2 - TNF Inhibitors

Question 1

Increased lesion and serum TNF-alpha levels correlate with severity of psoriasis

Answer 1

True

Question 2

TNF-alpha is a Th1 (T-helper 1 cell) cytokine that stimulates keratinocyte proliferation which then releases additional pro inflammatory cytokines

Answer 2

True

Question 3

TNF-alpha upregulates intracellular adhesion molecules on the surface of endothelial cells

Answer 3

True

Question 4

TNF-alpha is chemotactic for neutrophils

Answer 4

True

Question 5

Decreased liver function (such as in patients with liver disease) does not affect the efficacy of etanercept

Answer 5

True

Question 6

Etanercept can be used in patients with active hepatitis C infection

Answer 6

True (no adverse effects in these patients)

Question 7

Etanercept is a fully human dimeric fusion protein RECEPTOR that binds to both soluble and membrane bound TNF-alpha as well as TNF-beta

Answer 7

True

Question 8

The TNF-alpha inhibitors (Etanercept, Infliximab, Adalimumab) are Pregnancy Category B

Answer 8

True

Question 9

The TNF-alpha inhibitors (Etanercept, Infliximab, Adalimumab) are relatively contraindicated in patients with family history of demyelinating diseases i.e. Multiple sclerosis

Answer 9

True

Question 10

The TNF-alpha inhibitors (Etanercept, Infliximab, Adalimumab) is absolutely contraindicated in the setting of active or chronic infections

Answer 10

True

Question 11

Etanercept affects the mortality of patients with moderate to severe hepatitis

Answer 11

True (small clinical trial showed increased mortality)

Question 12

The TNF-alpha inhibitors have been associated with reactivation of Hep B fulminant hepatitis and caution and antiviral therapy is advised even without active disease

Answer 12

True

Question 13

2% of Etanercept patients will develop non-neutralising autoantibodies (not anti-drug antibodies)

Answer 13

True (and so these autoantibodies are not associated with ineffective treatment or adverse events)

Question 14

The most common adverse event associated with Etanercept is injection site reaction

Answer 14

True (delayed hypersensitivity type reaction)

Question 15

Anakinra (an IL-1 antagonist) used in conjunction with the TNF-alpha inhibitors (Etanercept, Infliximab, Adalimumab) is associated with an increased risk of serious infections

Answer 15

True

Question 16

Live-vaccines are absolutely contraindicated in patients on Etanercept (and other biological agents)

Answer 16

True (any vaccine is acceptable EXCEPT live-vaccines)

Question 17

Etanercept pre filled syringes stored in the refrigerator should be allowed to return to room temperature 15 minutes before injecting in order to reduce injection-related pain

Answer 17

True

Question 18

Infliximab is a CHIMERIC IgG monoclonal antibody specific to TNF-alpha

Answer 18

True

Question 19

The neutralising anti-drug antibodies in Infliximab treated patients may reduce efficacy of Infliximab in a minority of patients

Answer 19

True

Question 20

Infliximab neutralises soluble TNF-alpha and blocks membrane bound TNF-alpha

Answer 20

True

Question 21

Etanercept prevents TNF-alpha from binding to any cell surface receptors

Answer 21

True

Question 22

Infliximab should not be given to any patient with a hypersensitivity to murine (mouse) proteins

Answer 22

True (derived from mouse and human sources)

Question 23

Infliximab >5mg/kg is absolutely contraindicated in patients with congestive cardiac failure

Answer 23

True (absolute contraindication for >5mg/kg - significant mortality and hospitalisation, OK for lower dose)

Question 24

Infliximab may be prescribed in HIV patients

Answer 24

True (HIV patients with low viral loads and normal CD4 counts have tolerated Infliximab)

Question 25

20% of Infliximab patients experience infusion reactions

Answer 25

True

Question 26

Anti-drug antibodies to Infliximab is associated with an increased clearance rate of Infliximab and reduced efficacy

Answer 26

True

Question 27

Anti-drug antibodies to Infliximab is associated with an increased incidence of infusion reactions

Answer 27

True

Question 28

Higher antibody titres of anti-drug antibodies to Infliximab corresponds to severity of infusion reactions or serious infectious complications

Answer 28

False

Question 29

Increasing the dose per kg or shortening the interval between doses combats the formation of anti-drug antibodies to Infliximab

Answer 29

True (other methods include premedicating with oral corticosteroids and concomitant immunomodulatory therapy I.e. Methotrexate)

Question 30

Infliximab has been associated with hepatotoxicity

Answer 30

True (active liver failure, autoimmune hepatitis, jaundice, cholestasis)

Question 31

Adalimumab is a fully human IgG recombinant monoclonal antibody to TNF-alpha

Answer 31

True

Question 32

All 3 TNF-alpha inhibitors (Etanercept, Infliximab, Adalimumab) are metabolised via proteolysis and excreted into the bile and urine

Answer 32

True

Question 33

The most common adverse event for Adalimumab is injection site reaction

Answer 33

True

Question 34

The rate of neutralising (anti-drug) antibody production for Adalimumab was 5%, with no correlation with adverse event or disease activity

Answer 34

True

Question 35

Methotrexate can reduce the clearance of Adalimumab after multiple dosing, but this does not reduce Adalimumab's efficacy

Answer 35

True

Question 36

There is an increased risk of active TB infection with the TNF-alpha inhibitors

Answer 36

True (monoclonal antibodies Infliximab and Adalimumab associated with higher rates than Etanercept)

Question 37

Once TB infection has been treated, TNF-alpha inhibitors can be started

Answer 37

True

Question 38

Invasive fungal infections are associated with TNF-alpha inhibitors treatment

Answer 38

True

Question 39

TNF-alpha inhibitors are contraindicated in chronic carriers of Hepatitis B (Hep B surface antigen positive)

Answer 39

True (there is risk of reactivation of Hepatitis B and clinicians are cautioned before using these drugs in patients with history of Hep B)

Question 40

Patients with congestive cardiac failure should use TNF-alpha inhibitors with caution

Answer 40

True

Question 41

Positive ANA and anti-dsDNA induction has been associated with the TNF-alpha inhibitors, although the incidence of drug-induced lupus/SLE/lupus-like syndrome remains low

Answer 41

True

Question 42

TNF-alpha inhibitors may rarely cause haematologic toxicity (leukopenia, neutropenia, thrombocytopenia, pancytopenia)

Answer 42

True

Question 43

The risk of lymphoma and skin cancer is unclear in patients on TNF-alpha inhibitors

Answer 43

True

Question 44

Patients with underlying conditions that predispose to infection i.e. Diabetes should be monitored closely whilst on TNF-alpha inhibitors

Answer 44

True (it is reasonable to withdraw therapy in patients with active infections)