Monitoring Requirements for Patients on Infliximab
Patients on infliximab require regular monitoring for tuberculosis, platelet counts, infections, and clinical response, with particular attention to tuberculosis screening before and during treatment. 1
Tuberculosis Monitoring
- Before starting infliximab, all patients should undergo tuberculosis screening including clinical history, physical examination, chest radiograph, and tuberculin skin testing (if not on immunosuppressive therapy) 1
- Patients with abnormal chest radiographs or history of TB should be referred to a specialist with expertise in TB management 1
- Clinical awareness of TB should be maintained throughout anti-TNF treatment and for 6 months after cessation 1
- The majority of TB cases occur within three cycles of treatment (median 12 weeks), with extrapulmonary TB being common 1, 2
- For patients at high risk (black Africans over 15 years, South Asians born outside UK), chemoprophylaxis should be considered before starting infliximab 1
- Close cooperation between prescribing clinicians and TB specialists is strongly recommended 1
Laboratory Monitoring
- Platelet counts should be regularly monitored as thrombocytopenia occurs in 1 in 500 to 1 in 1000 patients 1
- Less frequent biochemistry and hematology monitoring is required compared to conventional drug therapies, but regular clinical review remains essential 1
- Monitor C-reactive protein (CRP) levels as treatment with infliximab typically decreases serum levels 3
Clinical Response Assessment
- Patients should be seen at 12 weeks to determine whether therapy should be continued, then at 3-6 month intervals 1
- For psoriasis, adequate response is defined as ≥50% reduction in baseline PASI score and ≥5-point improvement in DLQI within 3 months 1
- Therapy should be withdrawn if adequate response is not achieved after 3 months 1
Adverse Events Monitoring
- Monitor for infusion reactions, which commonly include headache, fever, chills, and myalgia during the first few weeks of treatment 1
- Watch for skin reactions, particularly a transient acute pruritic eruption between weeks 4-10 in flexural sites, arms, neck, and trunk 1
- Monitor for serious infections, particularly tuberculosis, which may present atypically in patients on infliximab 2, 4
- Be vigilant for signs of hepatotoxicity, serum sickness-like disease, and lymphoma 5
Special Considerations
- Elderly patients have a higher incidence of infections and serious adverse reactions; more careful monitoring is required 3
- For patients on concomitant immunosuppressants, tuberculin skin tests may be unreliable (false negative); risk assessment should be individualized 1, 6
- If a patient's condition does not improve during treatment, always consider the possibility of tuberculosis infection 6
- In areas with high TB burden, consider more frequent IGRA testing, especially during early treatment (first 40 weeks) 7
Overdose Management
- If overdose occurs, monitor for signs or symptoms of adverse reactions and institute appropriate symptomatic treatment 3