Neufassung der Empfehlungen der Kommission Pharmakotherapie der DGRh

[Biologicals 2012]

Therapy with biologicals for the management of rheumatic diseases has improved treatment options and dramatically increased expectations of patients and doctors. Remission is a reasonable therapeutic aim, as well as inhibition of progression of structural damage. In 2012, five TNF-α inhibitors and four other biologicals targeted against Il-1, IL-6, B-lymphocytes and cell-cell interaction, have become available. Safety data for biological therapy are reassuring, based on a large amount of study data and data collected from national registries. The most important side-effect is a slightly increased tendency to infections (up to doubled in the first treatment year, depending on other factors such as previous infections and comorbidities). An increased risk for cancer (with the exception of preliminary data supporting a possible increase of skin cancer) has not been observed for patients treated with anti-TNF-α. Screening for tuberculosis as well as completing of vaccinations is necessary before starting treatment.

Immunization of patients with rheumatoid arthritis with antitumor necrosis factor alpha therapy and methotrexate

PURPOSE OF REVIEW

The aim of this study is to highlight the recent findings on the use of methotrexate and/or TNFalpha-blockers in adult patients with rheumatoid arthritis and their effects on the immune response to various vaccines.

RECENT FINDINGS

Regarding influenza vaccination, methotrexate monotherapy is not associated with a decreased response, whereas the use of etanercept and infliximab in combination with methotrexate may cause lower titers and lower response rates. Concerning pneumococcal vaccination, methotrexate seems to impair responsiveness. The concomitant use of adalimumab and methotrexate is also associated with decreased response, whereas the concomitant use of etanercept or infliximab seems not to have an effect on response rates. As immunological pathways seem to play a major role, T-cell-dependent pneumococcal vaccines are designed to achieve higher response rates and protective titers.

SUMMARY

Patients with rheumatic disorders are more likely to develop preventable infectious diseases, which underlines the importance of adequate immunoprotective titers. Several studies have shown that the combination of methotrexate and certain TNFalpha-blockers are affecting the responsiveness to vaccines. Further findings indicate that the response also depends on what type of vaccine is used.

Moderne Behandlung des Morbus Bechterew

Bechterew's disease belongs to subgroup of spondyloarthritis. Even today there is still a delay of 5-10 years between the first occurrence of symptoms and the final diagnosis of ankylosing spondylitis. Without treatment the spine increasingly stiffens and the peripheral (mostly large) joints are often destroyed by inflammatory processes. Ankyloses of the joints between vertebrae and ribs may cause stiffness of the thorax. As the complaints most often start within the third decade of life and show a chronic progressive course, even young adults often have to deal with a considerable impairment due to pain and stiffness. Thus, early diagnosis is of utmost importance as today treatment with novel drugs is feasible and the TNFalpha inhibitors are particularly effective during the early stages of the disease. All conservative orthopedic measures are used concomitantly. Surgery encompasses the early resection of inflamed mucosa in joints. In later stages of the disease reconstructive methods, i.e. prosthetics are often applied. Spondylodesis to erect the body, necessary in the end stage of the disease, is beneficial, but elaborate.