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Garzanova LA, Ananyeva LP, Koneva OA, Desinova OV, Starovoytova MN, Ovsyannikova OB, Shayakhmetova RU, Glukhova SI. Safety and Tolerability of Rituximab in the Treatment of Systemic Sclerosis. DOKL BIOCHEM BIOPHYS 2024:10.1134/S1607672924700856. [PMID: 38861145 DOI: 10.1134/s1607672924700856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 06/12/2024]
Abstract
Rituximab (RTX) has been used for the treatment of systemic sclerosis (SSс) for a long time and has shown good efficacy for skin fibrosis and interstitial lung disease (ILD). However, data on tolerability and long-term adverse events (AEs) during RTX therapy in SSc are insufficient. The objective of this study was to assess the tolerability and safety of RTX in patients with SSс in a long-term prospective follow-up. Our open-label prospective study included 151 SSс patients who received at least one RTX infusion. The mean age of the patients was 47.9 ± 13.4 years; the majority of them were women (83%). The mean disease duration was 6.4 ± 5.8 years. The mean follow-up period after the first RTX infusion was 5.6 ± 2.6 years (845.6 patient-years (PY)). All patients received RTX in addition to ongoing therapy with prednisone and/or immunosuppressants. AEs were assessed and recorded by a doctor in the hospital immediately after RTX infusion and then by patient's reported outcome during the observation period. All causes of death were considered, regardless of treatment. A total of 85 AEs (56%) were registered, the overall incidence of AEs was 10/100 PY (95% confidence interval (CI) 8-12). The highest frequency of all AEs was observed in the first 2-6 months after the first course of RTX, however, these were mainly mild and moderate AEs (71%). The most frequent AEs were infections, they were observed in 40% of cases, with no serious opportunistic infections reported. The overall incidence of all infections was 7.1/100 PY (95% CI 5.5-9), serious infections-1.5/100 PY (95% CI 0.9-2.6). Infusion reactions occurred in 8% of patients. Other AEs were noted in 3% (0.6/100 PY, 95% CI 0.3-1.4). The overall incidence of serious AEs was 18%-3.2/100 PY (95% CI 2.2-4.6). There was a significant decrease of the immunoglobulin G (Ig G) during follow-up; however, its average values remained within normal limits. There were 17 deaths (11%) (2/100 PY, 95% CI 1.3-3.2). In most cases, patients died from the progression of the major organ failure, which arose before RTX treatment. In our study, the safety profile of RTX in SSс was assessed as favorable. It was similar to the AE profile in other autoimmune diseases treated with RTX. With an increase in the cumulative dose of RTX, no increase in AEs was observed. The mortality is comparable to the other severe autoimmune diseases in observational studies. Monitoring of IgG may be useful for patients with SSс on RTX therapy for early detection of the risk of developing infectious complications. RTX could be considered as a relatively safe drug for the complex therapy of SSс when standard therapy is ineffective or impossible.
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Affiliation(s)
- L A Garzanova
- Nasonova Research Institute of Rheumatology, Moscow, Russia.
| | - L P Ananyeva
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - O A Koneva
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - O V Desinova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | | | | | | | - S I Glukhova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
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Sen R, Riofrio M, Singh JA. A narrative review of the comparative safety of disease-modifying anti-rheumatic drugs used for the treatment of rheumatoid arthritis. Expert Opin Drug Saf 2024; 23:687-714. [PMID: 38695151 DOI: 10.1080/14740338.2024.2348575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/24/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Disease-modifying anti-rheumatic drugs (DMARDs) have improved the outcomes of patients with rheumatoid arthritis (RA). DMARDs are classified into three categories: conventional synthetic DMARDs, biological DMARDs (including biosimilars), and targeted synthetic DMARDs. DMARDs, by way of their effect on the immune system, are associated with increased risk of adverse events, including infections, malignancies, cardiovascular disease, gastrointestinal perforations, and other less common events. AREAS COVERED In this narrative literature review performed with searches of the PubMed database from 1 January 2010 through 1 January 2023, we compare the risk of safety events between DMARDs using data from both randomized clinical trials and observational studies. EXPERT OPINION DMARD use in RA is associated with higher rates of serious infections, tuberculosis reactivation, opportunistic infections, and possibly malignancies. Specific biologic DMARDs and higher doses are associated with elevated risks of various adverse events (gastrointestinal perforations, thromboembolism, serious infection). Shared decision-making is paramount when choosing a treatment regimen for patients based on their own comorbidities. JAKi are the newest class of medications used for RA with robust safety data provided in clinical trials. However, more real-world evidence and phase-IV pharmacovigilance data are needed to better understand comparative safety profile of DMARDs in RA.
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Affiliation(s)
- Rouhin Sen
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
| | - Maria Riofrio
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
| | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
- Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA
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Ota R, Hata T, Hirata A, Hamada T, Nishihara M, Neo M, Katsumata T. Risk of infection from glucocorticoid and methotrexate interaction in patients with rheumatoid arthritis using biologics: A retrospective cohort study. Br J Clin Pharmacol 2023; 89:2168-2178. [PMID: 36755477 DOI: 10.1111/bcp.15687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/25/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
AIMS This retrospective cohort study aimed to evaluate the effect of the interaction between methotrexate and glucocorticoids on the risk of developing bacterial infections in patients with rheumatoid arthritis (RA) using biological disease-modifying antirheumatic drugs (bDMARDs). METHODS We used the 2005-2018 JMDC claims database, a nationwide claims database in Japan. From the database of 7 175 048 patients, study patients were obtained by applying the following exclusion criteria: no use of bDMARDs; without information on the date of prescription; without RA as a disease; other than the new users of bDMARDs; and age <18 years. The exposures were glucocorticoids and methotrexate, and the outcome was bacterial infection. The interaction effects were examined using multivariate Cox regression analysis. Bacterial infections were identified according to antibiotic prescription and International Statistical Classification of Diseases and Related Health Problems, 10th revision codes. RESULTS A total of 2837 RA patients were identified, with a median age of 50 years. The incidence of infection was 16.8% (95% confidence interval: 15.5-18.3). The interaction term for the doses of glucocorticoids and methotrexate was significant. Additionally, a higher dose of glucocorticoid was a significant risk factor for developing bacterial infections on the side of high doses of methotrexate. The incidence of bacterial infections tended to increase significantly with increasing methotrexate doses coprescribed with glucocorticoids ≥5 mg or glucocorticoid doses coprescribed with methotrexate ≥8 mg. CONCLUSION Our results indicate a potential association between methotrexate dose and bacterial infections during bDMARDs administration with glucocorticoids in patients with RA.
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Affiliation(s)
- Ryosuke Ota
- Department of Pharmacy, Kindai University Nara Hospital, Nara, Japan
| | - Takeo Hata
- Department of Pharmacy, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
- Department of Hospital Quality and Safety Management, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Atsushi Hirata
- Department of Pharmacy, Kindai University Nara Hospital, Nara, Japan
| | - Takeshi Hamada
- Department of Pharmacy, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Masami Nishihara
- Department of Pharmacy, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
- Department of Hospital Quality and Safety Management, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Masashi Neo
- Department of Pharmacy, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
- Department of Orthopedic Surgery, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Takahiro Katsumata
- Department of Pharmacy, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
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Mena-Vázquez N, Lisbona-Montañez JM, Redondo-Rodriguez R, Mucientes A, Manrique-Arija S, Rioja J, Garcia-Studer A, Ortiz-Márquez F, Cano-García L, Fernández-Nebro A. Inflammatory profile of incident cases of late-onset compared with young-onset rheumatoid arthritis: A nested cohort study. Front Med (Lausanne) 2022; 9:1016159. [PMID: 36425102 PMCID: PMC9679221 DOI: 10.3389/fmed.2022.1016159] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/25/2022] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVES To describe the characteristics of patients between late-onset rheumatoid arthritis (LORA) with young-onset (YORA), and analyze their association with cumulative inflammatory burden. METHODS We performed a nested cohort study in a prospective cohort comprising 110 patients with rheumatoid arthritis (RA) and 110 age- and sex-matched controls. The main variable was cumulative inflammatory activity according to the 28-joint Disease Activity Score with erythrocyte sedimentation rate (DAS28-ESR). High activity was defined as DAS28 ≥ 3.2 and low activity as DAS28 < 3.2. The other variables recorded were inflammatory cytokines, physical function, and comorbid conditions. Two multivariate models were run to identify factors associated with cumulative inflammatory activity. RESULTS A total of 22/110 patients (20%) met the criteria for LORA (≥ 60 years). Patients with LORA more frequently had comorbid conditions than patients with YORA and controls. Compared with YORA patients, more LORA patients had cumulative high inflammatory activity from onset [13 (59%) vs. 28 (31%); p = 0.018] and high values for CRP (p = 0.039) and IL-6 (p = 0.045). Cumulative high inflammatory activity in patients with RA was associated with LORA [OR (95% CI) 4.69 (1.49-10.71); p = 0.008], smoking [OR (95% CI) 2.07 (1.13-3.78); p = 0.017], anti-citrullinated peptide antibody [OR (95% CI) 3.24 (1.15-9.13); p = 0.025], average Health Assessment Questionnaire (HAQ) score [OR (95% CI) 2.09 (1.03-14.23); p = 0.034], and physical activity [OR (95% CI) 0.99 (0.99-0.99); p = 0.010]. The second model revealed similar associations with inflammatory activity in patients with LORA. CONCLUSION Control of inflammation after diagnosis is poorer and comorbidity more frequent in patients with LORA than in YORA patients and healthy controls.
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Affiliation(s)
- Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Jose Manuel Lisbona-Montañez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Rocío Redondo-Rodriguez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Arkaitz Mucientes
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - José Rioja
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Aimara Garcia-Studer
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Fernando Ortiz-Márquez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Laura Cano-García
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- Unidad de Gestión Clínica (UGC) de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
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Noreña I, Fernández-Ruiz M, Aguado JM. Is there a real risk of bacterial infection in patients receiving targeted and biological therapies? ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2022; 40:266-272. [PMID: 35577446 DOI: 10.1016/j.eimce.2020.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/06/2020] [Indexed: 06/15/2023]
Abstract
Over the past decades, the advent of targeted and biological therapies has revolutionized the management of cancer and autoimmune, hematological and inflammatory conditions. Although a large amount of information is now available on the risk of opportunistic infections associated with some of these agents, the evidence regarding the susceptibility to bacterial infections is more limited. Biological agents have been shown to entail a variable risk of bacterial infections in pivotal randomized clinical trials and post-marketing studies. Recommendations on risk minimization strategies and therapeutic interventions are therefore scarce and often based on expert opinion, with only a few clear statements for some particular agents (i.e. meningococcal vaccination for patients receiving eculizumab). In the present review the available information regarding the incidence of and risk factors for bacterial infection associated with the use of different groups of biological agents is summarized according to their mechanisms of action, and recommendations based on this evidence are provided. Additional information coming from clinical research and real-world studies is required to address unmet questions in this emerging field.
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Affiliation(s)
- Ivan Noreña
- Teaching and Training Unit, Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany.
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain; School of Medicine, Universidad Complutense. Madrid, Spain
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6
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S Mehta N, Emami-Naeini P. A Review of Systemic Biologics and Local Immunosuppressive Medications in Uveitis. J Ophthalmic Vis Res 2022; 17:276-289. [PMID: 35765634 PMCID: PMC9185190 DOI: 10.18502/jovr.v17i2.10804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/28/2021] [Indexed: 01/15/2023] Open
Abstract
Uveitis is one of the most common causes of vision loss and blindness worldwide. Local and/or systemic immunosuppression is often required to treat ocular inflammation in noninfectious uveitis. An understanding of safety and efficacy of these medications is required to individualize treatment to each patient to ensure compliance and achieve the best outcome. In this article, we reviewed the effectiveness of systemic biologic response modifiers and local treatments commonly used in the management of patients with noninfectious uveitis.
