An antagonist to TNF-alpha should not be started in patients with a family or personal history of:
(1) multiple sclerosis
(2) optic neuritis
(3) transverse myelitis
(4) Guillain-Barre syndrome
(5) other demyelinating condition
The patient should be informed about the risks of developing a demyelinating condition during the therapy. Refusal by the patient is a contraindication to therapy.
A patient started on an anti-TNF alpha therapy should be instructed to immediately report any of the clinical findings associated with optic neuritis:
(1) ocular pain
(2) loss of visual acuity
(3) abnormality in visual fields
(4) abnormal perception of colors (dyschromatopsia)
The evaluation of a patient receiving anti-TNF-alpha therapy should include:
(1) testing of visual acuity
(2) checking of color vision
(3) testing of papillary response
(4) examination of the visual fields
(5) fundoscopy
(6) visually evoked potential (VEP) testing
If evidence of optic neuritis occurs:
(1) immediately stop the anti-TNF-alpha therapy
(2) rule out other causes of optic neuritis (sarcoid, infection, vasculitis, metabolic, tumor, etc)
(3) initiate corticosteroid therapy (intravenous methylprednisolone for 3 days, then oral prednisone with taper over 2-3 weeks)
(4) monitor closely for persistent/recurrent optic neuritis, multiple sclerosis or other demyelinating condition
