PRETREATMENT CHECKLIST

This checklist includes a number of topics specific to the administration of REMICADE®. Use this page or download a PDF to assess your patients prior to their initial infusion to ensure they are healthy enough for REMICADE®.

SERIOUS INFECTIONS

In the past 2 weeks, have you felt very tired or experienced fever; night sweats; sore throat; runny nose; flu-like symptoms; warm, red, or painful skin; face pain; earache; tooth pain; cough; breathing problems; painful urination; urine with blood; antibiotic use; headache; an open cut or sore; or an infection that won’t go away or an infection that keeps coming back?

Have you had surgery in the past 2 weeks? If so, did you have any complications from your surgery?

Did you experience any drainage from your incision?

Do you currently have any symptoms of an active infection, even if very minor?

Do you have diabetes or an immune system problem?

BACTERIAL/FUNGAL INFECTIONS

Have you resided in regions where histoplasmosis (Ohio Valley, Mississippi River Valley), and coccidioidomycosis (Southwestern US, particularly Arizona and the San Joaquin Valley in California), or other opportunistic fungal infections are endemic?

Have you ever had tuberculosis (TB), or have you recently been near anyone who might have TB?

Were you born or have you lived in or traveled to countries where there is more risk of getting TB?

  • When was your last chest x-ray?
  • When was your last TB test, and what was the result?

Are you at risk of bacterial, viral, or other infections due to opportunistic pathogens, including Legionella and Listeria?

Made a thorough history, physical, and test for latent TB infection part of your regular examination?

  • Please refer to the latest CDC guidelines and recommendations for TB testing in immunocompromised patients

Patients who have a history of latent or active TB in whom an adequate course of therapy cannot be confirmed should be considered for latent TB treatment

Treatment of latent TB infection should be initiated prior to treatment with REMICADE®

Antituberculosis therapy prior to initiating REMICADE® should also be considered in patients who have several or highly significant risk factors for TB infection and have a negative test for latent TB. The decision to initiate antituberculosis therapy in these patients should be made only following consultation with a physician with expertise in the treatment of TB, and taking into account both the risk for latent TB infection and the risks of antituberculosis therapy

Continue to evaluate risk factors, especially in patients 65 years and older, pediatric patients, patients with comorbid conditions, and/or patients taking concomitant immunosuppressant therapy. Monitor patients for signs and symptoms of TB, pneumonia, cellulitis, abscess, and skin ulceration

MALIGNANCIES

Do you have cancer or a history of cancer or other risk factors such as chronic obstructive pulmonary disease (COPD) or phototherapy for psoriasis?

Have you been treated for Crohn’s disease or ulcerative colitis with azathioprine (AZA) or 6-mercaptopurine (6-MP)?

CONTRAINDICATIONS

Have you ever been diagnosed with congestive heart failure or other heart conditions?

  • Have you experienced shortness of breath, swelling of the ankles or feet, or sudden weight gain?

HEPATITIS B REACTIVATION

Do you think you may be a carrier of hepatitis B virus infection?

Are you experiencing any signs of hepatitis B virus infection such as feeling unwell, poor appetite, tiredness, fever, skin rash, and/or joint pain?

Have you been tested or tested positive for hepatitis B virus?

HEPATOTOXICITY

Do you have a history of liver problems?

Have you ever been diagnosed with jaundice (yellowing of the skin and eyes)?

Is your urine dark brown?

Are you experiencing any right-side abdominal pain, fever, or extreme tiredness?

HEMATOLOGIC EVENTS

Do you have or have you ever had any ongoing blood problems?

Do you have a fever that does not go away?

Do you bruise or bleed easily?

Do you look very pale?

HYPERSENSITIVITY

Do you have any drug allergies?

Have you had an allergic reaction to any of the ingredients in REMICADE®?

NEUROLOGIC EVENTS

Do you have or have you ever had a condition that affects your nervous system, such as:

  • Multiple sclerosis, optic neuritis, or Guillain-Barré syndrome, or
  • Have you experienced numbness or tingling, or
  • Have you had a seizure?

AUTOIMMUNITY

Do you have or have you ever had a lupus-like syndrome, with symptoms such as:

  • Ongoing fever
  • Persistent aching
  • Fatigue

USE WITH OTHER DRUGS

Are you currently taking, or have you recently received treatment with, anakinra, abatacept, or tocilizumab?

VACCINATIONS

Have you recently received or are you scheduled to receive a vaccine?

Are pediatric patients up-to-date with all vaccinations?

  • Have you recently given birth?
  • Were you treated with REMICADE® during your pregnancy?
  • Has your infant recently received, or is your infant scheduled to receive, a vaccine?

OTHER CONSIDERATIONS

Are you pregnant or are you planning to become pregnant?