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Affiliation(s)
- Neesurg S Mehta
- Department of Ophthalmology and Vision Science, University of California, Davis, Sacramento, CA, USA
| | - Parisa Emami-Naeini
- Department of Ophthalmology and Vision Science, University of California, Davis, Sacramento, CA, USA
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Hassold N, Saidenberg N, Sigaux J, Lacroix M, Cruaud P, Walewski V, Bouchaud O, Méchaï F. Asymptomatic bacteriuria before biotherapy for rheumatic diseases: Shall we treat? Joint Bone Spine 2021; 89:105327. [PMID: 34906699 DOI: 10.1016/j.jbspin.2021.105327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Nolan Hassold
- Department of infectious diseases, Avicenne Hospital, Bobigny, France.
| | | | - Johanna Sigaux
- Department of rheumatology, Avicenne Hospital, Bobigny, France
| | | | - Philippe Cruaud
- Department of microbiology, Avicenne Hospital, Bobigny, France
| | | | - Olivier Bouchaud
- Department of infectious diseases, Avicenne Hospital, Bobigny, France
| | - Frédéric Méchaï
- Department of infectious diseases, Avicenne Hospital, Bobigny, France
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8
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Current Take on Systemic Sclerosis Patients' Vaccination Recommendations. Vaccines (Basel) 2021; 9:vaccines9121426. [PMID: 34960174 PMCID: PMC8708328 DOI: 10.3390/vaccines9121426] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune inflammatory rheumatic disease. The prevalence of SSc ranges from 7 to 700 cases per million worldwide. Due to multiple organ involvement and constant inflammatory state, this group of patients presents an increased risk of infectious diseases. This paper aimed to gather the up-to-date evidence on vaccination strategies for patients with SSc and to be a useful tool for the prevention and management of infectious diseases. The authors conducted a scoping review in which each paragraph presents data on a specific vaccine’s safety, immunogenicity, and efficacy. The work deals with the following topics: SARS-CoV-2, seasonal influenza, S. pneumoniae, HAV, HBV, HZV, N. meningitidis, H. influenzae, HPV, and diphtheria-tetanus-pertussis.
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Stamp LK, Farquhar H, Pisaniello HL, Vargas-Santos AB, Fisher M, Mount DB, Choi HK, Terkeltaub R, Hill CL, Gaffo AL. Management of gout in chronic kidney disease: a G-CAN Consensus Statement on the research priorities. Nat Rev Rheumatol 2021; 17:633-641. [PMID: 34331037 PMCID: PMC8458096 DOI: 10.1038/s41584-021-00657-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 11/08/2022]
Abstract
Gout and chronic kidney disease (CKD) frequently coexist, but quality evidence to guide gout management in people with CKD is lacking. Use of urate-lowering therapy (ULT) in the context of advanced CKD varies greatly, and professional bodies have issued conflicting recommendations regarding the treatment of gout in people with concomitant CKD. As a result, confusion exists among medical professionals about the appropriate management of people with gout and CKD. This Consensus Statement from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) discusses the evidence and/or lack thereof for the management of gout in people with CKD and identifies key areas for research to address the challenges faced in the management of gout and CKD. These discussions, which address areas for research both in general as well as related to specific medications used to treat gout flares or as ULT, are supported by separately published G-CAN systematic literature reviews. This Consensus Statement is not intended as a guideline for the management of gout in CKD; rather, it analyses the available literature on the safety and efficacy of drugs used in gout management to identify important gaps in knowledge and associated areas for research.
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Affiliation(s)
| | | | - Huai Leng Pisaniello
- Discipline of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Ana B Vargas-Santos
- Department of Internal Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Mark Fisher
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
- Prima CARE, Fall River, MA, USA
| | - David B Mount
- Renal Divisions, Brigham and Women's Hospital, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Hyon K Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert Terkeltaub
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Catherine L Hill
- Discipline of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Angelo L Gaffo
- University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham VA Medical Center, Birmingham, AL, USA
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10
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Ebina K. Drug efficacy and safety of biologics and Janus kinase inhibitors in elderly patients with rheumatoid arthritis. Mod Rheumatol 2021; 32:256-262. [PMID: 34894239 DOI: 10.1093/mr/roab003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/21/2021] [Accepted: 05/24/2021] [Indexed: 11/14/2022]
Abstract
Elderly patients with rheumatoid arthritis (RA) are frequently associated with higher disease activity and impaired physical function, although they show intolerance for conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), such as methotrexate, because of their comorbidities. However, the present treatment recommendation based on randomized controlled trials is not distinguished by age or comorbidities. Therefore, this review aimed to investigate the efficacy and safety of biological DMARDs (bDMARDs) and Janus kinase inhibitors (JAKi) in elderly patients. Present bDMARDs, including tumor necrosis factor inhibitors (TNFi), cytotoxic T lymphocyte-associated antigen-4-immunoglobulin (abatacept), interleukin (IL)-6 receptor antibody (tocilizumab and salirumab), and anti-CD20 antibody (rituximab), may be similarly or slightly less effective or safe in elderly patients compared with younger patients. Oral glucocorticoid use, prolonged disease duration, and very old patients appear to be associated with an increased risk of adverse events, such as serious infection. Some recent cohort studies demonstrated that non-TNFi showed better retention than TNFi in elderly patients. Both TNFi and non-TNFi agents may not strongly influence the risk of adverse events such as cardiovascular events and malignancy in elderly patients. Regarding JAKi, the efficacy appears to be similar, although the safety (particularly for serious infections, including herpes zoster) may be attenuated by aging.
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Affiliation(s)
- Kosuke Ebina
- Department of Musculoskeletal Regenerative Medicine, Osaka University, Graduate School of Medicine, Osaka 565-0871, Japan
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Schneeweiss MC, Perez-Chada L, Merola JF. Comparative safety of systemic immunomodulatory medications in adults with atopic dermatitis. J Am Acad Dermatol 2021; 85:321-329. [DOI: 10.1016/j.jaad.2019.05.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 05/12/2019] [Accepted: 05/16/2019] [Indexed: 12/21/2022]
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12
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Shoor S. Risk of Serious Infection Associated with Agents that Target T-Cell Activation and Interleukin-17 and Interleukin-23 Cytokines. Infect Dis Clin North Am 2021; 34:179-189. [PMID: 32444009 DOI: 10.1016/j.idc.2020.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Co-stimulatory T-cell inhibitors are used in the treatment of rheumatoid arthritis and to prevent rejection of renal transplants. Inhibitors of the intereukin (IL-17) cytokine are indicated for psoriasis, psoriatic arthritis and ankylosing spondylitis and anti- IL-23 drugs for psoriasis. Serious infections occur in 4.2% to 25.0% of co-stimulatory inhibitors and 1.0% to 2.0% with IL-17 or IL-23 inhibitors. Underlying disease, steroid dose greater than 7.5 to 10.0 mg, and comorbidities influence risk in individual patients. Opportunistic infections or reactivation of tuberculosis are rare.
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Affiliation(s)
- Stanford Shoor
- Stanford University, 1000 Welch Road Suite 203, Palo Alto, CA 94304, USA.
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13
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Grøn KL, Glintborg B, Nørgaard M, Mehnert F, Østergaard M, Dreyer L, Krogh NS, Hetland ML. Overall infection risk in rheumatoid arthritis during treatment with abatacept, rituximab and tocilizumab; an observational cohort study. Rheumatology (Oxford) 2021; 59:1949-1956. [PMID: 31764977 DOI: 10.1093/rheumatology/kez530] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/01/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Most infections in patients with RA are treated in primary care with antibiotics. A small fraction require hospitalization. Only a few studies exist regarding the overall risk of infection (i.e. prescription of antibiotics or hospitalization due to infection) in patients initiating non-TNF-inhibitor therapy. In Danish RA patients initiating abatacept, rituximab and tocilizumab treatment in routine care, the aims were to compare adjusted incidence rates (IR) of infections and to estimate relative risk of infections across the drugs during 0-12 and 0-24 months. METHODS This was an observational cohort study including all RA patients in the DANBIO registry starting a non-TNF-inhibitor from 2010 to 2017. Infections were defined as a prescription of antibiotics or hospitalization due to infection. Prescriptions, comorbidities and infections were captured through linkage to national registries. IRs of infections (age, gender adjusted) and rate ratios (as estimates of RR (relative risk)), adjusted for additional covariates) (Poisson regression) were calculated. RESULTS We identified 3696 treatment episodes (abatacept 1115, rituximab 1017, tocilizumab 1564). At baseline, rituximab users were older and had more previous cancer. During 0-12 months, 1747 infections occurred. Age and gender-adjusted IRs per 100 person-years were as follows: abatacept: 76 (95% CI: 69, 84); rituximab: 87 (95% CI: 79, 96); tocilizumab: 77 (95% CI: 71, 84). Adjusted RRs were 0.94 (95% CI: 0.81, 1.08) for abatacept and 0.94 (95% CI: 0.81, 1.03) for tocilizumab compared with rituximab and 1.00 (95% CI: 0.88, 1.14) for abatacept compared with tocilizumab. RRs around 1 were observed after 24 months. Switchers and ever smokers had higher risk compared with biologic-naïve and never smokers, respectively. CONCLUSION Overall infections were common in non-TNF-inhibitor-treated RA patients, with a tendency towards rituximab having the highest risk, but CIs were wide in all analyses. Confounding by indication may at least partly explain any differences.
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Affiliation(s)
- Kathrine L Grøn
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus
| | - Mikkel Østergaard
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Lene Dreyer
- Departments of Clinical Medicine and Rheumatology, Aalborg University and Aalborg University Hospital, Aalborg
| | | | - Merete L Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
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14
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Noreña I, Fernández-Ruiz M, Aguado JM. Is there a real risk of bacterial infection in patients receiving targeted and biological therapies? Enferm Infecc Microbiol Clin 2020; 40:S0213-005X(20)30398-0. [PMID: 33339658 DOI: 10.1016/j.eimc.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 11/03/2022]
Abstract
Over the past decades, the advent of targeted and biological therapies has revolutionized the management of cancer and autoimmune, hematological and inflammatory conditions. Although a large amount of information is now available on the risk of opportunistic infections associated with some of these agents, the evidence regarding the susceptibility to bacterial infections is more limited. Biological agents have been shown to entail a variable risk of bacterial infections in pivotal randomized clinical trials and post-marketing studies. Recommendations on risk minimization strategies and therapeutic interventions are therefore scarce and often based on expert opinion, with only a few clear statements for some particular agents (i.e. meningococcal vaccination for patients receiving eculizumab). In the present review the available information regarding the incidence of and risk factors for bacterial infection associated with the use of different groups of biological agents is summarized according to their mechanisms of action, and recommendations based on this evidence are provided. Additional information coming from clinical research and real-world studies is required to address unmet questions in this emerging field.
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Affiliation(s)
- Ivan Noreña
- Teaching and Training Unit, Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany.
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain; School of Medicine, Universidad Complutense. Madrid, Spain
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15
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Iyer P, Gao Y, Field EH, Curtis JR, Lynch CF, Vaughan-Sarrazin M, Singh N. Trends in Hospitalization Rates, Major Causes of Hospitalization, and In-Hospital Mortality in Rheumatoid Arthritis in the United States From 2000 to 2014. ACR Open Rheumatol 2020; 2:715-724. [PMID: 33215872 PMCID: PMC7738807 DOI: 10.1002/acr2.11200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 10/20/2020] [Indexed: 12/03/2022] Open
Abstract
Objective To evaluate national trends in hospitalizations and in‐hospital mortality in rheumatoid arthritis (RA). Methods National Inpatient Sample from 2000‐2014 and United States Census data were used to study temporal trends in adult RA hospitalizations, reasons for hospitalizations, and in‐hospital mortality. Results The data represented 183 983 hospitalizations with a primary diagnosis of RA. The annual rates of hospitalization for the primary diagnosis of RA decreased from 76.54 admissions per 1 million in 2000 to 29.96 per 1 million in 2014 (P trend < 0.0001). The hospital mortality rate declined from 0.70% to 0.41% (P trend < 0.0001) in this group. With a primary or nonprimary diagnosis of RA, the mortality rate ranged between 1.95 and 2.87 (P trend 0.08). For a nonprimary diagnosis of RA, we noted that the proportion of hospitalizations with a diagnosis of myocardial infarction (6.4% in 2000 to 4.6% in 2014; P < 0.001) significantly decreased, but the absolute number of hospitalizations significantly increased. In contrast, the proportion and the absolute number of hospitalizations with any diagnosis of sepsis, congestive heart failure, lung disease, and urinary tract infection increased significantly. We also noted a significant increase in the actual rate and proportions for hospitalizations for hip and knee arthroplasty. Among in‐hospital deaths when RA was a nonprimary diagnosis, the most common primary diagnosis was pneumonia (12.5 %) in 2000, whereas sepsis accounted for the most deaths in 2014 (31.4%). Conclusion We observed that hospitalization rates and in‐hospital mortality rates in patients with RA have changed significantly over the past 15 years.
