TNF and infection: If active infection is found, guidelines suggest a minimum of 2 weeks of therapy prior to initiation of immunosuppressive agents in coordination with an infectious disease specialist.12 Rare cases of optic neuritis, exacerbation of central nervous system disorders, and exacerbation of heart failure have also been described with anti-TNF therapy.13,14 For this reason, anti-TNFs are contraindicated in patients with New York Heart Association Functional Class III/IV heart failure and should be avoided in patients with demyelinating disorders.