Update on anti-TNF-alpha treatment in rheumatic diseases

A review. The development of inhibitors of Tumor Necrosis Factor (TNF) a, a pro-inflammatory cytokine playing a pivotal role in chronic inflammatory diseases, represents a milestone in the therapy of several rheumatic diseases. Currently, three TNFa-blocking drugs are available for clin. use in rheumatic diseases: infliximab, etanercept and adalimumab. These drugs rapidly reduce disease activity and probably change the poor outcome of several chronic rheumatic diseases, by preventing the development of bone erosions, joint deformity and disability. Although these drugs have proved to be effective and well tolerated in the short period, some concerns exist about long-term safety and efficacy. In fact, the long-term use of inhibitors of TNFa, a pivotal cytokine in host defense, might result in the development of infections and neoplasms, therefore the long-term safety has to be defined. The most frightening infection to date is tuberculosis, and guidelines for the screening of patient candidates to biol. treatment has significantly reduced the risk. Parasitic and viral infections do not contraindicate biol. therapy. Lymphoma has been reported in assocn. with TNFa antagonists, but whether or not there is a causal relationship is still debated. The use of biol. agents in other rheumatic inflammatory conditions is rapidly increasing, but their cost poses a considerable financial burden on healthcare systems and a careful economic evaluation is needed.