Managing infection in people taking immunomodulatory drugs
Active systemic inflammatory disease is associated with an increased risk of infection, as is treatment with immunomodulatory therapy. The relative risk of infection varies between individual immunomodulatory drugs and is greatest in people treated with high-dose corticosteroids (ie prednisolone 20 mg or more daily for at least 2 weeks, or equivalent), biological or targeted-synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), or combination therapy. Clinicians must always be alert to the possibility of infection (including opportunistic infection). If a person develops symptoms or signs of infection, complete a thorough assessment looking for a likely source. Clinicians should be aware that the usual signs and symptoms of infection are often absent in people treated with immunomodulatory drugs1.
Disease-modifying antirheumatic drugs should be withheld in people who are acutely unwell (eg dehydration, acute kidney injury) and specialist advice should be sought.
Stopping an immunomodulatory drug for a short period of time (eg less than 2 weeks) is unlikely to impact disease progression. If therapy needs to be withheld for a prolonged period, discuss with the person’s specialist. A suggested approach to managing intercurrent infections in people taking immunomodulatory drugs is described in Suggested approach for managing immunomodulatory therapy in people with an intercurrent infection.
|
Infection severity [NB1] |
Approach to immunomodulatory therapy [NB2] |
|---|---|
|
minor infection (eg URTI, small wound) not requiring treatment in hospital or antimicrobial therapy |
continue immunomodulatory therapy |
|
infection requiring antimicrobial therapy but not treatment in hospital |
withhold immunomodulatory therapy until symptoms resolve—closely monitor |
|
infection requiring treatment in hospital |
withhold immunomodulatory therapy—discuss the appropriateness and timing of restarting therapy with the specialist |
|
Note:
URTI = upper respiratory tract infection NB1: Atypical presentations of infection are more common among people treated with immunomodulatory drugs. Signs of an infection in these people can include malaise, fatigue, dyspnoea, pain and tachycardia. Fever is not always present, and occasionally serum C-reactive protein (CRP) concentration is not elevated. Have a low threshold for investigation and, if in doubt, discuss with the treating specialist. NB2: In people taking corticosteroids it is usually not appropriate to withhold therapy. In fact, increased doses may be required because of adrenocortical suppression—see Glucocorticoid replacement during intercurrent illness and surgery. | |
Specific advice on managing people with coronavirus disease (COVID-19) is beyond the scope of these guidelines. For advice, see National COVID-19 Clinical Evidence Taskforce: Living guidelines.