Risk Of Serious Infection and Malignancy
Patients treated with Infliximab are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids.
Infliximab should be discontinued if a patient develops a serious infection or sepsis.
Reported infections include:
Active tuberculosis, including reactivation of latent tuberculosis. Patients with tuberculosis have frequently presented with disseminated or extrapulmonary disease. Patients should be tested for latent tuberculosis before REMICADE use and during therapy. Treatment for latent infection should be initiated prior to REMICADE use.
- Invasive fungal infections, including histoplasmosis, coccidioidomycosis, candidiasis, aspergillosis, blastomycosis, and pneumocystosis. Patients with histoplasmosis or other invasive fungal infections may present with disseminated, rather than localized, disease. Antigen and antibody testing for histoplasmosis may be negative in some patients with active infection. Empiric anti-fungal therapy should be considered in patients at risk for invasive fungal infections who develop severe systemic illness.
- Bacterial, viral and other infections due to opportunistic pathogens, including Legionella and Listeria.
The risks and benefits of treatment with Infliximab should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection.
Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with Infliximab, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.
Lymphoma and other malignancies, some fatal, have been reported in children and adolescent patients treated with TNF blockers, including Infliximab.
Postmarketing cases of hepatosplenic T-cell lymphoma (HSTCL), a rare type of T-cell lymphoma, have been reported in patients treated with TNF blockers including Infliximab. These cases have had a very aggressive disease course and have been fatal. Almost all patients had received treatment with azathioprine or 6-mercaptopurine concomitantly with a TNF-blocker at or prior to diagnosis. The majority of reported Infliximab cases have occurred in patients with Crohn's disease or ulcerative colitis and most were in adolescent and young adult males.
MONITORING RECOMMENDATIONS RELATED TO BLACK BOX DATA
- Evaluate patients for latent tuberculosis with tuberculin skin test.
- Treatment of latent infection should be initiated prior to infliximab therapy.
FDA and Industry Communications
- FDA Information on TNF Blockers
- Boxed Warning Revision for TNF Blockers: Addition of Risk of Listeria and Legionella Bacterial Infection (Sept 2011)
- Safety Review Update on Reports of Hepatosplenic T-Cell Lymphoma in Adolescents and Young Adults Receiving TNF Blockers, Azathioprine and/or Mercaptopurine (April 2011)
- FDA Safety Alert: Increased Risk of Lymphoma and Other Malignancies in Children/Adolescents Treated with TNF Blockers (August 2009)
- Revised Boxed Warning: TNF Blockers (November 2009)
Patient Counseling Information