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Kruckow KL, Murray E, Shayhidin E, Rosenberg AF, Bowdish DME, Orihuela CJ. Chronic TNF exposure induces glucocorticoid-like immunosuppression in the alveolar macrophages of aged mice that enhances their susceptibility to pneumonia. Aging Cell 2024; 23:e14133. [PMID: 38459711 PMCID: PMC11296116 DOI: 10.1111/acel.14133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 01/22/2024] [Accepted: 02/12/2024] [Indexed: 03/10/2024] Open
Abstract
Chronic low-grade inflammation, particularly elevated tumor necrosis factor (TNF) levels, occurs due to advanced age and is associated with greater susceptibility to infection. One reason for this is age-dependent macrophage dysfunction (ADMD). Herein, we use the adoptive transfer of alveolar macrophages (AM) from aged mice into the airway of young mice to show that inherent age-related defects in AM were sufficient to increase the susceptibility to Streptococcus pneumoniae, a Gram-positive bacterium and the leading cause of community-acquired pneumonia. MAPK phosphorylation arrays using AM lysates from young and aged wild-type (WT) and TNF knockout (KO) mice revealed multilevel TNF-mediated suppression of kinase activity in aged mice. RNAseq analyses of AM validated the suppression of MAPK signaling as a consequence of TNF during aging. Two regulatory phosphatases that suppress MAPK signaling, Dusp1 and Ptprs, were confirmed to be upregulated with age and as a result of TNF exposure both ex vivo and in vitro. Dusp1 is known to be responsible for glucocorticoid-mediated immune suppression, and dexamethasone treatment increased Dusp1 and Ptprs expression in cells and recapitulated the ADMD phenotype. In young mice, treatment with dexamethasone increased the levels of Dusp1 and Ptprs and their susceptibility to infection. TNF-neutralizing antibody reduced Dusp1 and Ptprs levels in AM from aged mice and reduced pneumonia severity following bacterial challenge. We conclude that chronic exposure to TNF increases the expression of the glucocorticoid-associated MAPK signaling suppressors, Dusp1 and Ptprs, which inhibits AM activation and increases susceptibility to bacterial pneumonia in older adults.
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Affiliation(s)
- Katherine L. Kruckow
- Department of MicrobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Elizabeth Murray
- Department of MicrobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Elnur Shayhidin
- Firestone Institute for Respiratory HealthSt. Joseph's Healthcare HamiltonHamiltonOntarioCanada
- The M.G. DeGroote Institute for Infectious Disease ResearchMcMaster UniversityHamiltonOntarioCanada
| | - Alexander F. Rosenberg
- Department of MicrobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Informatics InstituteUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Dawn M. E. Bowdish
- Firestone Institute for Respiratory HealthSt. Joseph's Healthcare HamiltonHamiltonOntarioCanada
- The M.G. DeGroote Institute for Infectious Disease ResearchMcMaster UniversityHamiltonOntarioCanada
| | - Carlos J. Orihuela
- Department of MicrobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Jahnich N, Arkwright PD. Regional risk of tuberculosis and viral hepatitis with tumor necrosis factor-alpha inhibitor treatment: A systematic review. Front Pharmacol 2023; 14:1046306. [PMID: 36744250 PMCID: PMC9894886 DOI: 10.3389/fphar.2023.1046306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023] Open
Abstract
Background: TNFα inhibitors are regularly used to treat autoimmune diseases. Tuberculosis (TB) and viral hepatitis B are considered potential infectious complications, and screening and surveillance are therefore recommended. Current guidelines do not take into account regional differences in endemicity of these infections. Methods: A systematic literature review of TB and viral hepatitis in patients receiving TNFα-inhibitors was performed, searching in PubMed, Embase, MEDLINE and Web of Science databases. Studies were selected against predefined eligibility criteria and assessed using the Newcastle-Ottawa scale. The number of TB and viral hepatitis cases/1,000 TNFα-inhibitor patients were evaluated, and regional variation compared. Results: 105 observational studies involving over 140,000 patients were included. Overall, 1% of patients developed TB or viral hepatitis B. TB cases/1,000 TNFα-inhibitor patients were 4-fold higher in Asia, Africa, and South America than in Europe, North America, and Australasia where only 0%-0.4% of patients developed TB. Hepatitis B cases/1,000 patients were over 15-fold higher in countries with high prevalence (China, Taiwan, South Korea, Thailand) compared with low prevalence (p < 0.00001) where only 0.4% of patients developed hepatitis B. Only three of 143 patients developed viral hepatitis C, and there was insufficient data to allow regional sub-analysis. Conclusion: TB and viral hepatitis B infections in patients treated with TNFα inhibitors are largely confined to countries with high prevalence of these infections. As only 1/2,500 patients in low prevalence countries treated with TNFα inhibitors develop TB or viral hepatitis B, we suggest an individualized, risk-based approach, rather than universal screening for all patients.
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Affiliation(s)
| | - Peter D. Arkwright
- Lydia Becker Institute of Immunology and Inflammation, Manchester Incubator Building, University of Manchester, Manchester, United Kingdom
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3
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Itagaki M, Iketani O, Enoki Y, Chuang VTG, Taguchi K, Uno S, Uchida S, Namkoong H, Uwamino Y, Takano Y, Hasegawa N, Matsumoto K. Analysis of Risk Factors for Developing Tuberculosis in Patients Who Received Prophylactic Latent Tuberculosis Infection Treatment with Experience of Biologic Medications. Biol Pharm Bull 2023; 46:1832-1837. [PMID: 38044103 DOI: 10.1248/bpb.b23-00521] [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] [Indexed: 12/05/2023]
Abstract
Biologic medications have dramatically improved the treatment outcomes of immunological inflammatory diseases, but their immunosuppressive effects put patients at risk for tuberculosis (TB). We investigated the risk factors for developing TB in patients treated for latent tuberculosis infection (LTBI) who also had experience of using biologic medications. At Keio University Hospital, we retrospectively investigated patients treated with anti-mycobacterial drugs before or concurrently with biologic medications from January 2012 to August 2020. Patients in the 'follow-on cases group' who had a positive TB screening test after initiating biologic medications and subsequently started LTBI treatment were excluded. We researched and compared the patient characteristics for TB and non-TB patient groups. Of the 146 eligible patients, 5 (3.4%) developed TB. The incidence rate was 600/100000 person-years. There were no significant differences between TB and non-TB patient groups in the history of TB, interferon-gamma release assay (IGRA), duration of biologic medication therapy, LTBI treatment periods, concomitant use of calcineurin inhibitors or anti-rheumatic drugs. The percentage of patients who received prednisolone at a dose of ≥15 mg for more than 1 month was higher in those who developed TB than in those who did not (40.0 vs. 7.1%, p = 0.054); however, this difference was not statistically significant. Regular monitoring of TB is necessary for long-term concomitant use of high prednisolone doses during and after the administration of biologic medications.
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Affiliation(s)
- Marina Itagaki
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University
| | - Osamu Iketani
- Department of Infectious Diseases, Keio University School of Medicine
| | - Yuki Enoki
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University
| | - Victor Tuan Giam Chuang
- Discipline of Pharmacy, Curtin Medical School, Faculty of Health Sciences, Curtin University
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University
| | - Shunsuke Uno
- Department of Infectious Diseases, Keio University School of Medicine
| | - Sho Uchida
- Department of Infectious Diseases, Keio University School of Medicine
| | - Ho Namkoong
- Department of Infectious Diseases, Keio University School of Medicine
| | - Yoshifumi Uwamino
- Department of Infectious Diseases, Keio University School of Medicine
| | - Yaoko Takano
- Department of Infectious Diseases, Keio University School of Medicine
| | - Naoki Hasegawa
- Department of Infectious Diseases, Keio University School of Medicine
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4
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Mantilla MJ, Chaves JJ, Parra-Medina R, Mantilla JC. Opportunistic infections as a cause of death in patients with autoimmune diseases: An autopsy-based study. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2022; 55:230-235. [PMID: 36154728 DOI: 10.1016/j.patol.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/31/2021] [Accepted: 11/20/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Infections are an important cause of mortality in patients with autoimmune diseases and opportunistic infections account for a large percentage of these cases. It is often a clinical challenge to find a balance between immunosuppressive therapy and the risk of developing an infectious process. METHODS A retrospective, descriptive study of autopsy reports. RESULTS 15 patients with a premortem diagnosis of autoimmune disease were included. All patients died due to an opportunistic infection. The most commonly reported infection was tuberculosis, followed by invasive fungal infections. CONCLUSIONS The most prevalent pathogens were found in our autopsy-based study of patients with autoimmune diseases and opportunistic infections. Prevention and early detection strategies are vital in order to reach a correct diagnosis and begin the appropriate treatment as soon as possible.
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Affiliation(s)
| | - Juan José Chaves
- Department of Pathology, Fundación Universitaria de Ciencias de la Salud, Hospital San José, Bogotá, Colombia
| | - Rafael Parra-Medina
- Department of Pathology, Fundación Universitaria de Ciencias de la Salud, Hospital San José, Bogotá, Colombia
| | - Julio Cesar Mantilla
- Department of Pathology, Universidad Industrial de Santander, Hospital Universitario de Santander, Bucaramanga, Colombia.
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Yerima A, Akintayo R, Adebajo A. Implications of a diagnosis of rheumatoid arthritis in resource-poor countries. Best Pract Res Clin Rheumatol 2021; 36:101725. [PMID: 34906416 DOI: 10.1016/j.berh.2021.101725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatoid arthritis (RA) is a multisystemic autoimmune disease that predominantly affects synovial joints. It causes marked disability, reduces health-related quality of life, and leads to high mortality. The diagnosis of RA is often made by standard criteria, and the management of this condition is usually undertaken according to the established guidelines. In resource-poor settings, the diagnosis and management of RA are hampered by diverse factors such as late presentation, inadequate trained personnel, poor healthcare infrastructure, low socioeconomic status, poor access to both conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics, and a high burden of infectious diseases such as tuberculosis, hepatitis, and human immunodeficiency virus. There is a need to establish registries in these settings to provide adequate information on the pattern, medication, and long-term outcome of RA in resource-poor countries in order to provide a practical and evidence-based management guide for rheumatologists, which is appropriate for these settings.
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Affiliation(s)
- Abubakar Yerima
- Department of Medicine, University of Maiduguri, PMB 1069, Maiduguri, Borno State, Nigeria.
| | - Richard Akintayo
- Dumfries and Galloway, Royal Infirmary, Cargenbridge, Dumfries DG2 8RX, United Kingdom.
| | - Adewale Adebajo
- Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield S10 2RX, South Yorkshire, United Kingdom; Barnsley NHS Foundation Trust, Barnsley S75 2EP, South Yorkshire, United Kingdom.
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Rare manifestation of a large stenosing gastrointestinal tumor caused by Mycobacterium tuberculosis in a previously healthy man from Austria. Wien Med Wochenschr 2021; 172:268-273. [PMID: 34613520 PMCID: PMC9463224 DOI: 10.1007/s10354-021-00887-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal tuberculosis (TB) is a rare manifestation in low TB-incidence countries such as Austria. It is usually seen in immunocompromised patients or in migrants being more susceptible for extrapulmonary disease manifestations. CASE DESCRIPTION We report a very rare manifestation of severe gastrointestinal TB in a 49-year-old previously healthy man from Upper Austria. Endoscopy showed a large tumor mass obstructing about 2/3 of the lumen of the cecum. Positron emission tomography/computed tomography scan revealed not only a high metabolic activity in the tumor mass, but also active pulmonary lesions in both upper lung lobes. Bronchial secretion showed acid-fast bacilli in the microscopy and polymerase chain reaction was positive for M. tuberculosis complex. Phenotypic resistance testing showed no resistance for first-line anti-TB drugs. Treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was initiated. Based on therapeutic drug monitoring, the standard treatment regime was adapted to rifampicin high dose. TB treatment was well tolerated and the patient achieved relapse-free cure one year after the end of treatment. CONCLUSION Gastrointestinal involvement mimicking an intestinal tumor is a very rare TB manifestation in previously healthy Austrians. However, it should be kept in mind due to increasing migration from countries with higher rates of extrapulmonary TB and due to an increasing number of immunocompromised patients. TB telephone consultations can support medical professionals in the diagnosis and the management of complex TB patients. TB management is currently at a transitional stage from a programmatic to personalized management concept including therapeutic drug monitoring or biomarker-guided treatment duration to achieve relapse-free cure.
