Should irradiated blood products be used for patients receiving anti-Tumor Necrosis Factor (TNF) agents?

A transfusion medicine physician in Ohio wonders if any institution is routinely irradiating blood products for patients receiving anti-Tumor Necrosis Factor (TNF) agents? She reports that her institution currently DOES NOT provide irradiated blood products to patients specifically receiving anti-TNF agents, but that their Gastrointestinal (GI) and Rheumatology services use Remicade® (infliximab) and HUMIRA® (adalimumab) for Crohn's disease, and use ENBREL® (etanercept), Remicade® and Kineret® (anakinra) [an anti-IL1] for Juvenile Rheumatoid Arthritis (JRA) and systemic vasculitis. Several patients also receive low dose 6MP and MTX. The aforementioned treatments are for clinical practice, but clinical trials may also open. The question regarding the use of irradiated blood products for patients receiving anti-TNF agents has been raised because of a case in another state involving a pre-teenaged child with a history of JRA who was treated with ENBREL® for 3 years, at which time a diagnosis of osteomyelitis was made, Vancomycin and Meropenum were initiated, acute renal failure ensued, and prolonged diarrhea developed for which prednisone was given. Subsequently, a colon biopsy revealed absence of crypts and atrophy, and radiological studies (CT) and pathology interpretation were consistent with GVHD. A concern was raised that non-irradiated blood products, used for hemodialysis, might have triggered TA-GVHD.

The following responses have been received.

ADDENDA Aug. 5, 2005

1. A transfusion service manager at a large tertiary care hospital in Los Angeles reports that their transfusion service has a policy that all allogeneic cellular blood components must be irradiated prior to transfusion. The justification behind this policy is that their blood bank staff is often given insufficient information to determine if a patient is at risk for developing post transfusion GVHD. Their hospital is located in a large urban area where patients are apt to present in the Emergency Room for treatment unrelated to some other medical condition for which blood components (if needed) must be irradiated. Consequently, the transfusion service medical directors at her hospital have deemed it prudent to irradiate all RBC and platelet products. As a safe guard, their computer prevents the issuance of cellular blood components that are not irradiated.

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