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Affiliation(s)
| | - Yubo Gao
- Iowa City Veteran's Affairs Medical Center, and University of Iowa, Iowa City, Iowa
| | - Elizabeth H Field
- Iowa City Veteran's Affairs Medical Center, and University of Iowa, Iowa City, Iowa.,University of Iowa, Iowa City
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16
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Wyant T, Yang L, Rosario M. Comparison of the ELISA and ECL Assay for Vedolizumab Anti-drug Antibodies: Assessing the Impact on Pharmacokinetics and Safety Outcomes of the Phase 3 GEMINI Trials. AAPS JOURNAL 2020; 23:3. [PMID: 33200296 PMCID: PMC7669784 DOI: 10.1208/s12248-020-00518-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/06/2020] [Indexed: 01/12/2023]
Abstract
Vedolizumab immunogenicity has been assessed using an enzyme-linked immunosorbent assay (ELISA) with a ~ 0.5 μg/mL drug interference, which may underestimate on-drug immunogenicity. We aimed to compare immunogenicity results between ELISA and the new drug-tolerant electrochemiluminescence (ECL) assay (and the two versions of neutralizing assays, drug-sensitive versus drug-tolerant). The ECL assay drug tolerance is ~ 100 times higher than that of the ELISA (≥ 50 μg/mL vs. 0.5 μg/mL with a 500 ng/mL positive control), and assay sensitivity is < 5 ng/mL for both assays. Vedolizumab immunogenicity was assessed in 2000 GEMINI 1 and 2 patients originally tested by ELISA and retested by ECL assay. Anti-drug antibody (ADA) impact on infusion-related reactions and pharmacokinetics (PK) was examined using descriptive statistics and population PK analyses. By ECL assay, 6% (86/1427) of patients treated with vedolizumab as induction and maintenance therapy tested ADA-positive. Of these, 20 patients were persistently positive and 56 had neutralizing antibodies. By ELISA, 4% (56/1434) of these patients were ADA-positive, 9 were persistently positive, and 33 had neutralizing antibodies. Among 61 patients with infusion-related reactions, 6 (10%) were ADA-positive (2 persistently positive) by ECL assay. By ELISA, 3 (5%) patients were both ADA-positive and persistently positive. Most results (96%) were similar with both assays. In the updated population PK model, ADA-positive status was estimated to increase vedolizumab linear clearance by a factor of 1.10 (95% credible interval 1.03-1.17), which is consistent with previous reports. The impact of ADA on safety and PK modeling remained generally consistent using either ELISA or ECL assay. ClinicalTrials.gov: NCT00783718 and NCT00783692.
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Affiliation(s)
- Timothy Wyant
- Biolojic Inc., 100 Cambridge St., Cambridge, Massachusetts, USA. .,Takeda Pharmaceuticals International Inc., Cambridge, Massachusetts, USA.
| | - Lili Yang
- Development Center Americas Inc, Cambridge, Massachusetts, USA
| | - Maria Rosario
- Takeda Pharmaceuticals International Inc., Cambridge, Massachusetts, USA
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17
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Syed H, Ascoli C, Linssen CF, Vagts C, Iden T, Syed A, Kron J, Polly K, Perkins D, Finn PW, Novak R, Drent M, Baughman R, Sweiss NJ. Infection prevention in sarcoidosis: proposal for vaccination and prophylactic therapy. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2020; 37:87-98. [PMID: 33093774 PMCID: PMC7569559 DOI: 10.36141/svdld.v37i2.9599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
Sarcoidosis is a systemic inflammatory disease characterized by granuloma formation in affected organs and caused by dysregulated immune response to an unknown antigen. Sarcoidosis patients receiving immunosuppressive medications are at increased risk of infection. Lymphopenia is also commonly seen among patient with sarcoidosis. In this review, risk of infections, including opportunistic infections, will be outlined. Recommendations for vaccinations and prophylactic therapy based on literature review will also be summarized. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 87-98).
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Affiliation(s)
- Huzaefah Syed
- Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, VA, USA
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Catharina Fm Linssen
- Department of Medical Microbiology, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, the Netherlands
| | - Christen Vagts
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Thomas Iden
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Aamer Syed
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Jordana Kron
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Kelly Polly
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - David Perkins
- Division of Nephrology, University of Illinois at Chicago, Chicago, IL, USA
| | - Patricia W Finn
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Richard Novak
- Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
| | - Marjolein Drent
- ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands
| | - Robert Baughman
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Nadera J Sweiss
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA.,Division of Rheumatology, University of Illinois at Chicago, Chicago, IL, USA
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18
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Pawar A, Desai RJ, Gautam N, Kim SC. Risk of admission to hospital for serious infection after initiating tofacitinib versus biologic DMARDs in patients with rheumatoid arthritis: a multidatabase cohort study. THE LANCET. RHEUMATOLOGY 2020; 2:e84-e98. [PMID: 38263664 DOI: 10.1016/s2665-9913(19)30137-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The risk of serious infection is a major concern when prescribing a disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis. Little evidence exists with regard to serious infection risk associated with tofacitinib, a targeted synthetic (ts)DMARD, compared with biologic DMARDs (bDMARDs) among patients with rheumatoid arthritis. We compared the risk of serious infection in patients with rheumatoid arthritis initiating tofacitinib versus one of the seven bDMARDs. METHODS In this multidatabase cohort study, we identified eight mutually exclusive groups of patients with rheumatoid arthritis initiating tofacitinib or one of the seven bDMARDs using US public (Medicare 20012-15) and private (Optum Clinformatics 2012-18 and IBM MarketScan 2012-17) health insurance programmes. Eligible patients were aged 18 years or older, and had one inpatient visit or two or more outpatient visits (7-365 days apart) for rheumatoid arthritis using International Classification of Diseases 9th and 10th revision codes. The primary outcome was a composite endpoint of admission to hospital for serious infection including bacterial, viral, or opportunistic infection based on the inpatient principal diagnosis code. Secondary outcomes were individual types of serious infections and herpes zoster. We adjusted for more than 60 potential confounders through propensity score-based inverse probability treatment weighting in each database. Database-specific adjusted hazard ratios (aHRs) were combined using a fixed-effects meta-analysis. FINDINGS We identified 130 718 patients with rheumatoid arthritis across the three databases. During 100 790 person-years of follow-up, 3140 serious infections occurred (crude incidence rate per 100 person-years 3·12, 95% CI 3·01-3·23). The aHR for serious infection associated with tofacitinib was 1·41 (95% CI 1·15-1·73) versus etanercept, 1·20 (0·97-1·49) versus abatacept, 1·23 (0·94-1·62) versus golimumab, and 1·17 (0·89-1·53) versus tocilizumab. The serious infection risk with tofacitinib was similar to adalimumab (1·06, 0·87-1·30) and certolizumab (1·02, 0·80-1·29), and was lower than infliximab (0·81, 0·65-1·00). Tofacitinib was associated with a 2-fold higher risk of herpes zoster versus all bDMARDs. INTERPRETATION This study found potential differences between tofacitinib and several bDMARDs in the risk of admission to hospital for serious infection, as well as herpes zoster, in patients with rheumatoid arthritis. These results contribute to the evolving understanding of the overall risk-benefit profile of tofacitinib. FUNDING Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Harvard University, MA, USA.
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Affiliation(s)
- Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nileesa Gautam
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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19
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Chen SK, Liao KP, Liu J, Kim SC. Risk of Hospitalized Infection and Initiation of Abatacept Versus Tumor Necrosis Factor Inhibitors Among Patients With Rheumatoid Arthritis: A Propensity Score-Matched Cohort Study. Arthritis Care Res (Hoboken) 2019; 72:9-17. [PMID: 30570833 DOI: 10.1002/acr.23824] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/04/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi). METHODS Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection. RESULTS We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes. CONCLUSION In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.
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Affiliation(s)
- Sarah K Chen
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine P Liao
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jun Liu
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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20
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Kang EH, Jin Y, Desai RJ, Liu J, Sparks JA, Kim SC. Risk of exacerbation of pulmonary comorbidities in patients with rheumatoid arthritis after initiation of abatacept versus TNF inhibitors: A cohort study. Semin Arthritis Rheum 2019; 50:401-408. [PMID: 31813561 DOI: 10.1016/j.semarthrit.2019.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/23/2019] [Accepted: 11/08/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Biologic agents may pose a potential risk for exacerbations of pulmonary comorbidities in rheumatoid arthritis (RA) patients. METHODS Using U.S. Medicare and Truven MarketScan databases, we identified three cohorts of RA patients with interstitial lung disease (ILD), chronic obstructive pulmonary disease (COPD), or asthma who initiated abatacept or a TNF inhibitor (TNFi). The primary outcome was a composite exacerbation of individual pulmonary comorbidities based on inpatient or emergency department (ED) visits due to exacerbation of the given pulmonary comorbidity. To adjust for >60 baseline confounders, we used propensity-score fine stratification (PSS) and weighting. Negative binomial regression model estimated a cohort-specific incidence rate ratio (IRR) and 95% confidence interval (CI) of the primary outcome per database, comparing abatacept versus TNFi. Database-specific IRRs were combined using a random-effects meta-analysis. RESULTS We identified 3,295 ILD, 7,161 COPD, and 5,613 asthma patients with RA who initiated either abatacept or a TNFi. IR of composite exacerbation was high in all three pulmonary cohorts but highest in COPD cohort (3.59-11.80 per 100 person-years in ILD, 20.68-34.97 in COPD, and 4.66-13.78 in asthma). After PSS weighting, the combined IRR (95%CI) in abatacept initiators versus TNFi initiators was 0.44 (0.18-1.09) for ILD exacerbation, 0.91 (0.80-1.03) for COPD exacerbation, and 0.81 (0.54-1.22) for asthma exacerbation. CONCLUSION Among patients with RA and pulmonary comorbidities, exacerbations requiring inpatient or ED visits occurred frequently after initiating abatacept or TNFi. Overall, we found no significant difference in the risk of ILD, COPD or asthma exacerbation between abatacept and TNFi initiators, but precision of our estimates is limited.
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Affiliation(s)
- Eun Ha Kang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA; Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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21
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Maraspin V, Bogovič P, Rojko T, Ogrinc K, Ružić-Sabljić E, Strle F. Early Lyme Borreliosis in Patients Treated with Tumour Necrosis Factor-Alfa Inhibitors. J Clin Med 2019; 8:jcm8111857. [PMID: 31684103 PMCID: PMC6912410 DOI: 10.3390/jcm8111857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/19/2019] [Accepted: 10/30/2019] [Indexed: 12/30/2022] Open
Abstract
The study evaluated the course and outcome of erythema migrans in patients receiving tumour necrosis factor-alpha (TNF-α) inhibitors. Among 4157 adults diagnosed with erythema migrans in the period 2009–2018, 16 (2.6%) patients were receiving TNF-α inhibitors (adalimumab, infliximab, etarnecept, golimumab), often in combination with other immunosuppressants, for rheumatic (13 patients) or inflammatory bowel (three patients) disease. Findings in this group were compared with those in 32 sex- and age-matched immunocompetent patients diagnosed with erythema migrans in the same years. In comparison with the control group, the immunocompromised patients had a shorter incubation period (7 vs. 14 days; p = 0.0153), smaller diameter of erythema migrans (10.5 vs. 15.5 cm; p = 0.0014), and more frequent comorbidities other than immune-mediated diseases (62.5% vs. 25%, p = 0.0269), symptoms/signs of disseminated Lyme borreliosis (18.8% vs. 0%, p = 0.0324), and treatment failure (25% vs. 0%, p = 0.0094). After retreatment with an antibiotic, the clinical course of Lyme borreliosis resolved. Continuing TNF inhibitor treatment during concomitant borrelial infection while using identical approaches for antibiotic treatment as in immunocompetent patients resulted in more frequent failure of erythema migrans treatment in patients receiving TNF inhibitors. However, the majority of treatment failures were mild, and the course and outcome of Lyme borreliosis after retreatment with antibiotics was favourable.