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Syal G, Serrano M, Jain A, Cohen BL, Rieder F, Stone C, Abraham B, Hudesman D, Malter L, McCabe R, Holubar S, Afzali A, Cheifetz AS, Gaidos JKJ, Moss AC. Health Maintenance Consensus for Adults With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1552-1563. [PMID: 34279600 PMCID: PMC8861367 DOI: 10.1093/ibd/izab155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND With the management of inflammatory bowel disease (IBD) becoming increasingly complex, incorporating preventive care health maintenance measures can be challenging. The aim of developing these updated recommendations is to provide more specific details to facilitate their use into a busy clinical practice setting. METHOD Fifteen statements were formulated with recommendations regarding the target, timing, and frequency of the health maintenance interventions in patients with IBD. We used a modified Delphi method and a literature review to establish a consensus among the panel of experts. The appropriateness of each health maintenance statement was rated on a scale of 1 to 5 (1-2 as inappropriate, and 4-5 as appropriate) by each panelist. Interventions were considered appropriate, and statements were accepted if ≥80% of the panelists agreed with a score ≥4. RESULTS The panel approved 15 health maintenance recommendations for adults with IBD based on the current literature and expert opinion. These recommendations include explicit details regarding specific screening tools, timing of screening, and vaccinations for adults with IBD. CONCLUSIONS Patients with IBD are at an increased risk for infections, malignancies, and other comorbidities. Given the complexity of caring for patients with IBD, this focused list of recommendations can be easily incorporated in to clinical care to help eliminate the gap in preventative care for patients with IBD.
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Affiliation(s)
- Gaurav Syal
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Animesh Jain
- University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Christian Stone
- Comprehensive Digestive Institute of Nevada, Las Vegas, Nevada, USA
| | | | - David Hudesman
- New York University Langone Medical Center, New York, New York, USA
| | - Lisa Malter
- NYU Grossman School of Medicine, Bellevue Hospital Center, New York, New York, USA
| | | | | | - Anita Afzali
- Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Alan C Moss
- Boston University School of Medicine, Boston, Massachusetts, USA,Address correspondence to: Alan C. Moss, MD, MBBCh, BAO, Professor, Boston University School of Medicine, 830 Harrison Avenue, 2nd floor, Boston, MA, 02118, USA. E-mail:
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8
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Kroon EE, Kinnear CJ, Orlova M, Fischinger S, Shin S, Boolay S, Walzl G, Jacobs A, Wilkinson RJ, Alter G, Schurr E, Hoal EG, Möller M. An observational study identifying highly tuberculosis-exposed, HIV-1-positive but persistently TB, tuberculin and IGRA negative persons with M. tuberculosis specific antibodies in Cape Town, South Africa. EBioMedicine 2020; 61:103053. [PMID: 33038764 PMCID: PMC7648124 DOI: 10.1016/j.ebiom.2020.103053] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 02/08/2023] Open
Abstract
Background Mycobacterium tuberculosis (Mtb) infection is inferred from positive results of T-cell immune conversion assays measuring Mtb-specific interferon gamma production or tuberculin skin test (TST) reactivity. Certain exposed individuals do not display T-cell immune conversion in these assays and do not develop TB. Here we report a hitherto unknown form of this phenotype: HIV-1-positive persistently TB, tuberculin and IGRA negative (HITTIN). Methods A community-based case-control design was used to systematically screen and identify adults living with HIV (HIV+), aged 35–60 years, who met stringent study criteria, and then longitudinally followed up for repeat IGRA and TST testing. Participants had no history of TB despite living in TB hyper-endemic environments in Cape Town, South Africa with a provincial incidence of 681/100,000. Mtb-specific antibodies were measured using ELISA and Luminex. Findings We identified 48/286 (17%) individuals who tested persistently negative for Mtb-specific T-cell immunoreactivity (three negative Quantiferon results and one TST = 0mm) over 206±154 days on average. Of these, 97·2% had documented CD4 counts<200 prior to antiretroviral therapy (ART). They had received ART for 7·0±3·0 years with a latest CD4 count of 505·8±191·4 cells/mm3. All HITTIN sent for further antibody testing (n=38) displayed Mtb-specific antibody titres. Interpretation Immune reconstituted HIV+ persons can be persistently non-immunoreactive to TST and interferon-γ T-cell responses to Mtb, yet develop species-specific antibody responses. Exposure is evidenced by Mtb-specific antibody titres. Our identification of HIV+ individuals displaying a persisting lack of response to TST and IGRA T-cell immune conversion paves the way for future studies to investigate this phenotype in the context of HIV-infection that so far have received only scant attention.
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Affiliation(s)
- Elouise E Kroon
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Craig J Kinnear
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marianna Orlova
- Program in Infectious Diseases and Immunity in Global Health, The Research Institute of the McGill University Health Centre, 1001 boul Décarie, Site Glen Block E, Room EM3.3210, Montréal, QC H4A3J1, Canada; McGill International TB Centre, McGill University, Montréal, QC, Canada; Departments of Medicine and Human Genetics, McGill University, Montréal, QC, Canada
| | - Stephanie Fischinger
- Ragon Institute of MGH, MIT and Harvard, Boston, MA, USA; University of Duisburg-Essen, Institute for HIV research, Essen, Germany
| | - Sally Shin
- Ragon Institute of MGH, MIT and Harvard, Boston, MA, USA
| | - Sihaam Boolay
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ashley Jacobs
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa; Department of Infectious Diseases, Imperial College London, W12 ONN, United Kingdom; The Francis Crick Institute, London, NW1 1AT, United Kingdom
| | - Galit Alter
- Ragon Institute of MGH, MIT and Harvard, Boston, MA, USA
| | - Erwin Schurr
- Program in Infectious Diseases and Immunity in Global Health, The Research Institute of the McGill University Health Centre, 1001 boul Décarie, Site Glen Block E, Room EM3.3210, Montréal, QC H4A3J1, Canada; McGill International TB Centre, McGill University, Montréal, QC, Canada; Departments of Medicine and Human Genetics, McGill University, Montréal, QC, Canada
| | - Eileen G Hoal
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marlo Möller
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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9
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Ziyadeh NJ, Geldhof A, Noël W, Otero-Lobato M, Esslinger S, Chakravarty SD, Wang Y, Seeger JD. Post-approval Safety Surveillance Study of Golimumab in the Treatment of Rheumatic Disease Using a United States Healthcare Claims Database. Clin Drug Investig 2020; 40:1021-1040. [PMID: 32779120 PMCID: PMC7595963 DOI: 10.1007/s40261-020-00959-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background and Objective Golimumab is a fully human anti-tumor necrosis factor monoclonal antibody approved for the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS). This study estimated rates of prespecified outcomes in patients with RA, PsA or AS initiating golimumab versus matched patients initiating non-biologic systemic (NBS) medications. Methods Patients enrolled in a US health plan with rheumatic disease who initiated a study medication were accrued between April 2009 and November 2014. Golimumab initiators were matched by propensity score to NBS initiators in a 1:4 ratio. Outcomes were identified through September 2015. As-treated, as-matched, and nested case–control (NCC) analyses were conducted in the matched cohorts. Sensitivity analyses evaluated the impact of residual confounding and nondifferential misclassification of exposure and outcomes. Results Risks of outcomes were similar between golimumab and NBS initiators. In the as-treated analysis, the rate ratio (RR) for depression was elevated during current golimumab use versus golimumab non-use in the NBS cohort [RR 1.45, 95% confidence interval (CI) 1.31–1.61]. This finding was not replicated in as-matched (RR 1.08, 95% CI 0.97–1.19) or NCC (odds ratio 1.01, 95% CI 0.78–1.31) analyses, which focused on incident cases. Sensitivity analyses suggest that depression was sensitive to misclassification, and the RR changed from greater than to less than one across a plausible range of specificity. Conclusions This study suggests that there is no association between exposure to golimumab and an increased risk of prespecified outcomes. Increased depression risk in the as-treated analysis was not replicated in other analyses and may be associated with residual imbalance in baseline history or severity of depression. Electronic supplementary material The online version of this article (10.1007/s40261-020-00959-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Najat J Ziyadeh
- Optum Epidemiology, 1325 Boylston Street, 11th Floor, Boston, MA, 02215, USA.
| | | | - Wim Noël
- Janssen Biologics B.V., Leiden, The Netherlands
| | | | | | - Soumya D Chakravarty
- Janssen Scientific Affairs, LLC, Horsham, PA, USA
- Drexel University School of Medicine, Philadelphia, PA, USA
| | - Yiting Wang
- Janssen Research and Development, LLC, Newark, NJ, USA
| | - John D Seeger
- Optum Epidemiology, 1325 Boylston Street, 11th Floor, Boston, MA, 02215, USA
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10
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Miltinienė D, Deresevičienė G, Nakčerienė B, Davidavičienė VE, Danila E, Butrimienė I, Dadonienė J. Incidence of Tuberculosis in Inflammatory Rheumatic Diseases: Results from a Lithuanian Retrospective Cohort Study. ACTA ACUST UNITED AC 2020; 56:medicina56080392. [PMID: 32764422 PMCID: PMC7466317 DOI: 10.3390/medicina56080392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 11/16/2022]
Abstract
Background and objective: With an increase in survival rates among rheumatic patients, comorbidities and infections, in particular, have gained more importance, especially after the introduction of biologicals to the treatment algorithms. Tuberculosis (TB) infection has always been given a special attention in patients with rheumatic diseases (RD). Although Lithuanian population has one of the highest TB incidence rates among European countries, the incidence of TB in the rheumatic patients' population is still unknown. The aim of this study was to assess the incidence rate of TB in an inflammatory RD retrospective cohort and to compare that rate with a rate in a general population. Methods: Patients with the first-time diagnosis of inflammatory RD during the period between 1 January 2012 and 31 December 2017 were identified from the Lithuanian Compulsory Health Insurance Information System database SVEIDRA. All cases were cross-checked with Health Information center at the Institute of Hygiene, for the vital status of these patients and date of death if the fact of death was documented, and with Tuberculosis Register operated by Vilnius University Hospital Santaros Klinikos, for the confirmation of TB cases. Sex and age standardized incidence ratios (SIR) were calculated by dividing the observed numbers of TB among rheumatic patients by the expected number of cases, calculated using national rates from Lithuanian Department of Statistics Official Statistics website. Results: Overall, 8779 patients with newly diagnosed RD were identified during the 2013-2017 period, these included 458 patients who used biological disease modifying drugs (bDMARDs). The mean duration of the follow-up period was 2.71 years. The cohort consisted mainly of women (70%) and a half of the cohort were rheumatoid arthritis (RA) patients (53%). Mean age of patients at the time of RD diagnosis was 56 years (range = 18-97 years). There were 9 TB cases identified during 23,800 person years of follow-up: 2 cases among them were treated with bDMARDs. The mean calculated annual TB incidence in RD cohort was 37.81 per 100,000 person years, which is consistent with the incidence rate predicted by national estimates, with a resultant SIR of 0.90 (0.41-1.70). The unadjusted hazard ratio for bDMARD use versus no bDMARD use was 4.54 (0.94; 21.87) in a total cohort and very similar in rheumatoid arthritis cohort; in both cohorts, it was not a statistically significant risk. Conclusions: Here, we present the first nationwide cohort study to assess the incidence of TB in a broad spectrum of inflammatory RD. Although limited by short follow-up period, this study shows that TB incidence in RD cohort does not exceed TB incidence in the general Lithuanian population.
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Affiliation(s)
- Dalia Miltinienė
- State Research Institute Centre for Innovative Medicine, LT-08406 Vilnius, Lithuania;
- Institute of Clinical Medicine, Clinic of Rheumatology, Orthopaedics Traumatology and Reconstructive Surgery, Vilnius University Faculty of Medicine, LT-03101 Vilnius, Lithuania
- Correspondence:
| | - Giedrė Deresevičienė
- Centre of Rheumatology, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania; (G.D.); (I.B.)
| | - Birutė Nakčerienė
- Programs and Tuberculosis State Information System Department, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania; (B.N.); (V.E.D.)
