Be Alert to CNS Symptoms With TNF-α Blockade : In patients with family histories or other risk factors for multiple sclerosis, use TNF blockers cautiously.

“If you're forced to use TNF blockade because your patient has inflammatory bowel disease, RA [rheumatoid arthritis], or psoriasis that is not responding well to other [treatments], you need to watch closely for potential CNS demyelination, and that should include both clinical monitoring and periodic MRI. If a patient develops a CNS complication, TNF blockade should be interrupted and the investigation should include neurologic assessment to clarify the nature of the complication. That evaluation should include lumbar puncture, and treatment should include a corticosteroid. If the patient continues to have CNS demyelinating events following discontinuation of TNF blockade, you've probably unmasked incipient MS, in which case I would consider disease-modifying therapy for MS,” Dr. Cohen said.

The neurologist advised against looking for MS in every patient prior to starting a TNF inhibitor for treatment of inflammatory bowel disease, rheumatoid arthritis, or psoriasis. “In particular, I would not obtain an MRI unless there was some clinical suggestion of potential [for MS].” However, uveitis is a different story: “Uveitis is a manifestation that can occur in MS, so I would look very carefully for any indication of MS involvement” before beginning TNF blockade.