title: Biologic Therapies and Risk of Infection and Malignancy in Patients With Inflammatory Bowel Disease: A Systematic Review and Network Meta-analysis.
abstract: Safety issues are a major concern for patients considering treatments for inflammatory bowel disease (IBD). We performed a systematic review and meta-analysis to determine whether biologic agents affect the risk of infection or malignancy in adults with IBD.
  
  
  
  We searched PubMed, Embase, Scopus, Cochrane IBD Group Specialized Trials Register, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov through March 2016 for randomized placebo-controlled or head-to-head trials of biologic agents approved for treatment of adults with IBD (ie, adalimumab, certolizumab, golimumab, infliximab, natalizumab, or vedolizumab). Two reviewers independently extracted study data and outcomes (serious infections, opportunistic infections, tuberculosis, any infection, and malignancies) and rated each trial's risk of bias. We used conventional meta-analysis to synthesize direct evidence and a network meta-analysis for adjusted indirect treatment comparisons.
  
  
  
  We identified 49 randomized placebo-controlled studies comprising 14,590 participants. Synthesis of the evidence indicated that patients treated with biologics had a moderate increase in risk of any infection (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.10-1.29) and a significant increase in risk of opportunistic infections (OR, 1.90; 95% CI, 1.21-3.01). Risk of serious infections was not increased in patients treated with biologics (OR, 0.89; 95% CI, 0.71-1.12). On the contrary, biologics appeared to significantly reduce risk of serious infections in studies with low risk of bias (OR, 0.56; 95% CI, 0.35-0.90). We did not find an increased risk of malignancy with use of biologic agents (OR, 0.90; 95% CI, 0.54-1.50), but data were insufficient in terms of exposure and follow-up times. None of the indirect comparisons, either among the individual agents or between the anti-tumor necrosis factor and anti-integrin classes, reached significance for any of the outcomes analyzed.
  
  
  
  On the basis of a systematic review and meta-analysis, biologic agents increase the risk of opportunistic infections in patients with IBD, but not the risk of serious infections. It is necessary to continue to monitor the comparative and long-term safety profiles of these drugs.
authors.affiliation: IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy. Electronic address: sbonovas@gmail.com.
authors.forename: Stefanos
authors.initials: S
authors.lastname: Bonovas
authors.affiliation: IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy.
authors.forename: Gionata
authors.initials: G
authors.lastname: Fiorino
authors.affiliation: IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy.
authors.forename: Mariangela
authors.initials: M
authors.lastname: Allocca
authors.affiliation: Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain; Centre for Research in Environmental Epidemiology, Barcelona, Spain; Hellenic Center for Disease Control and Prevention, Athens, Greece.
authors.forename: Theodore
authors.initials: T
authors.lastname: Lytras
authors.affiliation: Hellenic Center for Disease Control and Prevention, Athens, Greece.
authors.forename: Georgios K
authors.initials: GK
authors.lastname: Nikolopoulos
authors.affiliation: Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Vandoeuvre-lès-Nancy, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Peyrin-Biroulet
authors.affiliation: Department of Biomedical Sciences, Humanitas University, Milan, Italy.
authors.forename: Silvio
authors.initials: S
authors.lastname: Danese
mesh_terms: D001691:Biological Therapy / Q000009:adverse effects* / Q000379:methods; D005770:Gastrointestinal Neoplasms / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D007155:Immunologic Factors / Q000008:administration & dosage / Q000009:adverse effects*; D015212:Inflammatory Bowel Diseases / Q000150:complications* / Q000628:therapy*; D009894:Opportunistic Infections / Q000453:epidemiology* / Q000209:etiology; D010919:Placebos / Q000008:administration & dosage; D016896:Treatment Outcome
chemical_list: D007155:Immunologic Factors; D010919:Placebos
keywords: Anti-TNF; Antibody; Cancer Risk Factor; Side Effect