- Vilnius University Life Sciences Center, LT-10257 Vilnius, Lithuania
| | - Valerija Edita Davidavičienė
- Programs and Tuberculosis State Information System Department, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania; (B.N.); (V.E.D.)
| | - Edvardas Danila
- Centre of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania;
- Institute of Clinical Medicine, Clinic of Chest Diseases, Immunology and Allergology, Vilnius University Faculty of Medicine, LT-03101 Vilnius, Lithuania
| | - Irena Butrimienė
- Institute of Clinical Medicine, Clinic of Rheumatology, Orthopaedics Traumatology and Reconstructive Surgery, Vilnius University Faculty of Medicine, LT-03101 Vilnius, Lithuania
- Centre of Rheumatology, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania; (G.D.); (I.B.)
| | - Jolanta Dadonienė
- State Research Institute Centre for Innovative Medicine, LT-08406 Vilnius, Lithuania;
- Institute of Health Sciences, Department of Public Health, Vilnius University Faculty of Medicine, LT-03101 Vilnius, Lithuania
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11
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Tuberculosis and viral hepatitis in patients treated with certolizumab pegol in Asia-Pacific countries and worldwide: real-world and clinical trial data. Clin Rheumatol 2020; 40:867-875. [PMID: 32740672 PMCID: PMC7895783 DOI: 10.1007/s10067-020-05248-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/13/2020] [Accepted: 06/18/2020] [Indexed: 11/25/2022]
Abstract
Introduction/objectives To evaluate the incidence rate (IR) of tuberculosis (TB) and viral hepatitis B and C (HBV/HCV) during certolizumab pegol (CZP) treatment, worldwide and in Asia-Pacific countries, across clinical trials and post-marketing reports (non-interventional studies and real-world practice). Method CZP safety data were pooled across 49 clinical trials from 1998 to June 2017. Post-marketing reports were from initial commercialization until March 2015 (TB)/February 2017 (HBV/HCV). All suspected TB and HBV/HCV cases underwent centralized retrospective review by external experts. Incidence rates (IRs) were calculated per 100 patient-years (PY) of CZP exposure. Results Among 11,317 clinical trial patients (21,695 PY), 62 TB cases were confirmed (IR 0.29/100 PY) including 2 in Japan (0.10/100 PY) and 3 in other Asia-Pacific countries (0.58/100 PY). From > 238,000 PY estimated post-marketing CZP exposure, there were 31 confirmed TB cases (0.01/100 PY): 5 in Japan (0.05/100 PY), 1 in other Asia-Pacific countries (0.03/100 PY). Reported regional TB IRs were highest in eastern Europe (0.17/100 PY), central Europe (0.09/100 PY), and Mexico (0.16/100 PY). Across clinical trials, there was 1 confirmed HBV reactivation and no HCV cases. From > 420,000 PY estimated post-marketing CZP exposure, 5 HBV/HCV cases were confirmed (0.001/100 PY): 2 HCV reactivations; 1 new HCV; plus 2 HBV reactivations in Japan (0.008/100 PY). Conclusions CZP TB risk is aligned with nationwide TB rates, being slightly higher in Asia-Pacific countries excluding Japan. Overall, TB and HBV/HCV risk with CZP treatment is currently relatively low, as risk can be minimized with patient/physician education, screening, and vigilant treatment, according to international guidelines.Key Points: • TB rates were highest in eastern/central Europe, Mexico, and Asia-Pacific regions. • With the implementation of stricter TB screening and risk evaluations in 2007, especially in high TB incidence countries, there was a notable reduction TB occurrence. • Safety profile of biologics in real-world settings complements controlled studies. • TB and hepatitis (HBV/HCV) risk with certolizumab pegol (CZP) treatment is low. |
Electronic supplementary material The online version of this article (10.1007/s10067-020-05248-4) contains supplementary material, which is available to authorized users.
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12
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Sarkar S, Panda S, Kim B, Raychaudhuri SK, Ghosh A, Raychaudhuri SP. Risk of tuberculosis with anti-tumor necrosis factor-alpha therapy in patients with psoriasis and psoriatic arthritis in Indian population. Indian J Dermatol Venereol Leprol 2020; 86:1-7. [PMID: 31719235 DOI: 10.4103/ijdvl.ijdvl_791_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Anti-tumor necrosis factor-alpha (TNF-α) immunotherapy has revolutionized the treatment of inflammatory diseases, such as psoriasis and psoriatic arthritis. However, a major concern is that patients receiving this therapy have an increased risk of infection, particularly of reactivation of latent tuberculosis (TB). There were an estimated 10.4 million new cases of tuberculosis in 2016, worldwide, and India has one of the largest TB case burden with an estimated incidence of 2.79 million cases of TB in the same year. Anti-TNF agents like etanercept and infliximab are available in India approved for psoriasis and psoriatic arthritis. But long-term use of these agents possesses a risk of reactivation of latent TB. In this review article, we assessed the risk of TB with anti-TNF therapy especially in patients with psoriasis and psoriatic arthritis in India. At the end of the article, we have also suggested a recommendation for screening of latent tuberculosis and its management, before starting anti-TNF-α therapy.
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Affiliation(s)
- Soumajyoti Sarkar
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, USA
| | - Saumya Panda
- Department of Dermatology, KPC Medical College, Kolkata, West Bengal, India
| | - Byungsoo Kim
- Department of Dermatology, School of Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea; Department of Dermatology, School of Medicine, University of California, Davis, CA, USA
| | | | - Asutosh Ghosh
- Department of Critical Care Medicine, IPGME and R, Kolkata, West Bengal, India
| | - Siba P Raychaudhuri
- Division of Rheumatology, Allergy and Clinical Immunology; Department of Dermatology, School of Medicine, University of California, Davis; VA Medical Center Sacramento, Mather, CA, USA
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13
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Evangelatos G, Koulouri V, Iliopoulos A, Fragoulis GE. Tuberculosis and targeted synthetic or biologic DMARDs, beyond tumor necrosis factor inhibitors. Ther Adv Musculoskelet Dis 2020; 12:1759720X20930116. [PMID: 32612710 PMCID: PMC7309385 DOI: 10.1177/1759720x20930116] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
Patients with autoimmune rheumatic diseases (ARD) have an increased risk for tuberculosis (TB). The use of tumor necrosis factor inhibitors (TNFi) and glucocorticoids in these patients has been associated with an increased prevalence of latent TB reactivation. Over the last few years, several biologic disease-modifying anti-rheumatic drugs (bDMARDs), other than TNFi (e.g. rituximab, abatacept, tocilizumab, secukinumab) and targeted synthetic DMARDs (tsDMARDs) [e.g. apremilast, Janus kinase (JAK) inhibitors] have been used for the treatment of patients with ARD. For many of these drugs, especially the newer ones like JAK inhibitors or antibodies against interleukin (IL)-23, most data stem from randomized clinical trials and few are available from real life clinical experience. We sought to review the current evidence for TB risk in patients with ARD treated with tsDMARDs or bDMARDs, other than TNFi. It seems that some of these drugs are associated with a lower TB risk, indirectly compared with TNFi treatment. In fact, it appears that rituximab, apremilast and inhibitors of IL-17 and IL-23 might be safer, while more data are needed for JAK inhibitors. As seen in TNFi, risk for TB is more pronounced in TB-endemic areas. Screening for latent TB must precede initiation of any tsDMARDs or bDMARDs. The growing use of non-TNFi agents has raised the need for more real-life studies that would compare the risk for TB between TNFi and other treatment modalities for ARD. Knowledge about the TB-safety profile of these drugs could help in the decision of drug choice in patients with confirmed latent TB infection or in TB endemic areas.
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Affiliation(s)
- Gerasimos Evangelatos
- Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Monis Petraki 10-12, Athens, 11521, Greece
| | - Vasiliki Koulouri
- Department of Physiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexios Iliopoulos
- Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
| | - George E Fragoulis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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Thomas K, Hadziyannis E, Hatzara C, Makris A, Tsalapaki C, Lazarini A, Klavdianou K, Antonatou K, Koutsianas C, Vassilopoulos D. Conversion and Reversion Rates of Tuberculosis Screening Assays in Patients With Rheumatic Diseases and Negative Baseline Screening Under Long-Term Biologic Treatment. Pathog Immun 2020; 5:34-51. [PMID: 32258853 PMCID: PMC7104555 DOI: 10.20411/pai.v5i1.349] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/27/2020] [Indexed: 12/21/2022] Open
Abstract
Background: To determine the conversion and reversion rates of tuberculosis (TB) screening tests (Tuberculin Skin Test-TST, Interferon Gamma Release Assay-IGRA: T-SPOT.TB) during biologic treatment in patients with rheumatic diseases and negative baseline screening. Methods: This was a long-term, longitudinal cohort study of 50 patients with rheumatic diseases and negative baseline TB screening (TST: < 5 mm, negative T-SPOT.TB) treated with tumor necrosis factor inhibitors (TNFi) or other non-TNFi biologics. Patients were rescreened at a mean time of 1.4 (first rescreening) and 6.9 (second rescreening) years from baseline, with both assays. The conversion (negative to positive) and reversion (positive to negative) rate was calculated for each TB screening test. Results: Fifty patients (mean age = 60 years) with various rheumatic diseases (rheumatoid arthritis: n = 24, spondyloarthropathies: n = 23, other: n = 3) were enrolled. During the first phase (baseline to first rescreening), all patients were treated with TNFi while during the second phase (first to second rescreening), TNFi (54%) and non-TNFi (46%) were used. Fifteen patients (30%) displayed conversion of at least 1 screening assay during follow-up (10 at the first and 5 at the second rescreening). This conversion rate was higher with TST (n = 11, 22% or 3.47/100 patient-years) compared to T-SPOT.TB (n = 4, 8% or 1.74/100 patient-years). Among the 10 converters at the first rescreening, 5 received isoniazid (INH) preventive therapy and 5 did not; an equal number of patients (3/5, 60%) reverted to negative with or without INH therapy. None of the patients developed active TB during follow-up (6.9 ± 1.0 years). Conclusions: Approximately one-third of patients with rheumatic diseases and negative baseline TB screening developed conversion of at least 1 screening test during long-term biologic treatment. This occurred most often with TST and was usually a transient event. These findings do not support routine serial TB retesting in biologic-treated patients with rheumatic diseases in the absence of TB risk factors.
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Affiliation(s)
- Konstantinos Thomas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Emilia Hadziyannis
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Chrisoula Hatzara
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Anastasia Makris
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Christina Tsalapaki
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Argyro Lazarini
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Kalliopi Klavdianou
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Katerina Antonatou
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Christos Koutsianas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
| | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit; 2nd Department of Medicine and Laboratory; Hippokration General Hospital; National and Kapodistrian University of Athens School of Medicine; Athens, Greece
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15
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Incidence of tuberculosis in patients receiving anti-TNF therapy for rheumatic diseases: a systematic review. Clin Rheumatol 2020; 39:1439-1447. [PMID: 31900748 DOI: 10.1007/s10067-019-04866-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/12/2019] [Accepted: 11/20/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The TNF inhibitors were the first immunobiologicals used to treat rheumatic diseases, but their use is associated with an increased risk of tuberculosis. The primary objective is to estimate the incidence of tuberculosis in patients with rheumatic diseases exposed to anti-TNF therapy. The secondary objectives are to evaluate the incidence of tuberculosis by region and subgroups of diseases, to review the presentation of tuberculosis in these patients, and to assess the time elapsed between onset of anti-TNF therapy and development of active granulomatous disease. METHODS A systematic review of the literature was conducted in MEDLINE, the Cochrane Library, and LILACS. The primary endpoint was described as incidence and secondary outcomes, through subgroup analyses and comparisons of means. RESULTS We included 52 observational studies. Among the exposed patients, 947 cases of tuberculosis were documented (62.2% pulmonary), with a cumulative incidence of 9.62 cases per 1000 patients exposed. TB incidence across different continents was distributed as follows: South America, 11.75 cases/1000 patients exposed; North America, 4.34 cases/1000 patients exposed; Europe, 6.28 cases/1000 patients exposed; and Asia, 13.47 cases/1000 patients exposed. There were no significant differences in TB incidence among the described diseases. The mean time elapsed from start of anti-TNF therapy until the endpoint was 18.05 months. CONCLUSION The incidence of TB in patients with rheumatic diseases exposed TNF inhibitor considering all countries was 9.62 cases per 1000 patients exposed. TB incidence was higher in South America and Asia compared with North America and Europe. Most cases occurred in the first XX months of use, and the pulmonary form predominated.Key Points• Higher incidence of tuberculosis in patients exposed to anti-TNF compared with the general population.• Higher incidence of TB in countries of South America and Asia compared with North America and Europe.
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16
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Abstract
People with immunoreactivity to tuberculosis are thought to have lifelong asymptomatic infection and remain at risk for active tuberculosis. Marcel A Behr and colleagues argue that most of these people are no longer infected
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Affiliation(s)
- Marcel A Behr
- Department of Medicine, McGill University, McGill International TB Centre, Montreal, H4A 3J1, Canada
| | - Paul H Edelstein
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, MRC Laboratory of Molecular Biology, Cambridge CB2 0QH, UK
| | - Lalita Ramakrishnan
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, MRC Laboratory of Molecular Biology, Cambridge CB2 0QH, UK
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17
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Adami G, Saag KG, Chapurlat RD, Guañabens N, Haugeberg G, Lems WF, Matijevic R, Peel N, Poddubnyy D, Geusens P. Balancing benefits and risks in the era of biologics. Ther Adv Musculoskelet Dis 2019; 11:1759720X19883973. [PMID: 31695755 PMCID: PMC6820177 DOI: 10.1177/1759720x19883973] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/01/2019] [Indexed: 12/28/2022] Open
Abstract
Biologics are substances synthetized from biological sources used in the prevention and treatment of several diseases. Rheumatologists have many years of experience with biologics for the treatment of immune-mediated diseases and osteoporosis. Randomized clinical trials and postmarketing studies have demonstrated that treatment with biologics can result, albeit infrequently, in serious adverse events. To date, several risk mitigation strategies have been identified and implemented. The objective of the present perspective review is to examine the risk mitigation strategies of biologic treatments, with special focus on anti-tumor necrosis factors and denosumab.