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Affiliation(s)
- Vera Maraspin
- Department of Infectious Diseases, University Medical Centre Ljubljana, Japljeva 2, 1525 Ljubljana, Slovenia.
| | - Petra Bogovič
- Department of Infectious Diseases, University Medical Centre Ljubljana, Japljeva 2, 1525 Ljubljana, Slovenia.
| | - Tereza Rojko
- Department of Infectious Diseases, University Medical Centre Ljubljana, Japljeva 2, 1525 Ljubljana, Slovenia.
| | - Katarina Ogrinc
- Department of Infectious Diseases, University Medical Centre Ljubljana, Japljeva 2, 1525 Ljubljana, Slovenia.
| | - Eva Ružić-Sabljić
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia.
| | - Franc Strle
- Department of Infectious Diseases, University Medical Centre Ljubljana, Japljeva 2, 1525 Ljubljana, Slovenia.
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22
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Ho CTK, Mok CC, Cheung TT, Kwok KY, Yip RML. Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology. Clin Rheumatol 2019; 38:3331-3350. [PMID: 31485846 DOI: 10.1007/s10067-019-04761-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022]
Abstract
The expanding range of treatment options for rheumatoid arthritis (RA), from conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to biological DMARDs (bDMARDs), biosimilar bDMARDs, and targeted synthetic DMARDs, has improved patient outcomes but increased the complexity of treatment decisions. These updated consensus recommendations from the Hong Kong Society of Rheumatology provide guidance on the management of RA, with a focus on how to integrate newly available DMARDs into clinical practice. The recommendations were developed based on evidence from the literature along with local expert opinion. Early diagnosis of RA and prompt initiation of effective therapy remain crucial and we suggest a treat-to-target approach to guide optimal sequencing of DMARDs in RA patients to achieve tight disease control. Newly available DMARDs are incorporated in the treatment algorithm, resulting in a greater range of second-line treatment options. In the event of treatment failure or intolerance, switching to another DMARD with a similar or different mode of action may be considered. Given the variety of available treatments and the heterogeneity of patients with RA, treatment decisions should be tailored to the individual patient taking into consideration prognostic factors, medical comorbidities, drug safety, cost of treatment, and patient preference.
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Affiliation(s)
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Tuen Mun, Hong Kong, China.
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Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, Breedveld FC, D'Amelio R, Dougados M, Kapetanovic MC, van Laar JM, de Thurah A, Landewé RBM, Molto A, Müller-Ladner U, Schreiber K, Smolar L, Walker J, Warnatz K, Wulffraat NM, Elkayam O. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2019; 79:39-52. [DOI: 10.1136/annrheumdis-2019-215882] [Citation(s) in RCA: 357] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 12/16/2022]
Abstract
To update the European League Against Rheumatism (EULAR) recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) published in 2011. Four systematic literature reviews were performed regarding the incidence/prevalence of vaccine-preventable infections among patients with AIIRD; efficacy, immunogenicity and safety of vaccines; effect of anti-rheumatic drugs on the response to vaccines; effect of vaccination of household of AIIRDs patients. Subsequently, recommendations were formulated based on the evidence and expert opinion. The updated recommendations comprise six overarching principles and nine recommendations. The former address the need for an annual vaccination status assessment, shared decision-making and timing of vaccination, favouring vaccination during quiescent disease, preferably prior to the initiation of immunosuppression. Non-live vaccines can be safely provided to AIIRD patients regardless of underlying therapy, whereas live-attenuated vaccines may be considered with caution. Influenza and pneumococcal vaccination should be strongly considered for the majority of patients with AIIRD. Tetanus toxoid and human papilloma virus vaccination should be provided to AIIRD patients as recommended for the general population. Hepatitis A, hepatitis B and herpes zoster vaccination should be administered to AIIRD patients at risk. Immunocompetent household members of patients with AIIRD should receive vaccines according to national guidelines, except for the oral poliomyelitis vaccine. Live-attenuated vaccines should be avoided during the first 6 months of life in newborns of mothers treated with biologics during the second half of pregnancy. These 2019 EULAR recommendations provide an up-to-date guidance on the management of vaccinations in patients with AIIRD.
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Ozen G, Pedro S, England BR, Mehta B, Wolfe F, Michaud K. Risk of Serious Infection in Patients With Rheumatoid Arthritis Treated With Biologic Versus Nonbiologic Disease-Modifying Antirheumatic Drugs. ACR Open Rheumatol 2019; 1:424-432. [PMID: 31777822 PMCID: PMC6858027 DOI: 10.1002/acr2.11064] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Objective The objective of this study is to examine the risk of serious infections (SIs) associated with biological disease‐modifying antirheumatic drugs (bDMARDs) compared with conventional synthetic disease‐modifying antirheumatic drugs (csDMARDs) in patients with rheumatoid arthritis (RA). Methods We studied patients with RA who initiated bDMARDs or csDMARDs from 2001 to 2016 in FORWARD–The National Databank for Rheumatic Diseases. Disease‐modifying antirheumatic drugs (DMARDs) were categorized into three groups: (1) csDMARDs (bDMARD‐naïve; reference), (2) tumor necrosis factor α inhibitors (TNFis), and (3) non‐TNFi biologics (abatacept, rituximab, tocilizumab, and anakinra). SIs were defined as those requiring intravenous antibiotics or hospitalization or those resulting in death. We calculated the propensity score (PS), which reflected the probability of receiving a specific DMARD group, and estimated the hazard ratio (HR) (with the 95% confidence interval [CI]) for SI from multivariable Cox models, adjusting for PS and time‐varying confounders. Results A total of 694 (5.9%) first SIs were identified in 11 623 patients with RA during 27 552 patient‐years of follow‐up. The SI incidence rate per 1000 patient‐years was 22.4 (95% CI 19.2‐26.1) for csDMARDs, 26.9 (95% CI 24.5‐29.6) for TNFis, and 23.3 (95% CI 19.0‐28.5) for non‐TNFi bDMARDs. Adjusted HRs for SIs were 1.33 (95% CI 1.05‐1.68) for TNFis and 1.48 (95% CI 1.02‐2.16) for non‐TNFi bDMARDs, compared with csDMARDs. The SI risk with non‐TNFi bDMARDs versus TNFis was not different. Other risk factors for SI were older age, higher comorbidity burden (particularly pulmonary disease), higher weighted cumulative prednisone dose, disability and disease activity, and number of prior csDMARD failures. Conclusion TNFis and non‐TNFi bDMARDs were associated with an increased SI risk compared with csDMARDs in RA, even after accounting for risk‐associated patient characteristics.
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Affiliation(s)
| | - Sofia Pedro
- FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
| | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System Omaha
| | - Bella Mehta
- Hospital for Special Surgery New York New York
| | - Frederick Wolfe
- FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
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George MD, Baker JF, Winthrop K, Alemao E, Chen L, Connolly S, Hsu JY, Simon TA, Wu Q, Xie F, Yang S, Curtis JR. Risk of Biologics and Glucocorticoids in Patients With Rheumatoid Arthritis Undergoing Arthroplasty: A Cohort Study. Ann Intern Med 2019; 170:825-836. [PMID: 31108503 PMCID: PMC7197029 DOI: 10.7326/m18-2217] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) are at increased risk for infection after arthroplasty, yet risks of specific biologic medications are unknown. OBJECTIVE To compare risk for postoperative infection among biologics and to evaluate the risk associated with glucocorticoids. DESIGN Retrospective cohort study. SETTING Medicare and Truven MarketScan administrative data from January 2006 through September 2015. PATIENTS Adults with RA who were having elective inpatient total knee or hip arthroplasty, either primary or revision, and had a recent infusion of or prescription for abatacept, adalimumab, etanercept, infliximab, rituximab, or tocilizumab before surgery. MEASUREMENTS Propensity-adjusted analyses using inverse probability weights evaluated comparative risks for hospitalized infection within 30 days and prosthetic joint infection (PJI) within 1 year after surgery between biologics or with different dosages of glucocorticoids. Secondary analyses evaluated non-urinary tract hospitalized infections and 30-day readmissions. RESULTS Among 9911 patients treated with biologics, 10 923 surgical procedures were identified. Outcomes were similar in patients who received different biologics. Compared with an 8.16% risk for hospitalized infection with abatacept, predicted risk from propensity-weighted models ranged from 6.87% (95% CI, 5.30% to 8.90%) with adalimumab to 8.90% (CI, 5.70% to 13.52%) with rituximab. Compared with a 2.14% 1-year cumulative incidence of PJI with abatacept, predicted incidence ranged from 0.35% (CI, 0.11% to 1.12%) with rituximab to 3.67% (CI, 1.69% to 7.88%) with tocilizumab. Glucocorticoids were associated with a dose-dependent increase in postoperative risk for all outcomes. Propensity-weighted models showed that use of more than 10 mg of glucocorticoids per day (vs. no glucocorticoid use) resulted in a predicted risk for hospitalized infection of 13.25% (CI, 9.72% to 17.81%) (vs. 6.78%) and a predicted 1-year cumulative incidence of PJI of 3.83% (CI, 2.13% to 6.87%) (vs. 2.09%). LIMITATION Residual confounding is possible, and sample sizes for rituximab and tocilizumab were small. CONCLUSION Risks for hospitalized infection, PJI, and readmission after arthroplasty were similar across biologics. In contrast, glucocorticoid use, especially with dosages above 10 mg/d, was associated with greater risk for adverse outcomes. PRIMARY FUNDING SOURCE Rheumatology Research Foundation, National Institutes of Health, and Bristol-Myers Squibb.
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Affiliation(s)
- Michael D George
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Joshua F Baker
- University of Pennsylvania Perelman School of Medicine and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania (J.F.B.)
| | - Kevin Winthrop
- Oregon Health & Science University, Portland, Oregon (K.W.)
| | - Evo Alemao
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Sean Connolly
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Jesse Y Hsu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Teresa A Simon
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Qufei Wu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Fenglong Xie
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Shuo Yang
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
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Ozen G, Pedro S, Schumacher R, Simon TA, Michaud K. Safety of abatacept compared with other biologic and conventional synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: data from an observational study. Arthritis Res Ther 2019; 21:141. [PMID: 31174592 PMCID: PMC6555014 DOI: 10.1186/s13075-019-1921-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/17/2019] [Indexed: 02/06/2023] Open
Abstract
Background To assess the risks of malignancies, infections and autoimmune diseases in patients with rheumatoid arthritis (RA) treated with abatacept compared with other biologic (b) disease-modifying antirheumatic drugs (DMARDs) or conventional synthetic (cs)DMARDs, in a US-wide observational RA cohort Methods Data were reviewed from patients (≥ 18 years) with RA who were registered with FORWARD, the National Databank for Rheumatic Diseases, and who initiated abatacept, other bDMARDs or csDMARDs between 2005 and 2015. Patients who switched treatment during the study could be allocated to more than one group. The incidence rates (IRs) by treatment were calculated for malignancies, hospitalized infections and autoimmune diseases identified by six monthly questionnaires and medical records. The hazard ratios (HRs) (95% confidence intervals [CIs]) for all outcomes with abatacept compared with other bDMARDs or csDMARDs were determined using marginal structural models adjusted for clinical confounders. Results In the study sample, 1496 initiated abatacept, 3490 initiated another bDMARD and 1520 initiated a csDMARD. The risk of malignancies with abatacept was not statistically significant versus other bDMARDs (HR [95% CI)] 1.89 [0.93, 3.84]) or versus csDMARDs (HR [95% CI] 0.93 [0.20, 4.27]). Patients receiving abatacept versus other bDMARDs were at a lower risk of hospitalized infections (HR [95% CI] 0.37 [0.18, 0.75]); the risk versus csDMARDs was lower with wide CIs (HR [95% CI] 0.31 [0.09, 1.05]). The relative risks for psoriasis were similar between treatment groups (HR [95% CI] 1.46 [0.76, 2.81] and HR [95% CI] 2.05 [0.59, 7.16] for abatacept versus other bDMARDs and versus csDMARDS, respectively). The IR (95% CI) of severe infusion/injection reactions was lower with abatacept compared with other bDMARDs (1.57 [1.11, 2.17] vs 2.31 [1.87, 2.82] per 100 patient-years, respectively). Conclusions In this analysis, abatacept was well tolerated and did not result in an overall increased risk of malignancies, infections or autoimmune diseases compared with other bDMARDs or csDMARDs. Electronic supplementary material The online version of this article (10.1186/s13075-019-1921-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gulsen Ozen
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Sofia Pedro
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA
| | | | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA. .,FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA.
