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Infectious and Malignant Complications of TNF Inhibitor Therapy in IBD

Targownik, Laura E MD, MSHS1; Bernstein, Charles N MD1

American Journal of Gastroenterology: December 2013 - Volume 108 - Issue 12 - p 1835–1842
doi: 10.1038/ajg.2013.294

Tumor necrosis factor (TNF) inhibitors are being increasingly utilized in the management of inflammatory bowel disease (IBD). Although the benefits associated with TNF inhibitor therapy are undeniable, concerns have been raised about the associated risk of infectious and malignant complications. In this narrative review, we will present the evidence from studies that have evaluated the association of TNF inhibitors and both overall and specific infections and malignancy. Overall, although TNF inhibitors may increase the risk of tuberculosis, varicella, and other opportunistic infections, there is little evidence suggesting that anti-TNF agents specifically raise the overall risk of serious infections. Similarly, there is little evidence that TNF antagonists raise the risk of developing malignancy over and above the risks from concomitant therapies and the underlying disease process. However, the risk of nonmelanoma skin cancers may be increased and that is further enhanced by use of combination TNF inhibitor and thiopurine therapy. The risk of non-Hodgkin's lymphoma is statistically increased among combination therapy users. The absolute risk remains a very small but feared risk. It is difficult to fully quantify the risk of these cancers among users of TNF inhibitor therapy in the absence of concurrent thiopurine therapy. We recommend that clinicians remain mindful about the potential risks of infectious and malignant complications in their IBD patients who are using TNF inhibitors, but that further research is required to better study these risks over the long-term course of therapy.

1 University of Manitoba IBD Clinical and Research Centre and Department of Internal Medicine, Winnipeg, Manitoba, Canada

Correspondence: Charles N. Bernstein, MD, University of Manitoba, IBD Clinical and Research Centre and Department of Internal Medicine, 804F-715 McDermot Avenue, Winnipeg, Manitoba, Canada R3E3P4. E-mail:

Received 28 May 2013; accepted 30 July 2013

published online 17 September 2013

© The American College of Gastroenterology 2013. All Rights Reserved.
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