What is the concern for someone with a Candida infection on Golimumab (golimumab)?

From the Guidelines

The primary concern for someone with a candida infection on golimumab is the increased risk of worsening infection due to golimumab's immunosuppressive effects, which can lead to severe morbidity and mortality if not promptly addressed. Golimumab, a TNF-alpha inhibitor, suppresses the immune system, allowing opportunistic infections like candidiasis to spread more easily and become more severe 1. The treatment of candida infection should be initiated promptly, typically with antifungal medications, and the choice of antifungal therapy should be guided by the severity of the infection, the species of Candida, and the patient's underlying health status.

Key Considerations

• The use of echinocandins has emerged as a preferred agent for most episodes of candidemia and invasive candidiasis due to their strong safety profile, convenience, early fungicidal activity, and trend toward better outcomes 1.
• Temporary discontinuation of golimumab may be necessary until the infection is controlled, and this decision should be made in consultation with both the prescribing rheumatologist or gastroenterologist and an infectious disease specialist.
• Patients should monitor for worsening symptoms such as spreading rash, fever, or increased pain, and seek immediate medical attention if these occur.

Management Approach

• Prompt initiation of antifungal therapy is critical to prevent the spread of infection and reduce the risk of morbidity and mortality.
• The choice of antifungal therapy should be guided by the severity of the infection, the species of Candida, and the patient's underlying health status.
• Close monitoring of the patient's response to treatment and adjustment of the treatment plan as needed is essential to ensure optimal outcomes.

Underlying Mechanism

• Golimumab's blockage of TNF-alpha creates an environment where candida can proliferate more easily, leading to an increased risk of worsening infection.
• The immune system plays a critical role in fighting fungal infections, and suppression of the immune system by golimumab can lead to severe consequences if not properly managed.

From the FDA Drug Label

1. 6 Use with Abatacept In controlled trials, the concurrent administration of another TNF blocker and abatacept was associated with a greater proportion of serious infections than the use of a TNF blocker alone;
2. 8 Switching Between Biological Disease-Modifying Antirheumatic Drugs Care should be taken when switching from one biological product to another biological product since overlapping biological activity may further increase the risk of infection.
3. 9 Hematologic Cytopenias There have been reports of pancytopenia, leukopenia, neutropenia, agranulocytosis, aplastic anemia, and thrombocytopenia in patients receiving golimumab.
4. 10 Vaccinations/Therapeutic Infectious Agents Live Vaccines Patients treated with SIMPONI may receive vaccinations, except for live vaccines. In patients receiving anti-TNF therapy, limited data are available on the response to live vaccination, or on the secondary transmission of infection by live vaccines Use of live vaccines could result in clinical infections, including disseminated infections.

The concern for someone with a candida infection on golimumab is the increased risk of serious infections. Patients treated with SIMPONI (golimumab) may be at a higher risk of developing disseminated infections, including fungal infections such as candida.

• Key points to consider:
  • Increased risk of serious infections with concurrent use of other biologic agents
  • Risk of disseminated infections with live vaccines
  • Reports of hematologic cytopenias, which may increase the risk of infection
  • Need for caution when switching between biologic agents due to overlapping activity and increased risk of infection 2

From the Research

Concerns for Someone with a Candida Infection on Golimumab

• The primary concern for someone with a candida infection on golimumab is the increased risk of invasive candidiasis, which is associated with high mortality rates and prolonged hospital stay 3.
• Golimumab, an immunosuppressive medication, can increase the risk of developing opportunistic infections, including candidiasis.
• The treatment of candidiasis in patients on golimumab may be challenging due to the potential for antifungal resistance and the need for careful selection of antifungal agents.

Antifungal Treatment Options

• Echinocandins, such as caspofungin and micafungin, are recommended as first-line treatments for invasive candidiasis 3.
• Azoles, such as fluconazole, can be used as second-line treatments in cases of fungal resistance or hypersensitivity 3.
• The combination of antifungal agents with protease inhibitors may be effective in preventing and treating candida biofilm infections 4.

Management of Invasive Candidal Infections

• A prospective, randomized, multicenter study compared fluconazole and amphotericin B in the treatment of candidal infections and found similar overall response rates, but fluconazole was better tolerated 5.
• The development of new antifungal agents and therapeutic strategies is necessary to address the growing problem of antifungal resistance 6.
• In vitro models have been used to evaluate the antifungal activity of various agents, including amphotericin B, fluconazole, and voriconazole, against catheter-related bloodstream Candida infection 7.