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Abatacept initiation in rheumatoid arthritis and the risk of serious infection: A population-based cohort study. Semin Arthritis Rheum 2019; 48:1053-1058. [DOI: 10.1016/j.semarthrit.2019.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 11/19/2022]
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Cannon GW, Erickson AR, Teng CC, Huynh T, Austin S, Wade SW, Stolshek BS, Collier DH, Mutebi A, Sauer BC. Tumour necrosis factor inhibitor exposure and radiographic outcomes in Veterans with rheumatoid arthritis: a longitudinal cohort study. Rheumatol Adv Pract 2019; 3:rkz015. [PMID: 31763619 DOI: 10.1093/rap/rkz015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/31/2019] [Indexed: 01/23/2023] Open
Abstract
Objectives The aim was to estimate the impact of TNF inhibitor (TNFi) exposure on radiographic disease progression in US Veterans with RA during the first year after initiating therapy. Methods This historical longitudinal cohort design used clinical and claims data to evaluate radiographic progression after initiation of TNFi. US Veterans with RA initiating TNFi treatment (index date), ≥ 6 months pre-index and ≥ 12 months post-index VA enrolment/activity, and initial (6 months pre-index to 30 days post-index) and follow-up (10-18 months post-index) bilateral hand radiographs were eligible. The cumulative TNFi exposure and change in modified Sharp score (MSS) between initial and follow-up radiographs were calculated. The percentage of patients with clinically meaningful change in MSS (≥ 5) for each month of exposure was assessed using a longitudinal marginal structural model with inverse probability of treatment weights. Mean values and CIs were generated using 1000 bootstrapped samples. Results For 246 eligible patients, the mean (s.d.) age was 58 (11) years; 81% were male. The mean (s.d.) initial MSS was 19.6 (33.4) (range 0-214). The mean change (s.d.) in MSS was 0.3 (3.6) (median 0, range -19 to 22). Patients with the greatest exposure had the least radiographic progression for both crude and adjusted model analyses. Adjusted rates of MSS change ≥ 5 points (95% CI) were 10.6% (9.8%, 11.4%) for patients with 3 months of exposure compared with 5.4% (5.1%, 5.7%) for patients with 12 months of exposure. Conclusion One-year changes in radiographic progression were small. Patients with the greatest cumulative TNFi exposure experienced the least progression.
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Affiliation(s)
- Grant W Cannon
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Alan R Erickson
- VA Nebraska-Western Iowa Health Care System and Division of Rheumatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Chia-Chen Teng
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Tina Huynh
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Sharon Austin
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Sally W Wade
- Wade Outcomes Research and Consulting, Salt Lake City, UT, USA
| | | | | | | | - Brian C Sauer
- Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.,Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
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Luís M, Freitas J, Costa F, Buttgereit F, Boers M, Jap DS, Santiago T. An updated review of glucocorticoid-related adverse events in patients with rheumatoid arthritis. Expert Opin Drug Saf 2019; 18:581-590. [PMID: 31056959 DOI: 10.1080/14740338.2019.1615052] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Glucocorticoids represent a cornerstone in the treatment of rheumatoid arthritis. Their effect as a disease-modifying treatment in rheumatoid arthritis is well established. Despite this, the risk of adverse events of glucocorticoids, especially in high doses and over a long time, is constantly highlighted. Data on the prevalence and impact of glucocorticoid-related adverse effects in rheumatoid arthritis is needed, therefore, to be regularly revisited. AREAS COVERED In this review, our primary aim was to provide an update of evidence from randomized controlled trials and observational cohort studies on the safety of glucocorticoid treatment in rheumatoid arthritis. Our secondary aim was to provide a critical overview of the concerns raised with both study designs - randomized clinical trials versus nonrandomized observational studies - regarding the assessment of the safety of glucocorticoids in rheumatoid arthritis. EXPERT OPINION In the meantime, adherence to recommendations and consensus on standardized methodologies for monitoring and reporting adverse events is essential to improve our knowledge and competence in the best management of glucocorticoids.
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Affiliation(s)
- Mariana Luís
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - João Freitas
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Flávio Costa
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Frank Buttgereit
- b Department of Rheumatology and Clinical Immunology , Charité University Medicine , Berlin , Germany
| | - Maarten Boers
- c Department of Epidemiology and Biostatistics, Amsterdam Rheumatology and Immunology Center , Amsterdam University Medical Centers, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Da Silva Jap
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal.,e Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Tânia Santiago
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal
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Yang P, Pageni P, Rahman MA, Bam M, Zhu T, Chen YP, Nagarkatti M, Decho AW, Tang C. Gold Nanoparticles with Antibiotic-Metallopolymers toward Broad-Spectrum Antibacterial Effects. Adv Healthc Mater 2019; 8:e1800854. [PMID: 30480381 PMCID: PMC6426663 DOI: 10.1002/adhm.201800854] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/20/2018] [Indexed: 11/10/2022]
Abstract
Bacterial infection has evolved into one of the most dangerous global health crises. Designing potent antimicrobial agents that can combat drug-resistant bacteria is essential for treating bacterial infections. In this paper, a strategy to graft metallopolymer-antibiotic bioconjugates on gold nanoparticles is developed as an antibacterial agent to fight against different bacterial strains. Thus, these nanoparticle conjugates combine various components in one system to display enhanced bactericidal efficacy, in which small sized nanoparticles provide high surface area for bacteria to contact, cationic metallopolymers interact with the negatively charged bacterial membranes, and the β-lactam antibiotics' sterilzation capabilities are improved via evading intracellular enzymolysis by β-lactamase. This nanoparticle-based antibiotic-metallopolymer system exhibits an excellent broad-spectrum antibacterial effect, particularly for Gram-negative bacteria, due to the synergistic effect of multicomponents on the interaction with bacteria.
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Affiliation(s)
| | - Parasmani Pageni
- Department of Chemistry and Biochemistry, University of South Carolina, Columbia, South Carolina 29208, United States
| | - Md Anisur Rahman
- Department of Chemistry and Biochemistry, University of South Carolina, Columbia, South Carolina 29208, United States
| | - Marpe Bam
- Department of Chemistry and Biochemistry, University of South Carolina, Columbia, South Carolina 29208, United States
| | - Tianyu Zhu
- Department of Pathology, Microbiology and Immunology, University of South Carolina, School of Medicine, Columbia, South Carolina 29209, United States
| | - Yung Pin Chen
- Department of Chemistry and Biochemistry, University of South Carolina, Columbia, South Carolina 29208, United States
| | - Mitzi Nagarkatti
- Department of Environmental Health Sciences, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina 29208, United States
| | - Alan W. Decho
- Department of Pathology, Microbiology and Immunology, University of South Carolina, School of Medicine, Columbia, South Carolina 29209, United States
- Department of Environmental Health Sciences, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina 29208, United States
| | - Chuanbing Tang
- Department of Chemistry and Biochemistry, University of South Carolina, Columbia, South Carolina 29208, United States
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Grøn KL, Arkema EV, Glintborg B, Mehnert F, Østergaard M, Dreyer L, Nørgaard M, Krogh NS, Askling J, Hetland ML. Risk of serious infections in patients with rheumatoid arthritis treated in routine care with abatacept, rituximab and tocilizumab in Denmark and Sweden. Ann Rheum Dis 2019; 78:320-327. [PMID: 30612115 DOI: 10.1136/annrheumdis-2018-214326] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/08/2018] [Accepted: 11/26/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To estimate (1) crude and age-and gender-adjusted incidence rates (IRs) of serious infections (SI) and (2) relative risks (RR) of SI in patients with rheumatoid arthritis (RA) initiating treatment with abatacept, rituximab or tocilizumab in routine care. METHODS This is an observational cohort study conducted in parallel in Denmark and Sweden including patients with RA in Denmark (DANBIO) and Sweden (Anti-Rheumatic Treatment in Sweden Register/Swedish Rheumatology Quality Register) who started abatacept/rituximab/tocilizumab in 2010-2015. Patients could contribute to more than one treatment course. Incident SI (hospitalisations listing infection) and potential confounders were identified through linkage to national registries. Age- and gender-adjusted IRs of SI per 100 person years and additionally adjusted RRs of SI during 0-12 and 0-24 months since start of treatment were assessed (Poisson regression). Country-specific RRs were pooled using inverse variance weighting. RESULTS We identified 8987 treatment courses (abatacept: 2725; rituximab: 3363; tocilizumab: 2899). At treatment start, rituximab-treated patients were older, had longer disease duration and more previous malignancies; tocilizumab-treated patients had higher C reactive protein. During 0-12 and 0-24 months of follow-up, 456 and 639 SI events were identified, respectively. The following were the age- and gender-adjusted 12-month IRs for abatacept/rituximab/tocilizumab: 7.1/8.1/6.1 for Denmark and 6.0/6.4/4.7 for Sweden. The 24-month IRs were 6.1/7.5/5.2 for Denmark and 5.6/5.8/4.3 for Sweden. Adjusted 12-month RRs for tocilizumab versus rituximab were 0.82 (0.50 to 1.36) for Denmark and 0.76 (0.57 to 1.02) for Sweden, pooled 0.78 (0.61 to 1.01); for abatacept versus rituximab 0.94 (0.55 to 1.60) for Denmark and 0.86 (0.66 to 1.13) for Sweden, pooled 0.88 (0.69 to 1.12); and for abatacept versus tocilizumab 1.15 (0.69 to 1.90) for Denmark and 1.14 (0.83 to 1.55) for Sweden, pooled 1.13 (0.91 to 1.42). The adjusted RRs for 0-24 months were similar. CONCLUSION For patients starting abatacept, rituximab or tocilizumab, differences in baseline characteristics were seen. Numerical differences in IR of SI between drugs were observed. RRs seemed to vary with drug (tocilizumab < abatacept < rituximab) but should be interpreted with caution due to few events and risk of residual confounding.
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Affiliation(s)
- Kathrine Lederballe Grøn
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark .,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Østergaard
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Dreyer
- Departments of Clinical Medicine and Rheumatology, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Fernández-Ruiz M, Aguado JM. Risk of infection associated with anti-TNF-α therapy. Expert Rev Anti Infect Ther 2018; 16:939-956. [PMID: 30388900 DOI: 10.1080/14787210.2018.1544490] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The advent, more than two decades ago, of monoclonal antibodies and soluble receptors targeting tumor necrosis factor (TNF)-α has revolutionized the therapeutic approach to otherwise difficult-to-treat autoimmune and inflammatory diseases. However, due to the pleiotropic functions played by this pro-inflammatory cytokine (with particular relevance in granuloma maintenance), TNF-α blockade may increase the incidence of serious infections. Areas covered: The present review summarizes the biological rationale supporting the impact of anti-TNF-α therapy on the host's susceptibility to infection. The structure, mode of action, and indications of available agents are reviewed, as well as the clinical evidence coming from clinical trials and observational registries. We discuss the impact of patient- and disease-related factors influencing the occurrence of infection. Finally, strategies for risk minimization are also covered, with particular attention to recommendations for screening of latent tuberculosis infection and management of chronic hepatitis B infection. Expert commentary: Methodological limitations (confounding by indication bias, patient dropout, or switching therapies) should be considered when interpreting observational data. Clinicians must individualize the infection risk assessment not only on the basis of the specific anti-TNF-α agent used or the expected duration of therapy, but also by taking into account the baseline susceptibility of a given patient.