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Affiliation(s)
- Giovanni Adami
- Rheumatology Unit, University of Verona, Pz Scuro 10, 37135, Verona, Italy
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Nuria Guañabens
- Rheumatology Department, Hospital Clinic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Glenn Haugeberg
- Division of Rheumatology, Medicine Department, Southern Hospital Trust, Trondheim, Norway
| | - Willem F Lems
- Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | | | - Nicola Peel
- Metabolic Bone Centre, Northern General Hospital Sheffield, UK
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases, and Rheumatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Piet Geusens
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
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18
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Anastasopoulou A, Ziogas DC, Samarkos M, Kirkwood JM, Gogas H. Reactivation of tuberculosis in cancer patients following administration of immune checkpoint inhibitors: current evidence and clinical practice recommendations. J Immunother Cancer 2019; 7:239. [PMID: 31484550 PMCID: PMC6727332 DOI: 10.1186/s40425-019-0717-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/23/2019] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors (ICBs) have revolutionized cancer treatment producing remarkable and durable responses for a range of malignancies. However, the additional modulation of immune response by ICBs may rarely cause immune-related infectious complications, including re-activation of latent tuberculosis infection (LTBC) with detrimental effects on those patients’ outcome. Here, we present two “real-world” melanoma cases that were treated in our department with blockade of PD-1/PD-L1 and developed active Mycobacterium tuberculosis (MTB) during immunotherapy. In view of these cases, we review the literature for ICB-associated MTB reactivation and discuss our considerations about the possible interactions of immunotherapy and the underlying co-existent mycobacterial infection. Based on the current evidence from preclinical findings prior to this experience, we raise questions regarding cancer patients who are at higher risk for developing MTB infection, whether ICB-treated patients should be considered immunocompromised, and how they should be managed for latent and/or active tuberculosis. Aside from the well-established clinical benefit of immunotherapy, the blockade of PD-1/PD-L1 axis may concurrently disrupt the immune control of specific opportunistic infections such as tuberculosis that should be carefully and expectantly managed in order to avoid compromising the outcome of cancer treatment and the affected patient’s survival.
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Affiliation(s)
- Amalia Anastasopoulou
- First Department of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens School of Medicine, 11527, Athens, Greece
| | - Dimitrios C Ziogas
- First Department of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens School of Medicine, 11527, Athens, Greece
| | - Michael Samarkos
- First Department of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens School of Medicine, 11527, Athens, Greece
| | - John M Kirkwood
- Division of Hematology/Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Helen Gogas
- First Department of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens School of Medicine, 11527, Athens, Greece.
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Bird P, Bensen W, El-Zorkany B, Kaine J, Manapat-Reyes BH, Pascual-Ramos V, Witcombe D, Soma K, Zhang R, Thirunavukkarasu K. Tofacitinib 5 mg Twice Daily in Patients with Rheumatoid Arthritis and Inadequate Response to Disease-Modifying Antirheumatic Drugs: A Comprehensive Review of Phase 3 Efficacy and Safety. J Clin Rheumatol 2019; 25:115-126. [PMID: 29794874 PMCID: PMC6445596 DOI: 10.1097/rhu.0000000000000786] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). We performed a comprehensive review of phase 3 studies of tofacitinib 5 mg twice daily (BID) (approved dose in many countries) in patients with moderate to severe RA and inadequate response to prior disease-modifying antirheumatic drugs. METHODS A search of PubMed and ClinicalTrials.gov identified 5 studies: ORAL Solo (NCT00814307), ORAL Sync (NCT00856544), ORAL Standard (included adalimumab 40 mg once every 2 weeks; NCT00853385), ORAL Scan (NCT00847613), and ORAL Step (NCT00960440). Efficacy and safety data for tofacitinib 5 mg BID, placebo, and adalimumab were analyzed. RESULTS Across the 5 studies, 1216 patients received tofacitinib 5 mg BID, 681 received placebo, and 204 received adalimumab. At month 3, tofacitinib demonstrated significantly higher 20%, 50%, and 70% improvement in American College of Rheumatology response criteria (ACR20, ACR50, and ACR70, respectively) response rates, greater improvement in Health Assessment Questionnaire-Disability Index, and a higher proportion of Disease Activity Score-defined remission than placebo. Frequencies of adverse events (AEs), serious AEs, and discontinuations due to AEs were similar for tofacitinib and placebo at month 3; serious infection events were more frequent for tofacitinib. In ORAL Standard, although not powered for formal comparisons, tofacitinib and adalimumab had numerically similar efficacy and AEs; serious AEs and serious infection events were more frequent with tofacitinib. CONCLUSIONS Tofacitinib 5 mg BID reduced RA signs and symptoms and improved physical function versus placebo in patients with inadequate response to prior disease-modifying antirheumatic drugs. Tofacitinib 5 mg BID had a consistent, manageable safety profile across studies, with no new safety signals identified.
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Affiliation(s)
- Paul Bird
- From the University of New South Wales, Sydney, New South Wales, Australia
| | - William Bensen
- St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Bernadette Heizel Manapat-Reyes
- Section of Rheumatology, Department of Medicine, University of the Philippines–Philippine General Hospital, Manila, Philippines
| | - Virginia Pascual-Ramos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Witcombe
- Pfizer Australia, Sydney, New South Wales, Australia; and
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20
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Aydin V, Akici A, Isli F, Aksoy M, Aydin M, Gursoz H. Relative risk of tuberculosis in patients with rheumatic diseases managed with anti-tumour necrosis factor-alpha therapy: A nationwide cohort study. J Clin Pharm Ther 2019; 44:553-560. [PMID: 30763469 DOI: 10.1111/jcpt.12814] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 12/16/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Anti-tumour necrosis factor-alpha (anti-TNF-α) therapy is known to raise the risk of granulomatous infections, leading to development of risk management strategies at national or global level. This study aimed to determine the relative risk (RR) of tuberculosis (TB) due to anti-TNF-α usage in patients with rheumatologic diseases (RDs) in a nationwide basis. METHOD This retrospective cohort study included patients with rheumatoid arthritis (RA), ankylosing spondylitis, juvenile idiopathic arthritis or psoriatic arthritis (PsA) that treated with or without anti-TNF-α agents, as registered in the national prescription information system between years 2013 and 2015. Two-year RR of TB after anti-TNF-α therapy initiation was calculated in this RD population, including main subgroups. RESULTS AND DISCUSSION The study cohort included 413 500 RD patients, where anti-TNF-α(+) arm (n = 2117) had mean age of 41.9 ± 13.4 years and male distribution of 54.3%. Four patients among anti-TNF-α users developed TB compared to 128 patients in anti-TNF-α-naïve group (189 vs 31 cases per 100 000 patients, respectively), yielding a 2-year RR of 6.07 (95% CI, 2.25-16.42) with an attributable risk of 0.16%. These RRs (95% CI), which were particularly pronounced, were 5.39 (1.69-7.17) in men, 6.12 (2.26-16.55) in adults, and 5.70 (1.41-23.08) in RA and 13.46 (1.58-114.40) in PsA patients. There was no difference between the anti-TNF-α users who developed and undeveloped TB regarding drug utilization characteristics, except significantly less immunosuppressive drug exposure in TB patients. WHAT IS NEW AND CONCLUSION This study is the first prescription-based nationwide study to suggest an elevated RR of TB in a comparably younger population with a broad spectrum of RDs managed with any approved anti-TNF-α drug in Turkey.
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Affiliation(s)
- Volkan Aydin
- Department of Pharmacology, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Akici
- Department of Pharmacology, Marmara University School of Medicine, Istanbul, Turkey
| | - Fatma Isli
- Turkish Medicines and Medical Devices Agency, Ministry of Health, Ankara, Turkey
| | - Mesil Aksoy
- Turkish Medicines and Medical Devices Agency, Ministry of Health, Ankara, Turkey
| | - Mehtap Aydin
- Department of Infectious Diseases and Clinical Microbiology, Baskent University School of Medicine, Istanbul, Turkey
| | - Hakki Gursoz
- Turkish Medicines and Medical Devices Agency, Ministry of Health, Ankara, Turkey
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21
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Incidence of infection other than tuberculosis in patients with autoimmune rheumatic diseases treated with bDMARDs: a real-time clinical experience from India. Rheumatol Int 2019; 39:497-507. [DOI: 10.1007/s00296-019-04245-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/21/2019] [Indexed: 12/15/2022]
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22
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Taxonera C, Ponferrada Á, Riestra S, Bermejo F, Saro C, Martín-Arranz MD, Cabriada JL, Barreiro-de Acosta M, de Castro ML, López-Serrano P, Barrio J, Suarez C, Iglesias E, Argüelles-Arias F, Ferrer I, Marín-Jiménez I, Hernández-Camba A, Bastida G, Van Domselaar M, Martínez-Montiel P, Olivares D, Rivero M, Fernandez-Salazar L, Nantes Ó, Merino O, Alba C, Gisbert JP, Botella B, Carpio D, Ceballos D, Verdejo C, Morales I, Legido J, Peñate M, Chaparro M, Algaba A, de Francisco R. Serial Tuberculin Skin Tests Improve the Detection of Latent Tuberculosis Infection in Patients With Inflammatory Bowel Disease. J Crohns Colitis 2018; 12:1270-1279. [PMID: 30052856 DOI: 10.1093/ecco-jcc/jjy104] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To assess the likelihood of detecting latent tuberculosis infection [LTBI] by the positive conversion of a serial tuberculin skin test [TST] at 1 year in inflammatory bowel disease [IBD] patients with negative baseline two-step TST. METHODS In this multicentre prospective cohort study, we evaluated rate and predictors of conversion of TST at 1 year in patients with negative baseline TST. We also evaluated management of patients who had a positive TST at baseline or a conversion at 1 year. In all patients we assessed TB cases occurring during follow-up. RESULTS Of the 192 IBD patients receiving anti-tumour necrosis factor [TNF] and 220 IBD controls not receiving anti-TNF, 35 [8.5%, 95% CI 5.7-11.3] had positive conversion (median TST induration 13 mm, interquartile range [IQR] 9-16). Ten anti-TNF cohort patients [5.2%, 95% CI 2.5-9.5] versus 25 controls [11.4%, 95% CI 7.5-16.3] had TST conversion [p = 0.029]. In multivariate analysis, conversion was associated with smoking habit (odds ratio [OR] 2.19, 95% CI 1.08-3.97; p = 0.028). Anti-TNF-treated patients had a lower conversion rate [OR 0.41, 95% CI 0.20-0.83; p = 0.013]. The likelihood of conversion correlates with fewer immunosuppressive therapies between baseline TST and TST at 1 year [p = 0.042]. One case of active TB [isoniazid-resistant strain] occurred in a patient with positive baseline TST receiving anti-TNF [0.05 events/100 patient-years]. CONCLUSIONS Serial TST at 1 year can detect LTBI in IBD patients receiving anti-TNF therapy with negative baseline TST. Serial TST seems to be advisable to reduce the risk of TB cases associated with inability to detect LTBI in pre-treatment screening.
