Harboe Erna, Damås Jan Kristian, Omdal Roald, Frøland Stig S, Sjursen Haakon
Infeksjonsseksjonen, Medisinsk divisjon, Stavanger universitetssjukehus, Norway.
Tidsskr Nor Laegeforen. 2012 Sep 4;132(16):1867-71. doi: 10.4045/tidsskr.12.0180.
New drugs for rheumatoid arthritis (RA) have resulted in an improvement in patients' functioning and morbidity, but are linked with increased risk of infections. Traditional immunosuppressant drugs are often used in combination with anti-tumour necrosis factor-alpha (TNF-α) inhibitors or anti-CD20 (rituximab).
The review is based on a search in PubMed and on the authors' own experience of treating infections in patients who receive immunosuppressant treatment.
Traditional immunomodulating treatment results in an increased risk of infection. The disease RA in itself increases the risk of infections. There is evidence of an increased incidence of infections with both extracellular bacteria and intracellular microorganisms such as mycobacteria, including Mycobacterium tuberculosis, and viruses in patients who are treated with TNF-α inhibitors. Patients who are about to start taking TNF-α inhibitors must therefore undergo a tuberculosis-risk assessment. Rituximab may increase the incidence of infection, but long-term observations are limited. Combination therapy involving different drugs that selectively modulate immune response is normally contraindicated because of the increased risk of infection.
The benefit of TNF-α inhibitors and rituximab treatment for RA must be weighed up against the increased risk of infections. Symptoms, findings and laboratory test results pertaining to serious infections may be influenced by immunomodulation therapy and thereby make clinical assessment difficult.
用于治疗类风湿性关节炎（RA）的新药已使患者的功能和发病率有所改善，但与感染风险增加有关。传统免疫抑制药物常与抗肿瘤坏死因子-α（TNF-α）抑制剂或抗CD20（利妥昔单抗）联合使用。
本综述基于在PubMed上的检索以及作者自身在治疗接受免疫抑制治疗患者感染方面的经验。
传统免疫调节治疗会增加感染风险。疾病RA本身也会增加感染风险。有证据表明，接受TNF-α抑制剂治疗的患者感染细胞外细菌和细胞内微生物（如分枝杆菌，包括结核分枝杆菌）以及病毒的发生率均有所增加。因此，即将开始服用TNF-α抑制剂的患者必须接受结核病风险评估。利妥昔单抗可能会增加感染发生率，但长期观察有限。由于感染风险增加，通常禁忌使用涉及选择性调节免疫反应的不同药物的联合治疗。
TNF-α抑制剂和利妥昔单抗治疗RA的益处必须与感染风险增加相权衡。与严重感染相关的症状、体征和实验室检查结果可能会受到免疫调节治疗的影响，从而使临床评估变得困难。