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Affiliation(s)
- Mario Fernández-Ruiz
- a Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine , Universidad Complutense , Madrid , Spain.,b Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002) , Instituto de Salud Carlos III , Madrid , Spain
| | - José María Aguado
- a Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine , Universidad Complutense , Madrid , Spain.,b Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002) , Instituto de Salud Carlos III , Madrid , Spain
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Zhang X, Hartung JE, Bortsov AV, Kim S, O'Buckley SC, Kozlowski J, Nackley AG. Sustained stimulation of β 2- and β 3-adrenergic receptors leads to persistent functional pain and neuroinflammation. Brain Behav Immun 2018; 73:520-532. [PMID: 29935309 PMCID: PMC6129429 DOI: 10.1016/j.bbi.2018.06.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 06/11/2018] [Accepted: 06/20/2018] [Indexed: 12/12/2022] Open
Abstract
Functional pain syndromes, such as fibromyalgia and temporomandibular disorder, are associated with enhanced catecholamine tone and decreased levels of catechol-O-methyltransferase (COMT; an enzyme that metabolizes catecholamines). Consistent with clinical syndromes, our lab has shown that sustained 14-day delivery of the COMT inhibitor OR486 in rodents results in pain at multiple body sites and pain-related volitional behaviors. The onset of COMT-dependent functional pain is mediated by peripheral β2- and β3-adrenergic receptors (β2- and β3ARs) through the release of the pro-inflammatory cytokines tumor necrosis factor α (TNFα), interleukin-1β (IL-1β), and interleukin-6 (IL-6). Here, we first sought to investigate the role of β2- and β3ARs and downstream mediators in the maintenance of persistent functional pain. We then aimed to characterize the resulting persistent inflammation in neural tissues (neuroinflammation), characterized by activated glial cells and phosphorylation of the mitogen-activated protein kinases (MAPKs) p38 and extracellular signal-regulated kinase (ERK). Separate groups of rats were implanted with subcutaneous osmotic mini-pumps to deliver OR486 (15 mg/kg/day) or vehicle for 14 days. The β2AR antagonist ICI118551 and β3AR antagonist SR59230A were co-administrated subcutaneously with OR486 or vehicle either on day 0 or day 7. The TNFα inhibitor Etanercept, the p38 inhibitor SB203580, or the ERK inhibitor U0126 were delivered intrathecally following OR486 cessation on day 14. Behavioral responses, pro-inflammatory cytokine levels, glial cell activation, and MAPK phosphorylation were measured over the course of 35 days. Our results demonstrate that systemic delivery of OR486 leads to mechanical hypersensitivity that persists for at least 3 weeks after OR486 cessation. Corresponding increases in spinal TNFα, IL-1β, and IL-6 levels, microglia and astrocyte activation, and neuronal p38 and ERK phosphorylation were observed on days 14-35. Persistent functional pain was alleviated by systemic delivery of ICI118551 and SR59230A beginning on day 0, but not day 7, and by spinal delivery of Etanercept or SB203580 beginning on day 14. These results suggest that peripheral β2- and β3ARs drive persistent COMT-dependent functional pain via increased activation of immune cells and production of pro-inflammatory cytokines, which promote neuroinflammation and nociceptor activation. Thus, therapies that resolve neuroinflammation may prove useful in the management of functional pain syndromes.
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MESH Headings
- Animals
- Catechol O-Methyltransferase/metabolism
- Catechol O-Methyltransferase Inhibitors/metabolism
- Catechols/pharmacology
- Cytokines/metabolism
- Etanercept/pharmacology
- Female
- Fibromyalgia/metabolism
- Fibromyalgia/physiopathology
- Hyperalgesia/metabolism
- Imidazoles/pharmacology
- Interleukin-1beta/metabolism
- Interleukin-6/metabolism
- Male
- Microglia/metabolism
- Mitogen-Activated Protein Kinases
- Neuroglia/metabolism
- Pain/metabolism
- Pain/physiopathology
- Phosphorylation
- Propanolamines/pharmacology
- Pyridines/pharmacology
- Rats
- Rats, Sprague-Dawley
- Receptors, Adrenergic, beta/metabolism
- Receptors, Adrenergic, beta-2/drug effects
- Receptors, Adrenergic, beta-2/metabolism
- Receptors, Adrenergic, beta-2/physiology
- Receptors, Adrenergic, beta-3/drug effects
- Receptors, Adrenergic, beta-3/metabolism
- Receptors, Adrenergic, beta-3/physiology
- Spinal Cord/metabolism
- Temporomandibular Joint Disorders/metabolism
- Temporomandibular Joint Disorders/physiopathology
- Tumor Necrosis Factor-alpha/metabolism
- p38 Mitogen-Activated Protein Kinases/metabolism
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Affiliation(s)
- Xin Zhang
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Pain Management Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jane E Hartung
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrey V Bortsov
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Seungtae Kim
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Division of Meridian and Structural Medicine, School of Korean Medicine, Pusan National University, Republic of Korea
| | - Sandra C O'Buckley
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Julia Kozlowski
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Andrea G Nackley
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA.
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Holroyd CR, Seth R, Bukhari M, Malaviya A, Holmes C, Curtis E, Chan C, Yusuf MA, Litwic A, Smolen S, Topliffe J, Bennett S, Humphreys J, Green M, Ledingham J. The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis. Rheumatology (Oxford) 2018; 58:e3-e42. [DOI: 10.1093/rheumatology/key208] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Christopher R Holroyd
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rakhi Seth
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Marwan Bukhari
- Rheumatology Department, University Hospitals of Morecombe Bay NHS Foundation Trust, Lancaster, UK
| | - Anshuman Malaviya
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Claire Holmes
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elizabeth Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Christopher Chan
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mohammed A Yusuf
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Anna Litwic
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- Rheumatology Department, Salisbury District Hospital, Salisbury, UK
| | - Susan Smolen
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Joanne Topliffe
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Sarah Bennett
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jennifer Humphreys
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Muriel Green
- National Rheumatoid Arthritis Society, Queen Alexandra Hospital, Portsmouth, UK
| | - Jo Ledingham
- Rheumatology Department, Queen Alexandra Hospital, Portsmouth, UK
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Frequency of Hospitalized Infections Is Reduced in Rheumatoid Arthritis Patients Who Received Biological and Targeted Synthetic Disease-Modifying Antirheumatic Drugs after 2010. J Immunol Res 2018; 2018:6259010. [PMID: 30186881 PMCID: PMC6112083 DOI: 10.1155/2018/6259010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/03/2018] [Indexed: 01/13/2023] Open
Abstract
Background Biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic (ts) DMARDs are important in rheumatoid arthritis (RA) treatment. The risk of hospitalized infection associated with bDMARDs/tsDMARDs in RA patients is unclear. Methods We retrospectively analyzed the cases of the 275 RA patients with 449 treatment episodes who were administered a bDMARD/tsDMARD at Nagasaki University Hospital in July 2003–January 2015. We determined the incidence and risk factors of infection requiring hospitalization in the patients during a 3-year observation period. Results Thirty-five (12.7%) of the patients experienced a hospitalized infection. The hospitalized infection risk did not differ significantly among several bDMARDs/tsDMARDs. A multivariate analysis revealed that the comorbidities of chronic lung disease (adjusted HR 5.342, 95% CI 2.409–12.42, p < 0.0001) and the initiation of bDMARDs/tsDMARDs before 2010 (adjusted HR 4.266, 95% CI 1.827–10.60, p = 0.0007) are significant independent risk factors for hospitalized infection. Compared to the before-2010 group, the group of patients whose treatment initiated in 2010 or later showed higher patient ages at the initiation of bDMARD/tsDMARD treatment and a higher rate of the use of prophylaxis with an antituberculosis agent, whereas the disease activities and number of the patients who received >5 mg of prednisolone were lower in the after-2010 group. Conclusions This is the first report that the frequency of hospitalized infection significantly decreased when the patients were treated with a bDMARD or tsDMARD after 2010. Our results indicate that the updated announcement of diagnosis and treatment criteria might contribute to a reduced risk of hospitalized infection and a better understanding of the use of bDMARDs/tsDMARDs by rheumatologists.
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36
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Swamy L, Monach P, Fine A, Breu AC. A Veteran With Fibromyalgia Presenting With Dyspnea. Fed Pract 2018; 35:22-25. [PMID: 30766377 PMCID: PMC6263444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Lakshmana Swamy
- is a Hospitalist and the Director of Resident Education at VA Boston Healthcare System and an Assistant Professor of Medicine at Harvard University in Massachusetts and supervises the VA Boston Medical Forum Chief Resident case conferences. All patients or their surrogate decision makers understand and have signed appropriate patient release forms. This article has received an abbreviated peer review
| | - Paul Monach
- is a Hospitalist and the Director of Resident Education at VA Boston Healthcare System and an Assistant Professor of Medicine at Harvard University in Massachusetts and supervises the VA Boston Medical Forum Chief Resident case conferences. All patients or their surrogate decision makers understand and have signed appropriate patient release forms. This article has received an abbreviated peer review
| | - Alan Fine
- is a Hospitalist and the Director of Resident Education at VA Boston Healthcare System and an Assistant Professor of Medicine at Harvard University in Massachusetts and supervises the VA Boston Medical Forum Chief Resident case conferences. All patients or their surrogate decision makers understand and have signed appropriate patient release forms. This article has received an abbreviated peer review
| | - Anthony C Breu
- is a Hospitalist and the Director of Resident Education at VA Boston Healthcare System and an Assistant Professor of Medicine at Harvard University in Massachusetts and supervises the VA Boston Medical Forum Chief Resident case conferences. All patients or their surrogate decision makers understand and have signed appropriate patient release forms. This article has received an abbreviated peer review
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Dalal DS, Duran J, Brar T, Alqadi R, Halladay C, Lakhani A, Rudolph JL. Efficacy and safety of biological agents in the older rheumatoid arthritis patients compared to Young: A systematic review and meta-analysis. Semin Arthritis Rheum 2018; 48:799-807. [PMID: 30185379 DOI: 10.1016/j.semarthrit.2018.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/06/2018] [Accepted: 07/23/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Biologic anti-rheumatic drugs are used with less frequency among older patients compared to young patients. This population is less represented in studies performed to evaluate the efficacy and safety of this drugs. We aimed to assess the efficacy and safety of biological agents between the older RA patients compared to young. METHODS A comprehensive, systematic search was conducted in major indexing databases using key terms for RA and each biological agent. The review process was completed by 2 investigators. Both randomized controlled trials and observational studies of at least 6-month duration conducted in adult RA patients were included. Outcomes of interest were clinical efficacy and safety. Effect-estimates were pooled using random-effects modeling if 4 or more studies used the same scale and time-frame for measuring outcomes. RESULTS 24 studies (16 focusing on anti-TNF agents) representing 63,705 patients (24% were older) were included. Older RA patients had worse baseline RA disease activity, longer disease duration at the time of enrollment in the trial (14.4 ± 3.6 vs. 10.9 ± 3.6 years; p < 0.001) and higher steroid use (73.2 vs. 64.7%, p < 0.001) than younger. 5 out of 6 studies assessing anti-TNF agents showed worse efficacy outcomes in older patients. The pooled OR of infection and ADRs with anti-TNF agents in older compared to young RA patients was OR 1.59 (95% CI: 1.45-1.76) and 1.40 (95% CI: 1.23-1.61) respectively. CONCLUSIONS Older patients had worse safety and efficacy with biological agents but also had worse baseline disease activity. There was significant heterogeneity in reporting outcomes and very limited studies in biological agents other than anti-TNF drugs.