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Affiliation(s)
- Carlos Taxonera
- Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - Ángel Ponferrada
- Department of Gastroenterology, Hospital Infanta Leonor, Madrid, Spain
| | - Sabino Riestra
- Department of Gastroenterology, Hospital Universitario Central de Asturias and Instituto de Investigación Biosanitaria del Principado de Asturias [ISPA], Oviedo, Spain
| | - Fernando Bermejo
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Cristina Saro
- Department of Gastroenterology, Hospital de Cabueñes, Gijón, Spain
| | | | | | - Manuel Barreiro-de Acosta
- Department of Gastroenterology, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - María Luisa de Castro
- Department of Gastroenterology, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Pilar López-Serrano
- Department of Gastroenterology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Cristina Suarez
- Department of Gastroenterology, Hospital Puerta de Hierro, Madrid, Spain
| | - Eva Iglesias
- Department of Gastroenterology, Hospital Reina Sofía, Córdoba, Spain
| | | | - Isabel Ferrer
- Department of Gastroenterology, Hospital de Manises, Manises, Spain
| | - Ignacio Marín-Jiménez
- Department of Gastroenterology, Hospital Gregorio Marañón and Instituto de Investigación Sanitaria Gregorio Marañón [IiSGM], Madrid, Spain
| | | | | | - Manuel Van Domselaar
- Department of Gastroenterology, Hospital Universitario de Torrejón, Madrid, Spain
| | | | - David Olivares
- Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - Montserrat Rivero
- Department of Gastroenterology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Óscar Nantes
- Department of Gastroenterology, Complejo Hospitalario de Navarra and Instituto de Investigación Sanitaria de Navarra [IdiSNA], Pamplona, Spain
| | - Olga Merino
- Department of Gastroenterology, Hospital Universitario Cruces, Bilbao, Spain
| | - Cristina Alba
- Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - Javier P Gisbert
- Department of Gastroenterology, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP] and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
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Reitblat O, Lerman TT, Cohen O, Reitblat T. The Effect of Prednisone on Tuberculin Skin Test Reaction in Patients with Rheumatoid Arthritis. Int J Rheumatol 2018; 2018:2586916. [PMID: 30420888 PMCID: PMC6215561 DOI: 10.1155/2018/2586916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/29/2018] [Accepted: 10/03/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To assess the correlation between prednisone and methotrexate (MTX) treatment duration and dosage with the TST induration diameter of the TST reaction among rheumatoid arthritis (RA) patients. METHOD We retrospectively analyzed consecutive cases of RA patients who were TNF-i therapy candidates. TST measurements, prednisone and methotrexate dosages, and treatment durations were recorded. A control group was randomly selected from healthy subjects. We compared TST reaction size between the following three groups: RA patients with current prednisone treatment, RA prednisone naïve patients, and healthy individuals. RESULTS Our study sample comprised 43 RA patients with prednisone treatment, 22 prednisone naïve patients, and 195 healthy subjects. There was no significant difference in mean TST between the groups (5.3±6.6, 7.8±6.2, and 7.6±7.0, respectively, p=0.149). No correlation was noted between TST size and prednisone u-y (r=0.229, p=0.140) or methotrexate u-y in patients with and without prednisone therapy (r=0.219, p=0.158; and r=-0.293, p=0.186, respectively). CONCLUSIONS Our results show that the TST reaction size among RA patients may not be affected by prednisone therapy. In addition, the TST reaction of RA patients may present similarly to that of healthy individuals. Therefore, we suggest that the criterion of a TST reaction of 5 mm to define latent TB infection in our population should be reevaluated.
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Affiliation(s)
- Olga Reitblat
- Barzilai Medical Center, Ashkelon, Israel
- Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Tsahi T. Lerman
- Barzilai Medical Center, Ashkelon, Israel
- Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Ornit Cohen
- Barzilai Medical Center, Ashkelon, Israel
- Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Tatiana Reitblat
- Barzilai Medical Center, Ashkelon, Israel
- Ben Gurion University of the Negev, Beer-Sheva, Israel
- Rheumatology Unit, Barzilai Medical Center, Ashkelon, Israel
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Quirós S, de la Rosa D, Uranga A, Madero R, Amaro R, Bruguera N, García JA, Gómez C, Iturbe D, Lera R, Luque L, Martínez AJ, Mínguez P, Navarro A, Sánchez G, Suárez-Cuartín G. Screening for latent tuberculosis infection in patients who are candidate for biological therapies in Spain? A multidisciplinary survey. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.arbr.2018.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Hasan T, Au E, Chen S, Tong A, Wong G. Screening and prevention for latent tuberculosis in immunosuppressed patients at risk for tuberculosis: a systematic review of clinical practice guidelines. BMJ Open 2018; 8:e022445. [PMID: 30209157 PMCID: PMC6144320 DOI: 10.1136/bmjopen-2018-022445] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 07/15/2018] [Accepted: 07/25/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Immunosuppressed individuals are at a high risk of latent tuberculosis infection (LTBI) and clinical practice guidelines for the screening and management of LTBI in at-risk patients have been developed. We assessed the scope, quality and consistency of clinical practice guidelines on screening for LTBI and the prevention of tuberculosis infection (TB) in high-risk patient populations. DESIGN We conducted a systematic review of clinical practice guidelines. Methodological quality of these guidelines was assessed using the Appraisal of Guidelines for Research and Education (AGREE) II instrument. Textual synthesis was used to summarise and compare the recommendations. DATA SOURCES Electronic databases (MEDLINE, EMBASE, PsycINFO) and guideline registries were searched from inception to December 2017. RESULTS Thirty-eight guidelines were included. Nineteen focused on patients receiving medical immunosuppression, seven on transplantation, three on patients with HIV and nine were generalised across all at risk populations. Most guidelines (n=32, 84%) used a systematic approach to identify and appraise the evidence. The methodological quality of the guidelines varied with the overall mean AGREE II scores ranging from 35% to 80%. Guidelines performed poorly in terms of editorial independence (average score 35%, range 0%-92%); however, most were robust in defining their scope and purpose (average score 80%, range 56%-100%). Guidelines recommended either or both the tuberculin skin test and the interferon gamma release assay for screening. Treatment of LTBI with isoniazid was consistently recommended. CONCLUSION Clinical practice guidelines on LTBI vary in quality and scope. The recommendations for screening varied across guidelines, while recommendations for treatment were largely consistent. Improving the consistency and quality of guidelines may help to optimise the screening and management of LTBI for improved patient outcomes.
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Affiliation(s)
- Tasnim Hasan
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Eric Au
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Sharon Chen
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Allison Tong
- Centre for Kidney Research, The Children’s Hospital, Westmead, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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26
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Ganzel C, Silverman B, Chemtob D, Ben Shoham A, Wiener-Well Y. The risk of tuberculosis in cancer patients is greatest in lymphoma and myelodysplastic syndrome/myeloproliferative neoplasm: a large population-based cohort study. Leuk Lymphoma 2018; 60:720-725. [PMID: 30188229 DOI: 10.1080/10428194.2018.1499904] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Patients with cancer are at high risk for tuberculosis (TB). This study combined the Israeli databases of cancer and TB and examined the development of TB among all newly diagnosed cancer cases from 1993 to 2013. Patients were classified into groups according to their different malignancies. Among 495,335 cancer patients, 335 developed TB following cancer diagnosis. The cumulative incidence of TB following cancer diagnosis was highest among MDS/MPN (148.8/100,000 patients) and lymphoma (154.1/100,000 patients) (p = .023). The HR of TB following cancer among hematologic patients was 2.51 (p < .001), relative to patients with in situ carcinomas/skin cancer and highest among MDS/MPN and lymphoma patients (2.74, p = .012 and 2.70, p < .001, respectively). Among lymphoma patients, a significant increased HR was found only among NHL patients (2.72, p < .001). The limitations include lack of information regarding risk factors for TB and of anti-cancer treatments. In conclusion, these data may encourage a heightened awareness for TB among patients with a background of lymphoma and MDS/MPN.
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Affiliation(s)
- Chezi Ganzel
- a Department of Hematology , Shaare Zedek Medical Center , Jerusalem , Israel
| | - Barbara Silverman
- b Israel National Cancer Registry, Israel Ministry of Health , Israel
| | - Daniel Chemtob
- c Department of Tuberculosis and AIDS, Ministry of Health, Jerusalem, Israel and Braun School of Public Health and Community Medicine, Faculty of Medicine , Hebrew University-Hadassah , Jerusalem , Israel
| | | | - Yonit Wiener-Well
- e Infectious Disease Unit , Shaare Zedek Medical Center , Jerusalem , Israel
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27
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Rodríguez-Jiménez P, Mir-Viladrich I, Chicharro P, Solano-López G, López-Longo F, Taxonera C, Sánchez-Martínez P, Martínez-Lacasa X, García-Gasalla M, Dorca J, Arias-Guillén M, García-García J, Dauden E. Consenso multidisciplinar sobre prevención y tratamiento de la tuberculosis en pacientes candidatos a tratamiento biológico. Adaptación al paciente dermatológico. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:584-601. [DOI: 10.1016/j.ad.2018.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 02/08/2023] Open
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Rodríguez-Jiménez P, Mir-Viladrich I, Chicharro P, Solano-López G, López-Longo F, Taxonera C, Sánchez-Martínez P, Martínez-Lacasa X, García-Gasalla M, Dorca J, Arias-Guillén M, García-García J, Dauden E. Prevention and treatment of tuberculosis infection in candidates for biologic therapy: A multidisciplinary consensus statement adapted to the dermatology patient. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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29
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Lee CK, Wong SHV, Lui G, Tang W, Tam LS, Ip M, Hung E, Chen M, Wu JC, Ng SC. A Prospective Study to Monitor for Tuberculosis During Anti-tumour Necrosis Factor Therapy in Patients With Inflammatory Bowel Disease and Immune-mediated Inflammatory Diseases. J Crohns Colitis 2018; 12:954-962. [PMID: 29757355 DOI: 10.1093/ecco-jcc/jjy057] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 05/09/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Biologic therapies have revolutionised the treatment of immune-mediated diseases including inflammatory bowel disease [IBD] and rheumatological disorders. However, biologic treatments are associated with an increased risk of reactivation of latent tuberculosis. Data from regular monitoring for latent tuberculosis infection [LTBI] during biologic treatment are lacking. METHODS Consecutive patients eligible for biologic therapies were screened for LTBI and prospectively followed up for 3 years. Incidence and risk factors of latent tuberculosis tests conversion (interferon gamma release assays [IGRA], tuberculin skin tests [TST], and chest radiography [CXR]) with clinical outcomes were studied. RESULTS A total of 108 patients [83 IBD; 25 rheumatological disorders] were included. At baseline, 18/108 [16.7%] patients [five IBD; 13 rheumatological disorders] were tested positive for LTBI. Of these, 14/18 [77.8%] patients received isoniazid monotherapy for 9 months. Of the remainder, 17/90 [18.9%] patients had LTBI test conversion while on biologic therapies and of these 14/17 [82.4%] received isoniazid monotherapy for 9 months. Age, sex, smoking status, alcohol use, travel history, disease type, and immunosuppressive therapy were not associated with LTBI test conversion. In subjects with IGRA conversion, serial IGRA levels normalised after completion of isoniazid except in one patient whose IGRA remained persistently elevated despite isoniazid and who subsequently developed active TB. CONCLUSIONS Conversion of LTBI is common and occurred early during biologic therapy in an area with intermediate TB burden. Subjects with latent TB tests conversion and persistently high IGRA levels may have an increased risk of TB reactivation or development of active TB, and they require close observation or intensive workup for active TB.
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Affiliation(s)
- Choon Kin Lee
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Sunny H V Wong
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Grace Lui
- Department of Medicine and Therapeutics, Division of Infectious Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Whitney Tang
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Lai San Tam
- Department of Medicine and Therapeutics, Division of Rheumatology, Chinese University of Hong Kong, Hong Kong, China
| | - Margaret Ip
- Department of Microbiology, Chinese University of Hong Kong, Hong Kong, China
| | - Esther Hung
- Department of Radiology, Chinese University of Hong Kong, Hong Kong, China
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, First Affliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Justin C Wu
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
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30
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Quirós S, de la Rosa D, Uranga A, Madero R, Amaro R, Bruguera N, García JA, Gómez C, Iturbe D, Lera R, Luque L, Martínez AJ, Mínguez P, Navarro A, Sánchez G, Suárez-Cuartín G. Screening for Latent Tuberculosis Infection in Patients who are Candidate for Biological Therapies in Spain? A Multidisciplinary Survey. Arch Bronconeumol 2018; 54:510-517. [PMID: 29941293 DOI: 10.1016/j.arbres.2018.04.004] [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: 02/09/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Treatment with biological therapies increases the incidence of tuberculous disease. The introduction of systematic screening for latent tuberculosis infection in patients who are to receive these therapies has reduced this risk. In 2016, the consensus document on the prevention and treatment of tuberculosis in patients who are candidates for biological treatment was published in Spain. The main objective of this study was to evaluate adherence to these guidelines. METHODS Multicenter, descriptive, observational study via an anonymous online survey sent to medical societies involved in biologics. RESULTS We received 747 responses. Most respondents performed screening at the right time in the right patients (93.7%). Only 36.6% of respondents requested the appropriate diagnostic test, while 56.3% correctly recommended chemoprophylaxis. Up to 96% were familiar with the recommended chemoprophylaxis regimens, while only 63.9% initiated them at the right time. The specialist area that participated most and screened most patients for latent tuberculosis infection was rheumatology (54%). In most cases, pulmonologists were involved in an advisory capacity. CONCLUSIONS This study shows poor overall adherence to recommendations, with only 56% of respondents reporting appropriate compliance. The incidence of tuberculous disease in patients who are to receive biological therapies could be reduced further by emphasizing the importance of the right diagnostic test and use of the diagnostic algorithm for latent tuberculosis infection.
