α α Pneumocystis jirovecii

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1 α α Key words α α Pneumocystis jirovecii I α

2 Table 1. Biologics currently approved in Japan for autoimmune inflammatory diseases (as of Dec, 2016) Classification Preparations that target cytokines or cytokine receptors Preparations that target functional molecules on the cell surface TNF inhibitors Chimeric anti-tnf antibody Human anti-tnf antibody PEGylated humanized anti-tnf antibody TNF receptor-fc fusion protein Generic Name Infliximab Adalimumab Golimumab Certolizumab pegol Etanercept IL-1 inhibitor Anti-IL-1b antibody Canakinumab IL-6 receptor inhibitor Humanized anti-il-6 receptor antibody Tocilizumab IL-12/23 inhibitor Human anti IL-12/IL-23p40 antibody Ustekinumab IL-17 inhibitor Human anti-il-17a monoclonal antibody Humanized anti-il-17a monoclonal antibody Fully human anti-il-17 receptor antibody Secukinumab Ixekizumab Brodalumab T-cell co-stimulatory molecular inhibitor CTLA4-Fc fusion protein Abatacept B-cell inhibitor Chimeric anti-human CD20 antibody Rituximab TNF: tumor necrosis factor, IL: interleukin, CTLA4: cytotoxic T-lymphocyte antigen 4 Table 2. Incidence of major infections in post-marketing studies (PMS) of all cases of rheumatoid arthritis patients administered biologics in Japan 1) Infliximab (5,000) Etanercept (13,894) Generic Name (No. of cases) Adalimumab (7,740) Tocilizumab (7,901) Abatacept (3,985) Pneumonia (%) Tuberculosis (%) PCP (%) NTM (%) Herpes zoster (%) N.D. PCP: Pneumocystis jirovecii pneumonia, NTM: non-tuberculous mycobacteriosis II TNF-α α α α γ α III

3 C: Cytokine and chemokine release Attraction and stimulation of CD4 and CD8 lymphocytes, /lymphocytes Increased T-cell adhension, antigen presentation Proliferation and recruitment of T and B cells TNF- Alveolar macrophage B: TNF- release and autocrine stimulation D: Activated T cells release interferon, further activating macrophages Increased antigen presentation Intracellular killing of bacilli Macrophage apoptosis, granuloma formation A: Phagocytosis of bacilli Fig. 1. Schematic representation of the central role of TNF- in the cellular immune response to M.tuberculosis infection (In: Gardam MA, et al. Lancet Infect Dis 2003, 3: ) 2) α α α α α α IV α α V TNF-α α α VI TNF-α α

4 Adequate medical interviews, chest X-ray and CT examinations, IGRA and/or tuberculin skin test Comprehensive assessment of tuberculosis Suspicious or unknown Evaluation possible Evaluation by respiratory specialist/radiologist Diagnosis Active tuberculosis Start of treatment for active tuberculosis *Three weeks prior to the administration of Biological Agents, anti-tuberculosis drugs (isoniazid, etc. ) are given and thereafter a dministered concurrently for a total of six to nine months Existing latent tuberculosis infection (including suspect cases) Start of treatment for latent tuberculosis infection* History of tuberculosis not recognized Start of Biological Agents administration Fig. 2. Preventative measures for tuberculosis before administration of biologics 1) Table 3. Efficacy of various durations of isoniazid therapy compared with placebo: all assigned participants (In: IUAT Committee on prophylaxis. Bull World Health Organ 1982, 60: ) 9) Regimen No. of participants entering regimen Cumulative no. of cases with tuberculosis 5-Year Incidence a Percentage reduction Relative risk Placebo 6, b weeks 6, (31) d weeks 6, b (69) d weeks 6, c (93) d 1.0 a Culture-positive tuberculosis per 1,000 persons at risk b Includes 1 case during the first 6 months of pill-taking c Includes 2 cases during the first 6 months of pill-taking d Percentage reduction in the completer/compliers α

5 VII α Mycobacterium marinum α α α VIII NTM Mycobacterium avium α Mycobacterium avium Mycobacterium abscessus M.marinum IX NTM M.avium Mycobacterium intracellulare M.abscessus α X NTM α α

6 XI NTM XII XIII PCP β XIV XV

7 Mycobacterium marinum Mycobacerium avium α α

8 Pneumocystis jirovecii

9 α α α

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