75 Administration of live vaccines (including BCG) to a neonate exposed to infliximab in the third trimester should be avoided. Human papilloma virus is a common sexually transmitted infection that has a causative role in the development of cervical dysplasia and cancer. Immune suppression may also contribute towards the development of both cervical and anal dysplasia.96 For some individuals, prolonged immunomodulation may also promote the development of HPV-related tumors. Women receiving biological agents should undergo regular gynecological screening for cervical

selleckchem cancer with a Papanicolaou test, which may need to be conducted more frequently than for usual community recommendations. In young women, human papilloma virus vaccination is a reasonable measure.93,97,98 The place of vaccination for men is less well AUY-922 defined. Monitoring.  Numerous trials have used anti-TNF trough levels to individualize therapy, but there is no broad application for this test currently, nor is it widely available. Disease monitoring is conducted according to clinical, biochemical and endoscopic parameters defined on an individual basis. Monitoring for complications of therapy should be performed at the scheduled physician visits. Some centers use anti-TNF

trough levels to determine the likelihood of relapse when ceasing biological agents.99,100 Anti-TNF levels may also be of use to predict relapse on withdrawal of immunosuppressive co-therapy.101 Cessation of therapy.  There are currently few data to guide cessation of therapy with biological agents. Prolonged remission in the absence of biological Tacrolimus (FK506) drug-related adverse events or treatment contraindication is reason to consider withdrawal of concurrent immunomodulators, and these decisions are best made in concert with a patient informed of the risks of therapy and cessation. Infliximab discontinuation may be successfully attempted in those without any biological indicators of disease activity with normal C-reactive protein and endoscopic mucosal healing.101 Relapse may be successfully

reinduced with further courses of infliximab but this is not guaranteed. Observational evidence suggests that azathioprine withdrawal in CD patients co-treated with an anti-TNF agent may be attempted after at least greater than 2 years of combination treatment, also in the absence of any biologic markers of disease activity or inflammation.102,103 Pregnancy.  Infliximab and adalimumab are both assigned to pregnancy category B by the US food and drug administration. Animal studies have not demonstrated teratogenic, embryotoxic or foetotoxic effects. The decision to discontinue treatment needs to take into account the importance of the drug in the maintenance of remission. Some reports indicate an increase in congenital malformations with anti-TNF therapy during pregnancy,104 while others have not.