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Affiliation(s)
- Sarai Quirós
- Servicio de Neumología, Hospital General Universitario La Paz-Carlos III- Cantoblanco, Madrid, España.
| | | | - Ane Uranga
- Servicio de Neumología, Hospital de Galdakao-Usansolo, Bizkaia, España
| | - Rosario Madero
- Sección de Bioestadística - IdiPAZ, Hospital General Universitario La Paz, Madrid, España
| | - Rosanel Amaro
- Servicio de Neumología, Hospital Clinic, Barcelona, España
| | - Nuria Bruguera
- Servicio de Neumología, Hospital Comarcal Sant Jaume de Calella, Barcelona, España
| | | | - C Gómez
- Servicio de Neumología, Hospital General de la Defensa, Zaragoza, España
| | - David Iturbe
- Servicio de Neumología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Rubén Lera
- Servicio de Neumología, Hospital Doctor Peset, Valencia, España
| | - Lydia Luque
- Servicio de Neumología, Hospital Moisés Broggi, Barcelona, España
| | - Abel J Martínez
- Servicio de Neumología, Hospital Universitario de Albacete, Albacete, España
| | - Patricia Mínguez
- Servicio de Neumología, Hospital Puerta de Hierro, Madrid, España
| | - Annie Navarro
- Servicio de Neumología, Mutua de Terrassa, Barcelona, España
| | - Gema Sánchez
- Servicio de Neumología, HGU Gregorio Marañón, Madrid, España
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Vortia E, Uko VE, Yen-Lieberman B, Frawley J, Worley SE, Danziger-Isakov L, Kaplan B, Mahajan L. Low Indeterminate Rates Associated With Use of the QuantiFERON-TB Gold In-Tube Test in Children With Inflammatory Bowel Disease on Long-term Infliximab. Inflamm Bowel Dis 2018; 24:877-882. [PMID: 29562270 DOI: 10.1093/ibd/izx077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Tumor necrosis factor alpha (TNF-α) inhibitors are linked with increased risk of reactivation of active tuberculosis. The QuantiFERON-TB Gold In-Tube test is approved for screening latent tuberculosis infection in children and adults. There are limited data on the test performance in children on long-term treatment with TNF-α inhibitors. The objective of this study was to assess the proportion of indeterminate results for the QuantiFERON-TB Gold In-Tube in children with inflammatory bowel disease (IBD) on long-term infliximab treatment and to evaluate the range of interferon-γ responses to mitogen. METHODS A single-center prospective study of children 5 to 19 years of age with IBD on long-term infliximab treatment (>3 months). Each child was assessed for tuberculosis exposure risk and had blood drawn for the QuantiFERON-TB Gold In-Tube. Data on the range of interferon-γ responses and final QuantiFERON-TB Gold In-Tube test results were collected. RESULTS Ninety-three children were included, with a median age of 16 years. The median total duration of infliximab therapy was 34 months (range, 3-119 months). The QuantiFERON-TB Gold In-Tube was indeterminate in 1 patient (1.1%), positive in 2 patients, and negative in 90 patients. The maximum interferon-γ response to mitogen (10 IU/mL) was observed in 82 patients (88%), with only 1 patient having an inadequate response. The proportion of indeterminate results was significantly lower than the prospectively hypothesized rate of 8%, based on prior studies in nonimmunosuppressed patients (P = 0.004). CONCLUSIONS Pediatric patients with IBD on long-term treatment with infliximab had an adequate interferon-γ response to mitogen and a low indeterminate rate when assessed with the QuantiFERON-TB Gold In-Tube test. This study demonstrates a robust interferon gamma response to phytohemagglutinin stimulation in a pediatric population on long-term therapy with infliximab. The QuantiFERON-TB Gold In-Tube test may therefore be useful as a periodic screening tactic for latent TB in children on long-term infliximab therapy.
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Affiliation(s)
- Eugene Vortia
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Victor E Uko
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jill Frawley
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sarah E Worley
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lara Danziger-Isakov
- Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Barbara Kaplan
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lori Mahajan
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
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Cagatay T, Bingol Z, Kıyan E, Yegin Z, Okumus G, Arseven O, Erkan F, Gulbaran Z, Erelel M, Ece T, Cagatay P, Kılıçaslan Z. Follow‐up of 1887 patients receiving tumor necrosis‐alpha antagonists: Tuberculin skin test conversion and tuberculosis risk. CLINICAL RESPIRATORY JOURNAL 2017; 12:1668-1675. [DOI: 10.1111/crj.12726] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/03/2017] [Accepted: 10/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Tulin Cagatay
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Zuleyha Bingol
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Esen Kıyan
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Zeynep Yegin
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Gulfer Okumus
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Orhan Arseven
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Feyza Erkan
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Ziya Gulbaran
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Mustafa Erelel
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Turhan Ece
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Penbe Cagatay
- High School of Health Care Professions Biostatistic, Istanbul UniversityIstanbul Turkey
| | - Zeki Kılıçaslan
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
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Gabriele F, Trachana M, Simitsopoulou M, Pratsidou-Gertsi P, Iosifidis E, Pana ZD, Roilides E. Performance of QuantiFERON®-TB Gold In-Tube assay in children receiving disease modifying anti-rheumatic drugs. World J Pediatr 2017. [PMID: 28646434 DOI: 10.1007/s12519-017-0050-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND To evaluate the performance of the Quantiferon®-TB Gold In-Tube (QFT-IT) interferon (IFN)-γ assay for the detection of latent tuberculosis infection (LTBI) in children receiving anti-rheumatic treatment in a tertiary referral hospital of Northern Greece. METHODS A total of 79 consecutive children receiving anti-rheumatic treatment [of which 18 screened prior to antitumor necrosis factor (TNF)-α treatment] were tested using Mantoux tuberculin skin test (TST) and QFT-IT. Association of both tests with risk factors for latent tuberculosis and Bacillus Calmette-Guerin immunization was determined. Influence of age, TNF-α inhibitors, systemic corticosteroids, conventional disease modifying anti-rheumatic drugs (DMARDs) and total duration of therapy on the QFT-IT mitogen-induced response was evaluated. RESULTS Agreement between TST and QFT-IT results was moderate (k=0.38). Frequency of QFT-IT indeterminate results was low (2.5%). In patients with risk factors for LTBI, the odds of a positive IFN-γ assay was increased by a factor of 27.6 (P=0.002), whereas there was no positive TST. There was a significant difference in the mitogen-induced IFN-γ secretion among various treatments (P=0.038). TNF-α inhibitors were associated with increased mitogen-induced IFN-γ secretion compared to monotherapy with conventional DMARDs (P=0.008). All children screened prior to anti-TNF-α treatment exhibited a negative QFT-IT and no active TB disease was detected during a 2-year follow-up. CONCLUSIONS QFT-IT may be a more reliable test than TST for detection of LTBI in children with rheumatic diseases receiving anti-rheumatic treatment. Drug regimen might influence the mitogen-induced IFN-γ secretion and the effect of TNF-α inhibitors might vary according to the specific agent administered.
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Affiliation(s)
- Francesca Gabriele
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, 1st Department of Pediatrics, Thessaloniki, Greece
| | - Maria Simitsopoulou
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Polixeni Pratsidou-Gertsi
- Pediatric Immunology and Rheumatology Referral Center, 1st Department of Pediatrics, Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Zoi Dorothea Pana
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece.
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Lee EH, Kang YA, Leem AY, Park MS, Kim YS, Kim SK, Chang J, Kim SY. Active Tuberculosis Incidence and Characteristics in Patients Treated with Tumor Necrosis Factor Antagonists According to Latent Tuberculosis Infection. Sci Rep 2017; 7:6473. [PMID: 28743918 PMCID: PMC5526863 DOI: 10.1038/s41598-017-06899-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 06/20/2017] [Indexed: 11/24/2022] Open
Abstract
This study aimed to determine the incidence and characteristics of active tuberculosis (TB) in patients treated with tumor necrosis factor (TNF) antagonists according to baseline latent tuberculosis infection (LTBI). Data were retrospectively obtained from 702 patients aged ≥20 years treated with TNF antagonists between November 2005 and June 2016 at Severance Hospital, a tertiary referral hospital in Seoul, South Korea. The interferon-gamma release assay (IGRA) with or without a tuberculin skin test (TST) was used to diagnose LTBI. Of the total of 702 patients, LTBI was diagnosed in 255 (36.3%) patients. 23.9% (168/702) had positive IGRA results, and 32.2% (165/512) had positive TST results. Five patients developed active TB after LTBI treatment, and 6 developed TB despite baseline negative LTBI results. After adjustment for age and sex, the standardized TB incidence ratio was 6.01 (95% CI 1.94–14.04) in the LTBI group and 5.14 (95% CI 1.88–11.18) in the baseline negative LTBI group. Clinicians should be aware of the risk of active TB in patients treated with TNF antagonists despite baseline negative LTBI screening results. Regular monitoring and serial tests should be considered during long-term TNF antagonist therapy, especially in intermediate to high TB burden country.
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Affiliation(s)
- Eun Hye Lee
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Kyu Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Abstract
In 2014, WHO reported approximately 9.6 million new cases of tuberculosis (TB) in the world, more than half of which are contributed by developing countries in Asia and Africa. Lack of modern diagnostic tools, underreporting of the new cases and underutilization of directly observed therapy (DOT) remain a concern in developing countries. Transient resurgence of TB during the HIV epidemic has subsided and the annual decline has resumed in developed countries including the USA. In 2014 though, the rate of decline has slowed down resulting in leveling of TB incidence in the USA. In developed countries like the USA, the incidence of TB remains high in those with certain risk factors for TB. This group includes immunocompromised patients, particularly those with positive HIV infection. Others at high risk include those with diabetes, cancer, those taking immunosuppressive drugs, and those with other medical conditions that reduce host immunity. If we look at age and ethnicity, elderly patients are at higher risk of developing TB. African-American, foreign-born, and homeless populations are also at higher risk of developing tuberculosis. Virulence of the mycobacteria, and immunological and genetically mediated factors are also mentioned, but these topics are not the primary goal of this article. This review, thus discusses the epidemiology, host factors, and those at high risk for developing active TB. A brief review of the current trends in drug resistance of mycobacteria is also presented.
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Taxonera C, Ponferrada Á, Bermejo F, Riestra S, Saro C, Martín-Arranz MD, Cabriada JL, Barreiro-de Acosta M, de Castro ML, López-Serrano P, Barrio J, Suarez C, Iglesias E, Argüelles-Arias F, Ferrer I, Marín-Jiménez I, Hernández-Camba A, Bastida G, Van Domselaar M, Martínez-Montiel P, Olivares D, Alba C, Gisbert JP. Early Tuberculin Skin Test for the Diagnosis of Latent Tuberculosis Infection in Patients with Inflammatory Bowel Disease. J Crohns Colitis 2017; 11:792-800. [PMID: 28333182 DOI: 10.1093/ecco-jcc/jjx022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/15/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Sensitivity of tuberculin skin test [TST] during screening for latent tuberculosis infection [LTBI] is affected by steroid and/or immunosuppressant therapy. The aim of this study was to compare performance of the two-step TST in inflammatory bowel disease patients immediately before anti-tumour necrosis factor [TNF] therapy as part of routine screening for LTBI vs control patients when the TST was carried out at an early stage. METHODS In this multicentre prospective controlled study, we evaluated the performance of two-step TST with 5-mm threshold. Factors associated with TST results were determined by logistic regression. RESULTS We evaluated 243 candidates for anti-TNF therapy and 337 control patients. Overall, 105 patients [18.1%] had an induration ≥ 5 mm in the first TST or in TST retest. LTBI was diagnosed in 25% of patients by TST retest. Twenty-eight [11.5%] anti-TNF group patients vs 77 [22.8%] control patients had a positive TST (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.28-0.70; P < 0.001]. In multivariate analysis, positive TST was associated with higher age [OR 2.63, 95% CI 1.21-5.72; P < 0.001] and 5-aminosalicylate therapy [OR 1.86, 95% CI 1.14-3.05; P = 0.013]. Negative TST was associated with steroid therapy [OR 0.36, 95% CI 0.16-0.83; P = 0.016], immunosuppressant therapy [OR 0.36, 95% CI 0.21-0.62; P < 0.001], or steroids + immunosuppressant therapy [OR 0.20, 95% CI 0.07-0.59; P = 0.004]. CONCLUSIONS The sensitivity of routine TST performed just before starting anti-TNF therapy is low. TST performed at an early stage enables screening in the absence of immunosuppressive treatment and thus maximises the diagnostic yield of TST for detecting LTBI.
