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Risks of Immunosuppressive Therapies Including Biologic Agents in Patients With Rheumatic Diseases and Co-Existing Chronic Viral Infections

Authors: Dimitrios Vassilopoulos, MD ; Leonard H Calabrese, DOFaculty and Disclosures


Abstract and Introduction


Purpose of review: A number of chronic viral infections could be reactivated by immunosuppressive agents used in rheumatic diseases. In this review, we will focus on the complex effect of immunosuppressive agents, including biologic agents, on the natural course of chronic viral infections as well as an approach to the prevention and management of therapy-induced viral reactivation.
Recent findings: Chronic viral infections that are affected by immunosuppression in the setting of an underlying rheumatic disease include those due to hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and latent infections from Epstein-Barr virus, JC virus, or varicella zoster virus. The most recent data of the effects of immunosuppressive agents are reviewed, with special emphasis on the effects of biologic therapies (anti-tumor necrosis factor, anti-B cell), on these viral agents.
Summary: Clinicians should be aware of the risk for viral reactivation of an underlying chronic viral infection during immunosuppressive therapy. Despite the existence of such risk, the presence of chronic viral infection is not a contraindication to immunosuppressive therapy, given that appropriate pretherapy screening and close monitoring is applied.


Chronic viral infections in the setting of a rheumatic disease create a number of diagnostic and therapeutic dilemmas to the caring physician. In most cases, the main concern is the potential of immunosuppressive therapies to exacerbate an underlying viral infection with detrimental effects for the host. This concern is particularly relevant today, with the widespread use of biologic agents for the treatment of a variety of rheumatic diseases.[1] These include agents that target either pro-inflammatory cytokines such as tumor necrosis factor (TNF; infliximab, etanercept, adalimumab) or interleukin-1 (anakinra), immune cells such as B cells (rituximab), or costimulatory molecules (abatacept).

In this review, we will focus on specific chronic viral infections that can be affected by immunosuppressive therapies with a special emphasis on the role of biologic agents.

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