  • Pregnancy checks should be performed before each infusion of REMICADE®

Are you breast-feeding or are you planning to breast-feed?

Are there any changes in your recent medical history?

Which medications are you currently taking?

What is your current weight?

 

REMICADE® is indicated for:

Crohn's Disease
  • Reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease (CD) who have had an inadequate response to conventional therapy
  • Reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing CD
Pediatric Crohn's Disease
  • Reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age or older with moderately to severely active CD who have had an inadequate response to conventional therapy
Ulcerative Colitis
  • Reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis (UC) who have had an inadequate response to conventional therapy
Pediatric Ulcerative Colitis
  • Reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active UC who have had an inadequate response to conventional therapy
Rheumatoid Arthritis
  • Reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active rheumatoid arthritis (RA) in combination with methotrexate (MTX)
Psoriatic Arthritis
  • Reducing signs and symptoms of active arthritis, inhibiting the progression of structural damage, and improving physical function in patients with psoriatic arthritis (PsA)
Ankylosing Spondylitis
  • Reducing signs and symptoms in patients with active ankylosing spondylitis (AS)
Plaque Psoriasis
  • The treatment of adult patients with chronic severe (ie, extensive and/or disabling) plaque psoriasis who are candidates for systemic therapy and when other systemic therapies are medically less appropriate.
  • REMICADE® should only be administered to patients who will be closely monitored and have regular follow-up visits with a physician

 

SERIOUS INFECTIONS

Patients treated with REMICADE® (infliximab) are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids. Discontinue REMICADE® if a patient develops a serious infection or sepsis.

Reported infections include:

  • Active tuberculosis (TB), including reactivation of latent TB. Patients frequently presented with disseminated or extrapulmonary disease. Patients should be tested for latent TB before and during treatment with REMICADE®.1,2 Treatment for latent infection should be initiated prior to treatment with REMICADE®.
  • Invasive fungal infections, including histoplasmosis, coccidioidomycosis, candidiasis, aspergillosis, blastomycosis and pneumocystosis. Patients may present with disseminated, rather than localized, disease. Empiric anti-fungal therapy should be considered in patients at risk for invasive fungal infections who develop severe systemic illness.
  • Bacterial, viral, and other infections due to opportunistic pathogens, including Legionella and Listeria.

The risks and benefits of treatment with REMICADE® should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection. Closely monitor patients for the development of signs and symptoms of infection during and after treatment with REMICADE®, including the possible development of TB in patients who tested negative for latent TB infection prior to initiating therapy, who are on treatment for latent TB, or who were previously treated for TB infection.

Risk of infection may be higher in patients greater than 65 years of age, pediatric patients, patients with co-morbid conditions and/or patients taking concomitant immunosuppressant therapy. In clinical trials, other serious infections observed in patients treated with REMICADE® included pneumonia, cellulitis, abscess, and skin ulceration.

MALIGNANCIES

Lymphoma and other malignancies, some fatal, have been reported in children and adolescent patients treated with TNF blockers, including REMICADE®. Approximately half of these cases were lymphomas, including Hodgkin's and non-Hodgkin's lymphoma. The other cases represented a variety of malignancies, including rare malignancies that are usually associated with immunosuppression and malignancies that are not usually observed in children and adolescents. The malignancies occurred after a median of 30 months after the first dose of therapy. Most of the patients were receiving concomitant immunosuppressants.

Postmarketing cases of hepatosplenic T-cell lymphoma, a rare type of T-cell lymphoma, have been reported in patients treated with TNF blockers, including REMICADE®. These cases have had a very aggressive disease course and have been fatal. The majority of reported REMICADE® cases have occurred in patients with Crohn’s disease or ulcerative colitis and most were in adolescent and young adult males. Almost all of these patients had received treatment with azathioprine or 6-mercaptopurine concomitantly with REMICADE® at or prior to diagnosis. Carefully assess the risks and benefits of treatment with REMICADE®, especially in these patient types.

In clinical trials of all TNF inhibitors, more cases of lymphoma were observed compared with controls and the expected rate in the general population. However, patients with Crohn’s disease, rheumatoid arthritis, or plaque psoriasis may be at higher risk for developing lymphoma. In clinical trials of some TNF inhibitors, including REMICADE®, more cases of other malignancies were observed compared with controls. The rate of these malignancies among patients treated with REMICADE® was similar to that expected in the general population whereas the rate in control patients was lower than expected. Cases of acute and chronic leukemia have been reported with postmarketing TNF-blocker use. As the potential role of TNF inhibitors in the development of malignancies is not known, caution should be exercised when considering treatment of patients with a current or a past history of malignancy or other risk factors such as chronic obstructive pulmonary disease (COPD).

