Treatment of Inflammatory Bowel Disease with Biologics

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heart during ischemic injury [ 103 ]. Furthermore, TNF-α induces production of
nitric oxide which maintains peripheral blood flow in patients with heart failure
[ 104 ]. A certain physiologic level of TNF-α is likely necessary for tissue remodel-
ing and repair in patients with cardiac injury, including heart failure [ 105 ]. Therefore,
anti-TNF therapy, with a resultant decrease in TNF-α, may interfere with myocar-
dium repair and remodeling [ 102 ], consequently leading to the development of
heart failure.

Diagnosis and Management

Anti-TNF therapy should be discontinued when symptoms of heart failure develop
[ 92 ]. Classic findings on diagnostic evaluation include decreased left ventricular
function on echocardiogram, increased pulmonary pressure on cardiac catheteriza-
tion, and/or pulmonary congestion on chest radiography [ 92 ].
Among the 10 patients younger than 50 years of age with new-onset heart fail-
ure, 9 of these 10 patients reported discontinuation of anti-TNF therapy [ 92 ]. With
heart failure treatment, 3 patients reported complete resolution of heart failure, 6
patients had improvement, and 1 patient died [ 92 ]. In patients who develop heart
failure after receiving anti-TNF therapy, rechallenging with another anti-TNF ther-
apy is not recommended. Anti-TNF therapy should be avoided in patients with
NYHA class III or IV [ 97 , 98 ]. In patients with NYHA class I or II heart failure,
providers should consider using an alternative therapy for IBD if possible [ 106 ]. If
anti-TNF therapy use is considered in these patients, a cardiology consultation and
a baseline echocardiography with close monitoring are advised.

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14 Noninfectious and Nonmalignant Complications of Anti-TNF Therapy