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Affiliation(s)
- Deepan S Dalal
- Warren Alpert School of Brown University, Providence, RI, USA.
| | | | - Tina Brar
- Warren Alpert School of Brown University, Providence, RI, USA
| | - Rasha Alqadi
- Warren Alpert School of Brown University, Providence, RI, USA; Roger Williams Medical Center, Providence, RI, USA
| | - Christopher Halladay
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
| | - Alisha Lakhani
- Warren Alpert School of Brown University, Providence, RI, USA
| | - James L Rudolph
- Warren Alpert School of Brown University, Providence, RI, USA; Center of Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
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38
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Feagan BG, Bhayat F, Khalid M, Blake A, Travis SPL. Respiratory Tract Infections in Patients With Inflammatory Bowel Disease: Safety Analyses From Vedolizumab Clinical Trials. J Crohns Colitis 2018; 12:905-919. [PMID: 29788248 PMCID: PMC6065483 DOI: 10.1093/ecco-jcc/jjy047] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Vedolizumab, a humanised monoclonal antibody for the treatment of inflammatory bowel disease, selectively blocks gut lymphocyte trafficking. This may reduce the risk of respiratory tract infections [RTIs] compared with systemic immunosuppressive therapies. To assess this possibility, we evaluated the rates of RTIs in clinical trials of vedolizumab. METHODS Patient-level data from Phase 3 randomised controlled trials [RCTs] of vedolizumab in ulcerative colitis [UC; GEMINI 1] and Crohn's disease [CD; GEMINI 2], and a long-term safety study [UC and CD] were pooled. Cox proportional hazards models were used to estimate the incidence of upper RTIs [URTIs] and lower RTIs [LRTIs] with adjustment for significant covariates. RESULTS In the RCTs [n = 1731 patients], the incidence of URTIs was numerically higher in patients receiving vedolizumab compared with those receiving placebo, although this difference was not statistically significant (38.7 vs 33.0 patients per 100 patient-years; hazard ratio [HR] 1.12; 95% confidence interval [CI]: 0.83-1.51; p = 0.463). The rate of LRTIs, including pneumonia, was numerically lower in the vedolizumab versus the placebo group: this difference was not statistically significant (7.7 vs 8.5 per 100 patient-years [HR 0.85; 95% CI: 0.48-1.52; p = 0.585]). Both URTIs and LRTIs were more frequent in patients with CD compared with UC. Most RTIs in patients receiving vedolizumab were not serious and did not require treatment discontinuation. CONCLUSIONS Vedolizumab therapy was not associated with an increased incidence of respiratory tract infection compared with placebo.
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Affiliation(s)
- Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, ON, Canada,Corresponding author: Brian G. Feagan, MD, FRCPC, Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, 1151 Richmond St N., London, ON, N6A 5B7, Canada. Tel.: 1 [519] 931–5289 or 858–5087; fax: 1 [519] 931–5278;
| | - Fatima Bhayat
- Global Patient Safety, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Mona Khalid
- Evidence and Value generation, Takeda International – UK Branch, London, UK
| | - Aimee Blake
- Evidence and Value generation, Takeda International – UK Branch, London, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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39
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Rutherford AI, Subesinghe S, Hyrich KL, Galloway JB. Serious infection across biologic-treated patients with rheumatoid arthritis: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Ann Rheum Dis 2018; 77:905-910. [PMID: 29592917 DOI: 10.1136/annrheumdis-2017-212825] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 03/16/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To compare the incidence of serious infection (SI) across biologic drugs used to treat rheumatoid arthritis (RA) using data from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis (BSRBR-RA). METHODS The BSRBR-RA is a prospective observational cohort study. This analysis included patients with RA starting a new biologic. The primary outcome was SI defined as an infectious event requiring admission to hospital, intravenous antibiotics or resulting in death. Event rates were calculated and compared across biologics using Cox proportional hazards with adjustment for potential confounders. Secondary outcomes were the rate of infection by organ class and 30-day mortality following infection. RESULTS This analysis included 19 282 patients with 46 771 years of follow-up. The incidence of SI was 5.51 cases per 100 patient years for the entire cohort (95% CI 5.29 to 5.71). Compared with etanercept, tocilizumab had a higher risk of SI (HR 1.22, 95% CI 1.02 to 1.47) and certolizumab pegol a lower risk of SI (HR 0.75, 95% CI 0.58 to 0.97) in the fully adjusted model. The 30-day mortality following SI was 10.4% (95% CI 9.2% to 11.6%). CONCLUSIONS The rate of SI was lower with certolizumab pegol than etanercept in the primary analysis but the result was no longer significant in several sensitivity analyses performed suggesting residual confounding may account for the observed difference. From these results, it would be wrong to conclude that certolizumab pegol has a lower rate of SI than other biologics; however, the risk does not appear to be significantly higher as has previously been suggested.
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Affiliation(s)
- Andrew I Rutherford
- Academic Rheumatology Department, King's College London, London, UK.,Rheumatology Department, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester University, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester Foundation Trust, Manchester, UK
| | - James B Galloway
- Academic Rheumatology Department, King's College London, London, UK.,Rheumatology Department, King's College Hospital NHS Foundation Trust, London, UK
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40
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Machado MADÁ, Moura CSD, Guerra SF, Curtis JR, Abrahamowicz M, Bernatsky S. Effectiveness and safety of tofacitinib in rheumatoid arthritis: a cohort study. Arthritis Res Ther 2018; 20:60. [PMID: 29566769 PMCID: PMC5865387 DOI: 10.1186/s13075-018-1539-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 02/08/2018] [Indexed: 12/13/2022] Open
Abstract
Background Tofacitinib is the first oral Janus kinase inhibitor approved for the treatment of rheumatoid arthritis (RA). We compared the effectiveness and safety of tofacitinib, disease-modifying antirheumatic drugs (DMARDs), tumor necrosis factor inhibitors (TNFi), and non-TNF biologics in patients with RA previously treated with methotrexate. Methods We used MarketScan® databases (2011–2014) to study methotrexate-exposed patients with RA who were newly prescribed tofacitinib, DMARDs other than methotrexate, and biologics. The date of first prescription was defined as the cohort entry. The therapy was considered effective if all of the following criteria from a claims-based algorithm were achieved at the first year of follow-up: high adherence, no biologic or tofacitinib switch or addition, no DMARD switch or addition, no increase in dose or frequency of index drug, no more than one glucocorticoid joint injection, and no new/increased oral glucocorticoid dose. The safety outcome was serious infections requiring hospitalization. Non-TNF biologics comprised the reference group. Results We included 21,832 patients with RA, including 0.8% treated with tofacitinib, 24.7% treated with other DMARDs, 61.2% who had started therapy with TNFi, and 13.3% treated with non-TNF biologics. The rates of therapy effectiveness were 15.4% for tofacitinib, 11.1% for DMARDs, 18.6% for TNFi, and 19.8% for non-TNF biologics. In adjusted analyses, tofacitinib and non-TNF biologics appeared to have similar effectiveness rates, whereas DMARD initiators were less effective than non-TNF biologics. We could not clearly establish if tofacitinib was associated with a higher rate of serious infections. Conclusions In patients with RA previously treated with methotrexate, our comparisons of tofacitinib with non-TNF biologics, though not definitive, did not demonstrate differences with respect to hospitalized infections or effectiveness. Electronic supplementary material The online version of this article (10.1186/s13075-018-1539-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marina Amaral de Ávila Machado
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 5252 de Maisonneuve West, Montreal, QC, Canada
| | - Cristiano Soares de Moura
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 5252 de Maisonneuve West, Montreal, QC, Canada
| | - Steve Ferreira Guerra
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 5252 de Maisonneuve West, Montreal, QC, Canada
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, SRC 076, USA
| | - Michal Abrahamowicz
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 5252 de Maisonneuve West, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Research Institute of McGill University Health Centre, 5252 de Maisonneuve West, Montreal, QC, Canada
| | - Sasha Bernatsky
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 5252 de Maisonneuve West, Montreal, QC, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, Research Institute of McGill University Health Centre, 5252 de Maisonneuve West, Montreal, QC, Canada.
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41
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Accortt NA, Lesperance T, Liu M, Rebello S, Trivedi M, Li Y, Curtis JR. Impact of Sustained Remission on the Risk of Serious Infection in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2018; 70:679-684. [PMID: 28960869 PMCID: PMC5947836 DOI: 10.1002/acr.23426] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 09/19/2017] [Indexed: 12/31/2022]
Abstract
Objective This retrospective analysis examined how sustained remission impacted risk of serious infections in patients with rheumatoid arthritis (RA) enrolled in a clinical registry. Methods Inclusion criteria included RA diagnosis, age ≥18 years, and ≥2 Clinical Disease Activity Index (CDAI) scores followed by a followup visit. Index date was the second of 2 visits in which a patient had sustained remission (CDAI ≤2.8), low disease activity (LDA; 2.8 < CDAI ≤10), or moderate‐to‐high disease activity (MHDA; CDAI >10). Followup extended from the index date until first serious infection (requiring intravenous antibiotics or hospitalization) or last followup visit. The crude incidence rate (IR) per 100 patient‐years for serious infections was calculated for the sustained remission, LDA, and MHDA groups. The multivariable‐adjusted incidence rate ratio (IRR) (adjusted for age, sex, and prednisone dose) compared serious infection rates across disease activity groups. Results Most patients were female (>70%); mean age was approximately 60 years. The crude IR (95% confidence interval [95% CI]) per 100 patient‐years for serious infections was 1.03 (0.85–1.26) in the sustained remission group (n = 3,355), 1.92 (1.68–2.19) in the sustained LDA group (n = 3,912), and 2.51 (2.23–2.82) in the sustained MHDA group (n = 5,062). Compared to sustained remission, the serious infection rate was higher in sustained LDA (adjusted IRR 1.69 [95% CI 1.32–2.15]). Compared to sustained LDA, the serious infection rate was higher in sustained MHDA (adjusted IRR 1.30 [95% CI 1.09–1.56]). Conclusion In this study, lower RA disease activity was associated with lower serious infection rates. This finding may motivate patients and health care providers to strive for remission rather than only LDA.
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Affiliation(s)
| | | | - Mei Liu
- Corrona LLC, Southborough, Massachusetts
| | | | | | - Youfu Li
- University of Massachusetts, Worcester
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42
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Sumida K, Molnar MZ, Potukuchi PK, Hassan F, Thomas F, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Treatment of rheumatoid arthritis with biologic agents lowers the risk of incident chronic kidney disease. Kidney Int 2018; 93:1207-1216. [PMID: 29409725 DOI: 10.1016/j.kint.2017.11.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 11/05/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023]
Abstract
Rheumatoid arthritis is associated with reduced kidney function, possibly due to chronic inflammation or the use of nephrotoxic therapies. However, little is known about the effects of using the newer novel non-nephrotoxic biologic agents on the risk of incident chronic kidney disease (CKD). To study this we used a cohort of 20,757 United States veterans diagnosed with rheumatoid arthritis with an estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73m2 or more, recruited between October 2004 and September 2006, and followed through 2013. The associations of biologic use with incident CKD (eGFR under 60 with a decrease of at least 25% from baseline, and eGFR under 45 mL/min/1.73m2) and change in eGFR (<-3, -3 to <0 [reference], and ≥0 mL/min/1.73m2/year) were examined in propensity-matched patients based on their likelihood to initiate biologic treatment, using Cox models and multinomial logistic regression models, respectively. Among 20,757 patients, 4,617 started biologic therapy. In the propensity-matched cohort, patients treated (versus not treated) with biologic agents had a lower risk of incident CKD (hazard ratios 0.95, 95% confidence interval [0.82-1.10] and 0.71 [0.53-0.94] for decrease in eGFR under 60 and under 45 mL/min/1.73m2, respectively) and progressive eGFR decline (multinomial odds ratios [95% CI] for eGFR slopes <-3 and ≥0 [versus -3 to <0] mL/min/1.73m2/year, 0.67 [0.58-0.79] and 0.76 [0.69-0.83], respectively). A significant deceleration of eGFR decline was also observed after biologic administration in patients treated with biologics (-1.0 versus -0.4 [mL/min/1.73m2/year] before and after biologic use). Thus, biologic agent administration was independently associated with lower risk of incident CKD and progressive eGFR decline.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan; Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary; Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fatima Hassan
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA.
