Psoriatic arthritis: General principles for TNF inhibitors

General recommendations

  • Anti-TNF agents are contraindicated in patients with active, serious infections
  • Tuberculosis testing (PPD) should be performed on all patients who will be treated with TNF inhibitors as there are reports of tuberculosis reactivation in patients treated with this class of drug177
  • Do not use with live vaccines; biologically inactive or recombinant vaccines may be considered, although the immune response of these vaccines could be compromised
  • Because there is an association between anti-TNF therapy and demyelinating diseases (ie, MS), TNF inhibitors should not be used in patients with MS or other demyelinating diseases; first-degree relatives of patients with MS have an increased risk of developing MS, with a sibling relative risk of between 18 and 36, evidence strongly suggesting that TNF inhibitors should not be used in first-degree relatives of patients with MS
  • Because there have been reports of new onset and worsening of CHF in patients treated with TNF inhibitors, caution should be used when considering TNF inhibitor use in patients with CHF; it is recommended that patients with New York Heart Association class III or IV CHF avoid all use of TNF inhibitors and patients with class I or II CHF undergo echocardiogram testing; if the ejection fraction of these patients is <50%, then TNF inhibitor treatment should potentially be avoided177
  • Hepatitis B reactivation after treatment with TNF inhibitors has been reported; in the appropriate clinical setting, patients should be screened for hepatitis B infection


177. Desai SB, Furst DE. Problems encountered during anti-tumor necrosis factor therapy. Best Pract Res 2006;20:757-90.

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Citation note

When referencing this guideline in a publication, please use the following citation: Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008 May;58(5):851-64.

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