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Affiliation(s)
- Carlos Taxonera
- Inflammatory Bowel Disease Unit, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - Ángel Ponferrada
- Department of Gastroenterology, Hospital Infanta Leonor, Madrid, Spain
| | - Fernando Bermejo
- Department of Gastroenterology, Hospital de Fuenlabrada, Madrid, Spain
| | - Sabino Riestra
- Department of Gastroenterology, Hospital Central de Asturias, Oviedo, Spain
| | - Cristina Saro
- Department of Gastroenterology, Hospital de Cabueñes, Gijón, Spain
| | | | | | | | - María Luisa de Castro
- Department of Gastroenterology, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Pilar López-Serrano
- Department of Gastroenterology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Cristina Suarez
- Department of Gastroenterology, Hospital Puerta de Hierro, Madrid, Spain
| | - Eva Iglesias
- Department of Gastroenterology, Hospital Reina Sofía, Córdoba, Spain
| | | | - Isabel Ferrer
- Department of Gastroenterology, Hospital de Manises, Manises, Spain
| | - Ignacio Marín-Jiménez
- Department of Gastroenterology, Hospital Gregorio Marañón and Instituto de Investigación Sanitaria Gregorio Marañón [IiSGM], Madrid, Spain
| | | | | | | | | | - David Olivares
- Inflammatory Bowel Disease Unit, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - Cristina Alba
- Inflammatory Bowel Disease Unit, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - Javier P Gisbert
- Department of Gastroenterology, Hospital de la Princesa, CIBEREHD, Madrid, Spain
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Bryant PA, Baddley JW. Opportunistic Infections in Biological Therapy, Risk and Prevention. Rheum Dis Clin North Am 2017; 43:27-41. [DOI: 10.1016/j.rdc.2016.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Cohen SB, Tanaka Y, Mariette X, Curtis JR, Lee EB, Nash P, Winthrop KL, Charles-Schoeman C, Thirunavukkarasu K, DeMasi R, Geier J, Kwok K, Wang L, Riese R, Wollenhaupt J. Long-term safety of tofacitinib for the treatment of rheumatoid arthritis up to 8.5 years: integrated analysis of data from the global clinical trials. Ann Rheum Dis 2017; 76:1253-1262. [PMID: 28143815 PMCID: PMC5530353 DOI: 10.1136/annrheumdis-2016-210457] [Citation(s) in RCA: 269] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/08/2016] [Accepted: 12/26/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). We report an integrated safety summary of tofacitinib from two phase I, nine phase II, six phase III and two long-term extension studies in adult patients with active RA. METHODS Data were pooled for all tofacitinib-treated patients (data cut-off: 31 March 2015). Incidence rates (IRs; patients with event/100 patient-years) and 95% CIs are reported for adverse events (AEs) of interest. RESULTS 6194 patients received tofacitinib for a total 19 406 patient-years' exposure; median exposure was 3.4 patient-years. IR (95% CI) for serious AEs was 9.4 (9.0 to 9.9); IR for serious infections was 2.7 (2.5 to 3.0). IR for (all) herpes zoster was 3.9 (3.6 to 4.2); IR for disseminated or multidermatomal herpes zoster was 0.3 (0.2 to 0.4). IR for opportunistic infections (excluding tuberculosis) was 0.3 (0.2 to 0.4) and was 0.2 (0.1 to 0.3) for tuberculosis. IR for malignancies (excluding non-melanoma skin cancer (NMSC)) was 0.9 (0.8 to 1.0); NMSC IR was 0.6 (0.5 to 0.7). IR for gastrointestinal perforations was 0.1 (0.1 to 0.2). Analysis of IR for serious infections, herpes zoster and malignancies by 6-month intervals did not reveal any notable increase in IR with longer-duration tofacitinib exposure. CONCLUSION This analysis of tofacitinib exposure up to 8.5 years allowed estimation of safety events with improved precision versus previous tofacitinib reports. AEs were generally stable over time; no new safety signals were observed compared with previous tofacitinib reports. TRIAL REGISTRATION NUMBERS NCT01262118, NCT01484561, NCT00147498, NCT00413660, NCT00550446, NCT00603512, NCT00687193, NCT01164579, NCT00976599, NCT01059864, NCT01359150, NCT00960440, NCT00847613, NCT00814307, NCT00856544, NCT00853385, NCT01039688, NCT00413699, NCT00661661; Results.
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Affiliation(s)
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Eun Bong Lee
- Seoul National University, Seoul, Republic of Korea
| | - Peter Nash
- University of Queensland, Queensland, Australia
| | | | | | | | | | | | | | - Lisy Wang
- Pfizer Inc, Groton, Connecticut, USA
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Gray EL, Goldberg HF. Baseline abnormal liver function tests are more important than age in the development of isoniazid-induced hepatoxicity for patients receiving preventive therapy for latent tuberculosis infection. Intern Med J 2016; 46:281-7. [PMID: 26648478 DOI: 10.1111/imj.12979] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND One of the cornerstones of Australia's public health programmes to eliminate tuberculosis (TB) is the identification and treatment of latent tuberculosis infection (LTBI). AIMS The main aim of this study is to determine the demographics, compliance, completion rates and adverse events of patients on preventive therapy (PT) for LTBI at our institution. The secondary aim is to determine the rates of isoniazid (INH) hepatotoxicity and identify any contributory factors. METHODS The method used was an audit using medical records of 100 consecutive patients (2010-2014) treated with PT for LTBI. RESULTS Seventy-two patients with confirmed LTBI started 9 months of INH and 22 started 4 months of rifampicin (RIF). The median age was 30 years. Half the patients were born in high TB-prevalence countries. Fifty-six per cent were contacts of index cases with confirmed TB, and 26% were pre-immunosuppression. Seventy-seven per cent completed PT with adequate compliance. Thirty-three per cent on INH and 23% on RIF experienced some liver function test (LFT) abnormality while on treatment. INH was ceased in 3% due to asymptomatic hepatic dysfunction (transaminases >5x upper limit of normal). No patients had permanent liver damage. Significant risk factors for liver dysfunction during PT were risk factors for liver disease (χ(3)(2) = 8.7; P = 0.03) or abnormal pre-therapy LFT (χ(3)(2)= 22.4; P < 0.001). No patients developed active TB. CONCLUSION The completion rate of 77% and rate of INH-induced hepatic dysfunction of 3% is comparable with the literature. We found no age association with the risk of INH-induced hepatic dysfunction; however, there was a significant and linear association with the degree of liver function abnormality during INH therapy and the presence of abnormal baseline LFT. Routine LFT monitoring allowed early cessation of INH in those with significant but asymptomatic hepatitis who did not meet criteria for ATS/CDC LFT monitoring.
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Affiliation(s)
- E L Gray
- Department of Respiratory Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - H F Goldberg
- Department of Respiratory Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Chiu YM, Tang CH, Hung ST, Yang YW, Fang CH, Lin HY. A real-world risk analysis of biological treatment (adalimumab and etanercept) in a country with a high prevalence of tuberculosis and chronic liver disease: a nationwide population-based study. Scand J Rheumatol 2016; 46:236-240. [PMID: 27766916 DOI: 10.1080/03009742.2016.1202318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Few studies on tumour necrosis factor (TNF) inhibitor-associated tuberculosis (TB) and hepatic events have been performed in regions where these risks are elevated. This study aimed to provide a direct comparison between adalimumab and etanercept in a high-risk population and to address the implications for physicians working with patients in such an environment. METHOD Data collected from the National Health Insurance Research Database (NHIRD) in Taiwan between 2007 and 2011 were analysed retrospectively for incidences of eight adverse events associated with TNF-α inhibitors. Hazard ratios (HRs) of adalimumab vs. etanercept were calculated using a Cox proportional hazards model. RESULTS During this 5-year period, 86 events of TB were reported after 5317 person-years of exposure to adalimumab (1.62 events per 100 person-years), compared to 44 events after 7690 person-years of exposure to etanercept (0.57 events per 100 person-years). For serious hepatic events that led to hospitalization, 0.75 events were reported per 100 person-years of exposure to adalimumab compared to 0.39 events per 100 person-years of exposure to etanercept. Adjusted HRs for TB [aHR 3.06, 95% confidence interval (CI) 2.09-4.49, p < 0.0001], hospitalization due to a hepatic event (aHR 2.05, 95% CI 1.27-3.30, p = 0.0035), and serious infection (aHR 1.48, 95% CI 1.19-1.84, p = 0.0005) attained significance. CONCLUSIONS TNF-α-targeting therapies with the monoclonal antibody adalimumab confers significant added risk of TB and serious hepatic events compared to therapies with the soluble fusion protein etanercept. Tailored strategies to attenuate these risks are warranted in high-risk regions such as Taiwan.
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Affiliation(s)
- Y-M Chiu
- a Division of Allergy, Immunology and Rheumatology , Changhua Christian Hospital , Changhua , Taiwan.,b Department of Nursing , College of Medicine and Nursing, HungKuang University , Taichung , Taiwan
| | - C-H Tang
- c School of Health Care Administration , Taipei Medical University , Taipei , Taiwan
| | - S-T Hung
- d Formosa Biomedical Technology Corporation , Taipei , Taiwan
| | - Y-W Yang
- e Pfizer Limited , Taipei , Taiwan
| | - C-H Fang
- e Pfizer Limited , Taipei , Taiwan
| | - H-Y Lin
- f Division of Allergy, Immunology and Rheumatology, Department of Medicine , Taipei Veterans General Hospital , Taipei , Taiwan.,g Faculty of Medicine , National Yang-Ming University , Taipei , Taiwan
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How Should We Manage Latent Tuberculosis Infection in Patients Receiving Anti-TNF-α Drugs: Literature Review. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016. [DOI: 10.5812/ircmj.27756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Cappello M, Morreale GC. The Role of Laboratory Tests in Crohn's Disease. CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2016; 9:51-62. [PMID: 27656094 PMCID: PMC4991576 DOI: 10.4137/cgast.s38203] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/12/2016] [Accepted: 07/16/2016] [Indexed: 02/07/2023]
Abstract
In the past, laboratory tests were considered of limited value in Crohn's disease (CD). In the era of biologics, laboratory tests have become essential to evaluate the inflammatory burden of the disease (C-reactive protein, fecal calprotectin) since symptoms-based scores are subjective, to predict the response to pharmacological options and the risk of relapse, to discriminate CD from ulcerative colitis, to select candidates to anti-tumor necrosis factors [screening tests looking for hepatitis B virus and hepatitis C virus status and latent tuberculosis], to assess the risk of adverse events (testing for thiopurine metabolites and thiopurine-methyltransferase activity), and to personalize and optimize therapy (therapeutic drug monitoring). Pharmacogenetics, though presently confined to the assessment of thiopurineme methyltransferase polymorphisms and hematological toxicity associated with thiopurine treatment, is a promising field that will contribute to a better understanding of the molecular mechanisms of the variability in response to the drugs used in CD with the attempt to expand personalized care and precision medicine strategies.
