Screening and prevention of infections associated with IL-4 and IL-5 inhibitors and anti-IgE monoclonal antibodies

Medication	Effect on immune system	Associated infections^*	Pre-treatment screening^¶	Pre-treatment vaccinations	Comments
IL-4 inhibitors
Dupilumab	Inhibits IL-4 and IL-13 proinflammatory cytokine pathways	Keratitis (due to HSV)^Δ	Screening for TBI, HBV, and HCV can be decided on a case-by-case basis^◊	Routine age-appropriate vaccinations	The impact of dupilumab on infections due to helminths and chronic infections with HBV, HCV, and HIV are unknown, as patients with these conditions were excluded from clinical trials.
IL-5 inhibitors and anti-IgE monoclonal antibody
Benralizumab (IL-5)	Inhibits IL-5, leading to depletion of circulating and tissue-resident eosinophils	Theoretical increased risk for parasitic infections (particularly benralizumab) No clear increased incidence of infection, although multiple cases of herpes zoster reactivation have been reported in patients taking mepolizumab	In patients at high risk for parasitic infection^§, obtain the following: Stool microscopy for ova, cysts, and parasites Strongyloides spp IgG serology	RZV (mepolizumab only)^¥	If pre-treatment screening was performed and revealed parasitic infection, treat prior to initiating biologic agent.
Mepolizumab (IL-5)
Reslizumab (IL-5)
Omalizumab (IgE)	Inhibits circulating IgE, preventing activation of mast cells and release of inflammatory proteins

This table serves as an overview of how to evaluate for and prevent infections in patients starting and/or taking IL-4 inhibitors, IL-5 inhibitors, or anti-IgE monoclonal antibody. Infections highlighted in bold have been specifically associated with the biologic agent and warrant extra consideration.

HBV: hepatitis B virus; HCV: hepatitis C virus; HIV: human immunodeficiency virus; HSV: herpes simplex virus; IL: interleukin; IgE: immunoglobulin E; RZV: recombinant zoster vaccine; TBI: tuberculosis infection.

* In addition to the infections listed, typical, common bacterial and viral infections should also be considered in the differential when infection is suspected in a patient taking the specified agent.

¶ For patients who do not have a negative HIV test documented in their records or are at increased risk of acquiring HIV (eg, men who have sex with men, engagement in sex work), the pre-treatment infectious screening process is a good opportunity to provide routine HIV screening prior to the initiation of immunosuppression. Treat any latent or active infections found on pre-treatment screening. Control of infection should be demonstrated prior to initiating immunosuppressive therapy.

Δ Most conjunctivitis seen in patients taking dupilumab is non-infectious, although bacterial and viral conjunctivitis can rarely occur.

◊ Since there are no data indicating increased risk of reactivation with TBI and HBV in patients taking dupilumab, screening for TBI, HBV, and HCV can be decided on a case-by-case basis, based on the patient's risk factors and prior screening history for each of these infections.

§ Individuals at increased risk of parasitic infection are those who live or recently traveled from parasite-endemic countries.

¥ Not necessary to delay starting biologic agent to complete vaccination. RZV vaccination is especially important in those over the age of 50 years.

Graphic 143346 Version 1.0

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Screening and prevention of infections associated with IL-4 and IL-5 inhibitors and anti-IgE monoclonal antibodies