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Han SH. Vaccination for Patients with Rheumatic Diseases in the Era of Biologics. JOURNAL OF RHEUMATIC DISEASES 2018. [DOI: 10.4078/jrd.2018.25.2.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Sang Hoon Han
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Vashisht P, O'dell J. Not all TNF inhibitors in rheumatoid arthritis are created equal: important clinical differences. Expert Opin Biol Ther 2017; 17:989-999. [PMID: 28594252 DOI: 10.1080/14712598.2017.1340453] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Anti-TNF therapy has dramatically changed how we manage rheumatoid arthritis. There are many similarities among the five approved agents but also some important differences. Rheumatologists have 5 different options to choose from when they are ready to commence anti-TNF therapy. Although all block the TNF cytokine, there are important critical differences among them that affect their safety profile and clinical utility in certain scenarios. Unfortunately, there are no head to head trials to compare the different anti-TNF agents and none appear to be in the horizon. Areas covered: This article reviews the various clinical situations where it may be important to use a particular anti-TNF agent. The authors also give their expert opinion and future perspectives on the area. Expert opinion: Although there are many similarities among the five different TNFi that are clinically available, there are important clinical niches, where the limited data that are available, that clearly support the preferential use of a particular agent or class of agents. Assays or tests that allow us to find the 'sweet spot' of TNF inhibition at the level of each patient are long overdue.
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Affiliation(s)
| | - James O'dell
- b Internal Medicine , Chief Division of Rheumatology , Omaha , NE , USA
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Singh JA. Infections With Biologics in Rheumatoid Arthritis and Related Conditions: a Scoping Review of Serious or Hospitalized Infections in Observational Studies. Curr Rheumatol Rep 2017; 18:61. [PMID: 27613285 DOI: 10.1007/s11926-016-0609-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biologic use is a major advance in the treatment of several autoimmune conditions, including rheumatoid arthritis. In this review, we summarize key studies of serious/hospitalized infections in rheumatoid arthritis (RA). RA is a risk factor for infections. High RA disease activity is associated with higher risk of serious infection. The risk of serious infections with tumor necrosis factor inhibitor (TNFi) biologics is increased in the first 6 months of initiating therapy, and this risk was higher compared to the use of traditional disease-modifying anti-rheumatic drugs (DMARDs). Emerging data also suggest that biologics may differ from each other regarding the risk of serious or hospitalized infections. Past history of serious infections, glucocorticoid dose, and older age were other important predictors of risk of serious infections in patients treated with biologics.
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Affiliation(s)
- Jasvinder A Singh
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA. .,Division of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA. .,Medicine Service, Birmingham VA Medical Center, Birmingham, AL, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Safety and Efficacy of Biological Disease-Modifying Antirheumatic Drugs in Older Rheumatoid Arthritis Patients: Staying the Distance. Drugs Aging 2017; 33:387-98. [PMID: 27154398 DOI: 10.1007/s40266-016-0374-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The population of older individuals with rheumatoid arthritis (RA) is rapidly expanding, mainly due to increased life expectancy. While targeted biological therapies are well established for the treatment of this disease, their use may be lower in older patients (age > 65 years) and very old patients (age > 75 years) as a result of perceived higher risks for adverse events in this population, taking into account comorbidity, polypharmacy, and frailty. In this review, we discuss the available evidence for the use of biological therapies in this growing patient group with specific attention towards the eventual reasons for biological treatment failure or withdrawal. The majority of data is found in secondary analyses of clinical trials and in retrospective cohorts. The most information available is on tumor necrosis factor (TNF) blockers. Older patients seem to have a less robust response to anti-TNF agents than a younger population, but drug survival as a proxy for efficacy does not seem to be influenced by age. Despite an overall rate of adverse effects comparable to that in younger patients, older RA patients are at higher risk of serious infections. Other biologics appear to have an efficacy similar to anti-TNF agents, also in older RA patients. Again, the drug survival rates for tocilizumab, rituximab, and abatacept resemble those in young RA patients with good general tolerability and safety profiles. The cardiovascular risk and the risk of cancer, increased in RA patients and in the older RA patients, do not appear to be strongly influenced by biologicals.
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Christou EAA, Giardino G, Worth A, Ladomenou F. Risk factors predisposing to the development of hypogammaglobulinemia and infections post-Rituximab. Int Rev Immunol 2017; 36:352-359. [PMID: 28800262 DOI: 10.1080/08830185.2017.1346092] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rituximab (RTX) is a monoclonal antibody against CD20, commonly used in the treatment of hematological malignancies and autoimmune diseases. The use of RTX is related to the development of hypogammaglobulinemia and infections. Aim of this review is to summarize the evidence supporting the association of specific risk factors with the development of hypogammaglobulinemia and infections post-RTX. Immunological complications are more common in patients with malignant diseases as compared to non-malignant diseases. Moreover, the use of more than one dose of RTX, maintenance regimens, low pre-treatment basal immunoglobulin levels and the association with Mycophenolate and purine analogues represent risk factors for the development of hypogammaglobulinemia. The number of RTX courses, the evidence of low IgG levels for more than 6 months, the use of G-CSF, the occurrence of chronic lung disease, cardiac insufficiency, extra-articular involvement in patients with rheumatoid arthritis, low levels of IgG and older age have been correlated with a higher risk of infections. Even though the heterogeneity of the studies in terms of study population age and underlying disease, RTX schedules as well as differences in pre-treatment or concomitant therapy doesn't allow drawing definitive conclusions, the study of the literature highlight the association of specific risk factors with the occurrence of hypogammaglobulinemia and/or infections. A long term randomized controlled clinical trial could be useful to define a personalized evidence-based risk management plan for patients treated with RTX.
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Affiliation(s)
- Evangelos A A Christou
- a Division of Internal Medicine, Medical School , University of Ioannina , Ioannina , Greece
| | - Giuliana Giardino
- b Department of Translational Medical Sciences , Federico II University , Naples , Italy
| | - Austen Worth
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
| | - Fani Ladomenou
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
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Doss J, Mo H, Carroll RJ, Crofford LJ, Denny JC. Phenome-Wide Association Study of Rheumatoid Arthritis Subgroups Identifies Association Between Seronegative Disease and Fibromyalgia. Arthritis Rheumatol 2017; 69:291-300. [PMID: 27589350 DOI: 10.1002/art.39851] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 08/11/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The differences between seronegative and seropositive rheumatoid arthritis (RA) have not been widely reported. We performed electronic health record (EHR)-based phenome-wide association studies (PheWAS) to identify disease associations in seropositive and seronegative RA. METHODS A validated algorithm identified RA subjects from the de-identified version of the Vanderbilt University Medical Center EHR. Serotypes were determined by rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) values. We tested EHR-derived phenotypes using PheWAS comparing seropositive RA and seronegative RA, yielding disease associations. PheWAS was also performed in RF-positive versus RF-negative subjects and ACPA-positive versus ACPA-negative subjects. Following PheWAS, select phenotypes were then manually reviewed, and fibromyalgia was specifically evaluated using a validated algorithm. RESULTS A total of 2,199 RA individuals with either RF or ACPA testing were identified. Of these, 1,382 patients (63%) were classified as seropositive. Seronegative RA was associated with myalgia and myositis (odds ratio [OR] 2.1, P = 3.7 × 10-10 ) and back pain. A manual review of the health record showed that among subjects coded for Myalgia and Myositis, ∼80% had fibromyalgia. Follow-up with a specific EHR algorithm for fibromyalgia confirmed that seronegative RA was associated with fibromyalgia (OR 1.8, P = 4.0 × 10-6 ). Seropositive RA was associated with chronic airway obstruction (OR 2.2, P = 1.4 × 10-4 ) and tobacco use (OR 2.2, P = 7.0 × 10-4 ). CONCLUSION This PheWAS of RA patients identifies a strong association between seronegativity and fibromyalgia. It also affirms relationships between seropositivity and chronic airway obstruction and between seropositivity and tobacco use. These findings demonstrate the utility of the PheWAS approach to discover novel phenotype associations within different subgroups of a disease.
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Affiliation(s)
| | - Huan Mo
- Loma Linda University Medical Center, Loma Linda, California
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Morel J, Constantin A, Baron G, Dernis E, Flipo RM, Rist S, Combe B, Gottenberg JE, Schaeverbeke T, Soubrier M, Vittecoq O, Dougados M, Saraux A, Mariette X, Ravaud P, Sibilia J. Risk factors of serious infections in patients with rheumatoid arthritis treated with tocilizumab in the French Registry REGATE. Rheumatology (Oxford) 2017; 56:1746-1754. [DOI: 10.1093/rheumatology/kex238] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Indexed: 12/13/2022] Open
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Mori S, Yoshitama T, Hidaka T, Sakai F, Hasegawa M, Hashiba Y, Suematsu E, Tatsukawa H, Mizokami A, Yoshizawa S, Hirakata N, Ueki Y. Comparative risk of hospitalized infection between biological agents in rheumatoid arthritis patients: A multicenter retrospective cohort study in Japan. PLoS One 2017; 12:e0179179. [PMID: 28594905 PMCID: PMC5464634 DOI: 10.1371/journal.pone.0179179] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/24/2017] [Indexed: 12/20/2022] Open
Abstract
Objective Knowing the risk of hospitalized infection associated with individual biological agents is an important factor in selecting the best treatment option for patients with rheumatoid arthritis (RA). This study examined the comparative risk of hospitalized infection between biological agents in a routine care setting. Methods We used data for all RA patients who had first begun biological therapy at rheumatology divisions of participating community hospitals in Japan between January 2009 and December 2014. New treatment episodes with etanercept, infliximab, adalimumab, abatacept, or tocilizumab were included. Patients were allowed to contribute multiple treatment episodes with different biological agents. Incidence rates (IRs) of hospitalized infection during the first year of follow-up were examined. Cox regression analysis was used to calculate hazard ratios (HRs) for overall hospitalized infection and for pulmonary hospitalized infection, adjusting for possible confounders. Results A total of 1596 new treatment episodes were identified. The incidence of overall hospitalized infection during the first year was 86 with 1239 person-years (PYs), yielding a crude IR of 6.9 per 100 PYs (95% confidence interval [CI], 5.6–8.6). After correction for confounders, no significant difference in risk of hospitalized infection was observed between treatment groups: adjusted HRs (95% CI) were 1.54 (0.78–3.04) for infliximab, 1.72 (0.88–3.34) for adalimumab, 1.11 (0.55–2.21) for abatacept, and 1.02 (0.55–1.87) for tocilizumab compared with etanercept. Patient-specific factors such as age, RA functional class, body mass index (BMI), prednisolone use, and chronic lung disease contributed more to the risk of hospitalized infection than specific biological agents. The incidence of pulmonary hospitalized infection was 50 and a crude IR of 4.0 per 100 PYs (95% CI, 3.1–5.3). After adjustment for confounders, adalimumab had a significantly higher HR for pulmonary hospitalized infection compared with tocilizumab: an adjusted HR (95% CI) was 4.43 (1.72–11.37) for adalimumab. BMI, prednisolone use, diabetes mellitus, and chronic lung disease were also significant factors associated with the risk of pulmonary hospitalized infection. Conclusions The magnitude of the risk of overall hospitalized infection was not determined by the type of biological agents, and patient-specific risk factors had more impact on the risk of hospitalized infection. For pulmonary hospitalized infections, the use of adalimumab was significantly associated with a greater risk of this complication than tocilizumab use.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization (NHO) Kumamoto Saishunsou National Hospital, Kohshi, Kumamoto, Japan
- * E-mail:
| | - Tamami Yoshitama
- Yoshitama Clinic for Rheumatic Diseases, Kirishima, Kagoshima, Japan
| | - Toshihiko Hidaka
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Mizue Hasegawa
- Department of Respiratory Medicine, Tokyo Women’s Medical University Yachiyo Medical Center, Yachiyo, Chiba
| | - Yayoi Hashiba
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - Eiichi Suematsu
- Department of Internal Medicine and Rheumatology, Clinical Research Institute, NHO Kyushu Medical Center, Fukuoka, Japan
| | | | - Akinari Mizokami
- Department of Rheumatology, Japan Community Healthcare Organization (JCHO) Isahaya General Hospital, Isahaya, Nagasaki, Japan
| | - Shigeru Yoshizawa
- Department of Rheumatology, NHO Fukuoka National Hospital, Fukuoka, Japan
| | - Naoyuki Hirakata
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
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