Melanoma and Merkel cell carcinoma have been reported in patients treated with TNF-blocker therapy, including REMICADE®. Periodic skin examination is recommended for all patients, particularly those with risk factors for skin cancer.

CONTRAINDICATIONS

REMICADE® is contraindicated in patients with moderate to severe (NYHA Class III/IV) congestive heart failure (CHF) at doses greater than 5 mg/kg. Higher mortality rates at the 10 mg/kg dose and higher rates of cardiovascular events at the 5 mg/kg dose have been observed in these patients. REMICADE® should be used with caution and only after consideration of other treatment options. Patients should be monitored closely. Discontinue REMICADE® if new or worsening CHF symptoms appear. REMICADE® should not be (re)administered to patients who have experienced a severe hypersensitivity reaction or to patients with hypersensitivity to murine proteins or other components of the product.

HEPATITIS B REACTIVATION

TNF inhibitors, including REMICADE®, have been associated with reactivation of hepatitis B virus (HBV) in patients who are chronic carriers. Some cases were fatal. Patients should be tested for HBV infection before initiating REMICADE®. For patients who test positive, consult a physician with expertise in the treatment of hepatitis B. Exercise caution when prescribing REMICADE® for patients identified as carriers of HBV and monitor closely for active HBV infection during and following termination of therapy with REMICADE®. Discontinue REMICADE® in patients who develop HBV reactivation and initiate antiviral therapy with appropriate supportive treatment. Exercise caution when considering resumption of REMICADE® and monitor patients closely.

HEPATOTOXICITY

Severe hepatic reactions, including acute liver failure, jaundice, hepatitis, and cholestasis have been reported rarely in patients receiving REMICADE® postmarketing. Some cases were fatal or required liver transplant. Aminotransferase elevations were not noted prior to discovery of liver injury in many cases. Patients with symptoms or signs of liver dysfunction should be evaluated for evidence of liver injury. If jaundice and/or marked liver enzyme elevations (eg, ≥5 times the upper limit of normal) develop, REMICADE® should be discontinued, and a thorough investigation of the abnormality should be undertaken.

HEMATOLOGIC EVENTS

Cases of leukopenia, neutropenia, thrombocytopenia, and pancytopenia (some fatal) have been reported. The causal relationship to REMICADE® therapy remains unclear. Exercise caution in patients who have ongoing or a history of significant hematologic abnormalities. Advise patients to seek immediate medical attention if they develop signs and symptoms of blood dyscrasias or infection. Consider discontinuation of REMICADE® in patients who develop significant hematologic abnormalities.

HYPERSENSITIVITY

REMICADE® has been associated with hypersensitivity reactions that differ in their time of onset. Acute urticaria, dyspnea, and hypotension have occurred in association with infusions of REMICADE®. Serious infusion reactions including anaphylaxis were infrequent. Medications for the treatment of hypersensitivity reactions should be available.

NEUROLOGIC EVENTS

TNF inhibitors, including REMICADE®, have been associated in rare cases with CNS manifestation of systemic vasculitis, seizure, and new onset or exacerbation of CNS demyelinating disorders, including multiple sclerosis and optic neuritis, and peripheral demyelinating disorders, including Guillain-Barré syndrome. Exercise caution when considering REMICADE® in patients with these disorders and consider discontinuation if these disorders develop.

AUTOIMMUNITY

Treatment with REMICADE® may result in the formation of autoantibodies and, rarely, in development of a lupus-like syndrome. Discontinue treatment if symptoms of a lupus-like syndrome develop.

ADVERSE REACTIONS

In clinical trials, the most common REMICADE® adverse reactions occurring in >10% of patients included infections (eg, upper respiratory, sinusitis, and pharyngitis),
infusion-related reactions, headache, and abdominal pain.

USE WITH OTHER DRUGS

Concomitant use of REMICADE® with anakinra, abatacept, tocilizumab, or other biologics used to treat the same conditions as REMICADE® is not recommended because of the possibility of an increased risk of infection. Care should be taken when switching from one biologic to another, since overlapping biological activity may further increase the risk of infection.

LIVE VACCINES/THERAPEUTIC INFECTIOUS AGENTS

Live vaccines or therapeutic infectious agents should not be given with REMICADE® due to the possibility of clinical infections, including disseminated infections.

Bring pediatric patients up to date with all vaccinations prior to initiating REMICADE®. At least a 6-month waiting period following birth is recommended before the administration of any live vaccine to infants exposed in utero to REMICADE®.

For more information, please see full Prescribing Information and Medication Guide for REMICADE®. Provide the Medication Guide to your patients and encourage discussion. (Requires Adobe® Reader®. Click here to download.)

References:

1. American Thoracic Society, Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med. 2000;161:S221-S247.

2. See latest Centers for Disease Control guidelines and recommendations for tuberculosis testing in immunocompromised patients.

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