A short excerpt from a September 16, 2011 YouTube conversation featuring Jeffrey Bland, PhD and another clinician discussing TNF-alpha blocking agents. The speakers debate the timing of biologic therapy—'top-down' (start with biologics) versus 'step-up' (start with lifestyle/lesser meds)—and question the long-term relative risks and risk–benefit considerations of prolonged biologic use.
Is the standard of care now in the acute case using these blocking agents, and if so, what kind of relative risk does a patient experience over time on these medications?
Very good question. The use of these blocking agents, let's say for TNF alpha, have been around for a while and when to use them seems to be the question now. More recently, I guess, many academic individuals and certainly others use this approach called top down therapy. So they use the heavy biologicals first in the approach to patients rather than the step up therapy in terms of stepping up with their lifestyle and diet and some lighter medications and supplements and working their way up to the heavier biologicals when needed. So there's debate in our community as to which to use first. Some can argue with those with more aggressive disease that the biologicals make more sense, because if their disease is uncontrolled, then you need to step up to the highest therapy. Where others have very mild symptoms and are very functional, you may not want to go in that direction right away. So that's how we have our own little controversy within our field as to when to use these biological agents and.
What'S the relative risk if a patient was to be placed on those over the long term? Are there things that have emerged from your experience that are the risk benefit part of our decision making?
Yes. I rarely use those medications in my own practice, but what I have seen and what I know of is that they can develop all kinds of infections. They range from bacterial infections to the most concerning would be tuberculosis because you are really surveilling and shutting down the immune system. Others have concerns about lymphoma or malignancies. There's been many studies. Some studies show that there's a marginal increase in lymphomas and other studies show there's no increase. But we're aware that there may be something out there with malignancies because you are certainly suppressing immune surveillance with this biological type of approach.