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Affiliation(s)
- Maria Cappello
- Senior Registrar in Gastroenterology, Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo School of Medicine, Palermo, Italy
| | - Gaetano Cristian Morreale
- Trainee in Gastroenterology, Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo School of Medicine, Palermo, Italy
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Affiliation(s)
- Richard G. Langley
- From the Division of Dermatology, Department of Medicine, Dalhousie University, Halifax, NS; Department of Medicine, University of Toronto, Toronto, ON; The Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Toronto, ON; Division of Advanced Therapeutics in Arthritis, Mount Sinai Hospital, Toronto, ON; Division of Dermatology, University of Montreal, Montreal, QC; Innovaderm Research Incorporated, Montreal, QC; Probity Medical Research, Waterloo, ON
| | - Edward C. Keystone
- From the Division of Dermatology, Department of Medicine, Dalhousie University, Halifax, NS; Department of Medicine, University of Toronto, Toronto, ON; The Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Toronto, ON; Division of Advanced Therapeutics in Arthritis, Mount Sinai Hospital, Toronto, ON; Division of Dermatology, University of Montreal, Montreal, QC; Innovaderm Research Incorporated, Montreal, QC; Probity Medical Research, Waterloo, ON
| | - Robert Bissonnette
- From the Division of Dermatology, Department of Medicine, Dalhousie University, Halifax, NS; Department of Medicine, University of Toronto, Toronto, ON; The Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Toronto, ON; Division of Advanced Therapeutics in Arthritis, Mount Sinai Hospital, Toronto, ON; Division of Dermatology, University of Montreal, Montreal, QC; Innovaderm Research Incorporated, Montreal, QC; Probity Medical Research, Waterloo, ON
| | - Kim A. Papp
- From the Division of Dermatology, Department of Medicine, Dalhousie University, Halifax, NS; Department of Medicine, University of Toronto, Toronto, ON; The Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Toronto, ON; Division of Advanced Therapeutics in Arthritis, Mount Sinai Hospital, Toronto, ON; Division of Dermatology, University of Montreal, Montreal, QC; Innovaderm Research Incorporated, Montreal, QC; Probity Medical Research, Waterloo, ON
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Winthrop KL, Park SH, Gul A, Cardiel MH, Gomez-Reino JJ, Tanaka Y, Kwok K, Lukic T, Mortensen E, Ponce de Leon D, Riese R, Valdez H. Tuberculosis and other opportunistic infections in tofacitinib-treated patients with rheumatoid arthritis. Ann Rheum Dis 2016; 75:1133-8. [PMID: 26318385 PMCID: PMC4893093 DOI: 10.1136/annrheumdis-2015-207319] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 07/02/2015] [Accepted: 07/05/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To evaluate the risk of opportunistic infections (OIs) in patients with rheumatoid arthritis (RA) treated with tofacitinib. METHODS Phase II, III and long-term extension clinical trial data (April 2013 data-cut) from the tofacitinib RA programme were reviewed. OIs defined a priori included mycobacterial and fungal infections, multidermatomal herpes zoster and other viral infections associated with immunosuppression. For OIs, we calculated crude incidence rates (IRs; per 100 patient-years (95% CI)); for tuberculosis (TB) specifically, we calculated rates stratified by patient enrolment region according to background TB IR (per 100 patient-years): low (≤0.01), medium (>0.01 to ≤0.05) and high (>0.05). RESULTS We identified 60 OIs among 5671 subjects; all occurred among tofacitinib-treated patients. TB (crude IR 0.21, 95% CI of (0.14 to 0.30)) was the most common OI (n=26); median time between drug start and diagnosis was 64 weeks (range 15-161 weeks). Twenty-one cases (81%) occurred in countries with high background TB IR, and the rate varied with regional background TB IR: low 0.02 (0.003 to 0.15), medium 0.08 (0.03 to 0.21) and high 0.75 (0.49 to 1.15). In Phase III studies, 263 patients diagnosed with latent TB infection were treated with isoniazid and tofacitinib concurrently; none developed TB. For OIs other than TB, 34 events were reported (crude IR 0.25 (95% CI 0.18 to 0.36)). CONCLUSIONS Within the global tofacitinib RA development programme, TB was the most common OI reported but was rare in regions of low and medium TB incidence. Patients who screen positive for latent TB can be treated with isoniazid during tofacitinib therapy.
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Affiliation(s)
- K L Winthrop
- Oregon Health and Science University, Portland, Oregon, USA
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - A Gul
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M H Cardiel
- Centro de Investigación Clínica de Morelia SC, Morelia, Mexico
| | - J J Gomez-Reino
- Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Y Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - K Kwok
- Pfizer Inc, New York, New York, USA
| | - T Lukic
- Pfizer Inc, New York, New York, USA
| | | | | | - R Riese
- Pfizer Inc, Groton, Connecticut, USA
| | - H Valdez
- Pfizer Inc, New York, New York, USA
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Lee JW, Choi CH, Park JH, Kim JW, Kang SB, Koo JS, Kim YH, Kim YS, Joo YE, Chang SK. Clinical features of active tuberculosis that developed during anti-tumor necrosis factor therapy in patients with inflammatory bowel disease. Intest Res 2016; 14:146-51. [PMID: 27175115 PMCID: PMC4863048 DOI: 10.5217/ir.2016.14.2.146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 03/20/2016] [Accepted: 03/21/2016] [Indexed: 12/27/2022] Open
Abstract
Background/Aims Anti-tumor necrosis factor (TNF) therapy for active ulcerative colitis (UC) and Crohn's disease (CD) is associated with increased risks of tuberculosis (TB) infection. We analyzed the incidence and clinical features of Korean patients with inflammatory bowel disease (IBD) who developed active TB during anti-TNF therapy. Methods Ten cases of active TB developed in patients treated with infliximab (n=592) or adalimumab (n=229) for UC (n=160) or CD (n=661) were reviewed. We analyzed demographics, interval between start of anti-TNF therapy and active TB development, tests for latent TB infection (LTBI), concomitant medications, and the details of diagnosis and treatments for TB. Results The incidence of active TB was 1.2% (10/821): 1.5% (9/592) and 0.4% (1/229) in patients receiving infliximab and adalimumab, respectively. The median time to the development of active TB after initiation of anti-TNF therapy was three months (range: 2–36). Three patients had past histories of treatment for TB. Positive findings in a TB skin test (TST) and/or interferon gamma releasing assay (IGRA) were observed in three patients, and two of them received anti-TB prophylaxis. Two patients were negative by both TST and IGRA. The most common site of active TB was the lungs, and the active TB was cured in all patients. Conclusions Active TB can develop during anti-TNF therapy in IBD patients without LTBI, and even in those with histories of TB treatment or LTBI prophylaxis. Physicians should be aware of the potential for TB development during anti-TNF therapy, especially in countries with a high prevalence of TB.
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Affiliation(s)
- Jang Wook Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chang Hwan Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ji Hoon Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeong Wook Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sang Bum Kang
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Ja Seol Koo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young-Ho Kim
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
| | - Young Eun Joo
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sae Kyung Chang
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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Ruan Q, Zhang S, Ai J, Shao L, Zhang W. Screening of latent tuberculosis infection by interferon-γ release assays in rheumatic patients: a systemic review and meta-analysis. Clin Rheumatol 2016; 35:417-25. [PMID: 25376466 DOI: 10.1007/s10067-014-2817-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 10/26/2014] [Indexed: 10/24/2022]
Abstract
The aim of this study is to assess the diagnostic value of interferon-γ release assays (IGRAs) for latent tuberculosis infection (LTBI) in patients with rheumatic disease before receiving biologic agents. MEDLINE and EMBASE databases were used for searching studies concerning the evaluation on the performance of IGRAs [QuantiFERON-TB Gold (QFT-G), QuantiFERON-TB Gold In-Tube (QFT-GIT) and T-SPOT.TB] in rheumatic patients before biological therapy. After assessing the quality of all studies included in the review, we summarized the results in subgroups using forest plots and calculated pooled estimates if applicable. The search identified 11 studies with a total sample size of 1940 individuals. Compared with the tuberculin skin test (TST), the pooled agreements in QFT-G/GIT and T-SPOT.TB were 72 % (95 % confidence interval (CI) 65, 78 %) and 75 % (95 % CI 67, 83 %), respectively. BCG vaccination was positively correlated with positive rates of TST (pooled odds ratio (OR) 1.64, 95 % CI 1.06, 2.53). Compared with TST, IGRAs were better associated with the presentence of one or more tuberculosis (TB) risk factors. Neither steroid nor disease-modifying anti-rheumatic drugs (DMARDs) significantly affect positive IGRA results. In contrast, TST positivity was significantly impacted by the use of steroid (pooled OR 0.45, 95 % CI 0.30, 0.69), but less significantly by the use of DMARDs (pooled OR 0.78, 95 % CI 0.50, 1.21). In conclusion, in rheumatic patients with previous BCG vaccination or currently on steroid therapy, IGRAs would be the better choice to identify LTBI by decreasing the false-positivity and false-negativity rate compared with conventional TST.
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Affiliation(s)
- Qiaoling Ruan
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, 200040, Shanghai, China
| | - Shu Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, 200040, Shanghai, China
| | - Jingwen Ai
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, 200040, Shanghai, China
| | - Lingyun Shao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, 200040, Shanghai, China
| | - Wenhong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, 200040, Shanghai, China.
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Berns M, Hommes DW. Anti-TNF-α therapies for the treatment of Crohn’s disease: the past, present and future. Expert Opin Investig Drugs 2016; 25:129-43. [DOI: 10.1517/13543784.2016.1126247] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Harigai M, Ishiguro N, Inokuma S, Mimori T, Ryu J, Takei S, Takeuchi T, Tanaka Y, Takasaki Y, Yamanaka H, Watanabe M, Tamada H, Koike T. Postmarketing surveillance of the safety and effectiveness of abatacept in Japanese patients with rheumatoid arthritis. Mod Rheumatol 2016; 26:491-8. [PMID: 26635183 PMCID: PMC4898160 DOI: 10.3109/14397595.2015.1123211] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: To perform a postmarketing surveillance study evaluating the safety and effectiveness of abatacept in Japanese patients with rheumatoid arthritis (RA). Methods: Safety and effectiveness data were collected for all RA patients (at 772 sites) treated with intravenous abatacept between September 2010 and June 2011. Patients were treated by the approved dosing regimen according to the package insert. Treatment effectiveness was evaluated at baseline and at weeks 4, 12, and 24 using Disease Activity Score 28 (DAS28) according to erythrocyte sedimentation rate or serum C-reactive protein concentrations. Results: Overall, 3882 and 3016 abatacept-naïve RA patients were included in safety and effectiveness analyses, respectively. Adverse drug reactions (ADRs) were reported for 15.66% of patients and serious ADRs were detected for 2.52% of patients. The incidence of serious infections was 1.03% and these were mainly attributed to different types of bacterial pneumonia. Disease activity improved significantly over 6 months. Separate multivariate analysis identified predictors of severe ADR, and severe infections and factors predictive of clinically meaningful DAS28 improvement after 6 months of treatment with abatacept. Conclusions: Abatacept was efficacious and well tolerated in a clinical setting. No new safety concerns were detected.
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Affiliation(s)
- Masayoshi Harigai
- a Graduate School of Medical and Dental Sciences , Tokyo Medical and Dental University , Tokyo , Japan
| | - Naoki Ishiguro
- b Graduate School & Faculty of Medicine , Nagoya University , Nagoya , Japan
| | | | - Tsuneyo Mimori
- d Kyoto University Graduate School of Medicine , Kyoto , Japan
| | - Junnosuke Ryu
- e Nihon University School of Medicine , Tokyo , Japan
| | - Syuji Takei
- f Faculty of Medicine, School of Health Sciences , Kagoshima University , Kagoshima , Japan
| | | | - Yoshiya Tanaka
- h University of Occupational and Environmental Health , Fukuoka , Japan
| | | | | | | | | | - Takao Koike
- l NTT Sapporo Medical Center Minami , Sapporo , Japan , and.,m Hokkaido University Graduate School of Medicine , Sapporo , Japan
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Winthrop KL, Novosad SA, Baddley JW, Calabrese L, Chiller T, Polgreen P, Bartalesi F, Lipman M, Mariette X, Lortholary O, Weinblatt ME, Saag M, Smolen J. Opportunistic infections and biologic therapies in immune-mediated inflammatory diseases: consensus recommendations for infection reporting during clinical trials and postmarketing surveillance. Ann Rheum Dis 2015; 74:2107-16. [DOI: 10.1136/annrheumdis-2015-207841] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/28/2015] [Indexed: 12/27/2022]
Abstract
No consensus has previously been formed regarding the types and presentations of infectious pathogens to be considered as ‘opportunistic infections’ (OIs) within the setting of biologic therapy. We systematically reviewed published literature reporting OIs in the setting of biologic therapy for inflammatory diseases. The review sought to describe the OI definitions used within these studies and the types of OIs reported. These findings informed a consensus committee (infectious diseases and rheumatology specialists) in deliberations regarding the development of a candidate list of infections that should be considered as OIs in the setting of biologic therapy. We reviewed 368 clinical trials (randomised controlled/long-term extension), 195 observational studies and numerous case reports/series. Only 11 observational studies defined OIs within their methods; no consistent OI definition was identified across studies. Across all study formats, the most numerous OIs reported were granulomatous infections. The consensus group developed a working definition for OIs as ‘indicator’ infections, defined as specific pathogens or presentations of pathogens that ‘indicate’ the likelihood of an alteration in host immunity in the setting of biologic therapy. Using this framework, consensus was reached upon a list of OIs and case-definitions for their reporting during clinical trials and other studies. Prior studies of OIs in the setting of biologic therapy have used inconsistent definitions. The consensus committee reached agreement upon an OI definition, developed case definitions for reporting of each pathogen, and recommended these be used in future studies to facilitate comparison of infection risk between biologic therapies.
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Celada LJ, Drake WP. Targeting CD4(+) T cells for the treatment of sarcoidosis: a promising strategy? Immunotherapy 2015; 7:57-66. [PMID: 25572480 DOI: 10.2217/imt.14.103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Sarcoidois is an inflammatory disease of unknown origin characterized by the abnormal accumulation of noncaseating granulomas at sites of disease activity in multiple organs throughout the body with a predilection for the lungs. Because the exact trigger that leads to disease activity is still under investigation, current treatment options are contingent on the organ or organs affected. Corticosteroids are the therapy of choice, but antimalarials and TNF-α antagonists are also commonly prescribed. Recent findings provide evidence for the use of CD20 B-cell-depleting therapy as an alternative method of choice. However, because sarcoidosis is predominantly a T-helper cell-driven disorder, an overwhelming amount of compelling evidence exists for the use of CD4(+) T-cell targeted therapy.
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Affiliation(s)
- Lindsay J Celada
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-2363, USA
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