What are the neurological side effects of infliximab (tumor necrosis factor-alpha inhibitor)?

Neurological Side Effects of Infliximab

Infliximab therapy has been associated with several neurological side effects, most notably demyelinating disorders, which require immediate discontinuation of the medication if symptoms develop. 1

Common Neurological Side Effects

• Peripheral demyelinating disorders are the most frequently reported serious neurological adverse effects, including:

  • Guillain-Barré syndrome 2
  • Chronic inflammatory demyelinating polyneuropathy 2
  • Multifocal motor neuropathy 2, 3

• Central nervous system demyelination has also been reported, though less frequently than peripheral disorders 1, 4

• Other reported neurological complications include:

  • Seizures and encephalopathy 5
  • Parkinsonism 6
  • Neuropathies of various types 2, 4

Risk Assessment and Monitoring

• TNF antagonists as a class may be associated with the development or worsening of demyelinating disease 1
• The exact mechanism of neurological complications is not fully understood, but appears to be related to the immunomodulatory effects of TNF inhibition 7
• Patients with a personal history of demyelinating disorders should not receive infliximab 1
• Caution should be exercised in patients with a first-degree relative with demyelinating disease 1

Clinical Presentation

• Neurological symptoms may present as:
  • Asymmetrical and progressive weakness in limbs 3
  • Sensory abnormalities 4
  • Focal neurological deficits 4
  • Seizures (rare) 5
  • Movement disorders such as tremor 6

Management of Neurological Side Effects

• If neurological symptoms suggestive of demyelination develop during TNF antagonist therapy:

  • Treatment should be withdrawn immediately 1
  • Specialist neurological consultation should be sought 1
  • MRI of the brain and/or spine with and without contrast may be indicated 1
  • CSF analysis may be helpful in cases of suspected central demyelination 1

• For severe neurological symptoms:

  • Intravenous immunoglobulin may be effective, particularly in cases of multifocal motor neuropathy 3
  • Corticosteroids may be considered in some cases 1

Special Considerations

• Neurological side effects may resolve after discontinuation of infliximab, though recovery time varies 3, 6
• Alternative treatment options for the underlying condition should be considered when neurological complications occur 3
• The risk of demyelination appears to be a class effect of TNF antagonists, so switching to another TNF inhibitor is not recommended 1

Monitoring Recommendations

• Maintain high clinical suspicion for neurological symptoms during infliximab therapy 1
• Educate patients to report new or worsening neurological symptoms promptly 1
• Consider baseline neurological assessment before initiating therapy in high-risk patients 1

While neurological complications are relatively rare, their potential severity warrants vigilance and prompt action if symptoms develop during infliximab treatment.