How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?

I agree with Dr. Cappelli but there is an additional layer to the question. The concern is not just with efficacy of BCG treatment for bladder carcinoma when on these medications. There is the concern than anti-TNF therapy may increase the risk of dissemination of BCG, analogous to the experience with reactivation and dissemination of TB and other mycobacterial infections.

Murine models and case reports have supported these concerns, which appear to be greater with the monoclonal antibodies to T...

I would hold at the time that intravesical BCG is decided upon to maximize the potential efficacy of the BCG therapy. As for when to restart, it depends on how the patient is doing from an RA standpoint and what medication they were on. It is probably good to wait at least two weeks to restart after completion.