Tumour necrosis factor inhibitors: maximizing patient safety
A. P. Cairns and
A. J. Taggart
Department of Rheumatology, Musgrave Park Hospital, Stockman's Lane, Belfast, BT9 7BJ, Northern Ireland
SIR, The tumour necrosis factor
(TNF-
)-inhibiting drugs infliximab and etanercept have revolutionized the management of severe rheumatoid arthritis and other inflammatory arthropathies. By blocking TNF-
they exert potent immunosuppressive effects in a group of patients already at increased risk of infection [1]. Whilst controlled clinical trials have shown no overall increase in the risk of sepsis with these agents [2, 3], there have been a number of reports of serious infection amongst patients who have received these drugs in everyday clinical practice [48]. Whilst it remains to be seen whether the link between the drug therapy and sepsis is causal, there is no doubt that the risk of infection is an important safety issue in these patients.
We have attempted to maximize patient safety using a programme of education and safety monitoring. All of our patients are instructed about the potential risks of anti-TNF-
therapy (including sepsis) prior to commencing treatment. They are told to consult their doctor if they develop any signs of infection and those who are receiving etanercept are asked to stop their injections immediately if they feel unwell. In spite of this, a number of patients have failed to discontinue anti-TNF therapy whilst receiving antibiotic therapy for intercurrent infection because of a concern that their joint symptoms might return.
Patients receiving long-term corticosteroids are often asked to carry a card to remind themselves and any attending physician of the risks of suddenly stopping treatment. Using the same principle, we have designed a biological therapy treatment card to highlight the risks of infection whilst on these drugs (Fig. 1
). This emphasizes the importance of stopping biological therapy and seeking help immediately if the patient develops symptoms suggestive of infection. The card is a handy credit card size that can be easily carried in the wallet or purse. It contains details of our 24 h telephone helpline, which is available to patients and health-care professionals who may be unfamiliar with these new therapies.
Our experience in treating nearly 100 patients with anti-TNF-
drugs [9] has convinced us of their value to patients with severe inflammatory arthritis. Now that The National Institute for Clinical Excellence has recommended that funding be provided for these drugs [10], it is important that we take every measure to maximize patient safety, and we suggest that rheumatology units consider using similar cards for their patients.
Notes
Correspondence to: A. P. Cairns. E-mail: andrewcairns{at}doctors.org.uk 
References
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Accepted 10 June 2002