Can a patient with pneumonia and a history of autoimmune disease, such as rheumatoid arthritis, Crohn's disease, or psoriasis, resume Remicade (Infliximab) treatment?

Remicade (Infliximab) Should Be Withheld During Active Pneumonia and Resumed Only After Complete Resolution of Infection

Infliximab must be discontinued in the presence of serious infection, including pneumonia, and should not be restarted until the infection has completely resolved with appropriate antibiotic therapy. 1

Immediate Management During Active Pneumonia

• Stop infliximab immediately when pneumonia is diagnosed, as anti-TNF therapy should not be started in the presence of infection and must be discontinued during serious infections 1
• Initiate appropriate antibiotic therapy based on the causative organism and clinical severity 1
• Monitor closely for clinical deterioration, as infliximab increases infection risk approximately twofold, with serious infections including pneumonia being among the most common adverse events 1

Critical Safety Considerations

Infection Risk Profile

• Pneumonia was specifically reported as more frequent in infliximab-treated patients compared to placebo (4.4% vs 0% in sarcoidosis trials; 10 vs 1 case in COPD trials) 1
• The FDA label documents that infections are the most common adverse events with infliximab, with lower respiratory tract infections including pneumonia being specifically noted as serious adverse reactions 2
• Opportunistic infections including Pneumocystis jiroveci pneumonia have been reported, with a 27% mortality rate in one review of 84 cases, occurring on average 21 days after infusion 3

Underlying Disease Considerations

• Patients with autoimmune diseases (rheumatoid arthritis, Crohn's disease, psoriasis) already have baseline increased infection risk that is further amplified by TNF inhibition 1
• Concomitant immunosuppressive medications commonly used with infliximab (methotrexate, azathioprine, corticosteroids) compound infection risk 1, 3

Criteria for Resuming Infliximab After Pneumonia

Minimum Requirements Before Restarting

• Complete clinical resolution of pneumonia symptoms (fever, cough, dyspnea, chest pain) 1
• Completion of full antibiotic course appropriate for the causative organism 1
• Radiographic improvement or resolution on chest imaging if initially abnormal 1
• Normalization of inflammatory markers (CRP, ESR, white blood cell count) if elevated 1

Timing Considerations

• For uncomplicated community-acquired pneumonia treated in the outpatient setting, consider restarting infliximab 7-14 days after complete symptom resolution 1
• For pneumonia requiring hospitalization or with complications, timing should be individualized based on severity, but generally wait at least 2-4 weeks after clinical resolution before resuming 1
• Ensure patient is completely asymptomatic and has returned to baseline functional status before reinfusion 1

Monitoring After Resumption

Pre-Infusion Assessment

• Obtain vital signs including temperature to rule out occult infection 1
• Assess for any residual respiratory symptoms (cough, dyspnea, chest discomfort) 2
• Consider repeat chest radiograph if initial pneumonia was severe or slow to resolve 1

Ongoing Surveillance

• Instruct patient to monitor temperature frequently and report fever immediately 1
• Educate patient to report signs of recurrent infection including cough, fever, chills, shortness of breath, or changes in breathing 1
• Monitor for signs of opportunistic infections given the increased risk with anti-TNF therapy 1

Common Pitfalls to Avoid

• Do not resume infliximab based solely on subjective improvement without objective evidence of infection resolution (afebrile status, normal inflammatory markers, radiographic improvement) 1
• Do not restart too early even if patient feels better, as premature resumption increases risk of recurrent or persistent infection 1
• Do not overlook atypical or opportunistic pathogens (Pneumocystis, Nocardia, tuberculosis) that may require prolonged therapy before safely resuming immunosuppression 3, 4
• Do not forget to screen for latent tuberculosis before resuming, as reactivation TB is a significant risk with infliximab, particularly with extrapulmonary involvement 1

Alternative Management Strategies

• If recurrent pneumonias occur on infliximab, consider switching to a different mechanism of action (IL-6 inhibitor, JAK inhibitor, or different TNF inhibitor with potentially lower infection risk) 1, 5
• Evaluate for underlying predisposing factors (structural lung disease, immunoglobulin deficiency, chronic aspiration) that may require additional management 1
• Consider prophylactic strategies if patient has recurrent infections, though specific recommendations for infliximab are not established 1