106868
1

Confirm diagnosis with a test for rheumatoid factor

5%

(7/139)

2

Confirm diagnosis with elevated ESR and CRP

6%

(9/139)

3

Test for latent mycobacterial infection

83%

(116/139)

4

Obtain a radiograph demonstrating osteophytes

0%

(0/139)

5

Obtain an exercise stress test

4%

(5/139)

M 3 C

Select Answer to see Preferred Response

(M1.MK.14.201) A 36-year-old female presents with a 6-month history of stiffness in her joints. She reports bilateral knee pain that is worse in the morning prior to activity and stiffness of the fingers in both hands. Anti-CCP antibody tests are positive. Over several months, the patient's symptoms prove unresponsive to NSAIDs and methotrexate, and the decision is made to begin infliximab. Which of the following drugs has the most similar mechanism to inflixmab?

QID: 106235
1

Imatinib

20%

(11/55)

2

Indomethacin

5%

(3/55)

3

Cyclophosphamide

4%

(2/55)

4

Trastuzumab

67%

(37/55)

5

Allopurinol

0%

(0/55)

M 1 D

Select Answer to see Preferred Response

Evidence (3)
EXPERT COMMENTS (3)
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