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Kawato R, Rokutanda R, Okada M, Matsushita M, Yamaji K, Tamura N. Effect of Prophylactic Dose of Trimethoprim-Sulfamethoxazole on Serum Creatinine in Japanese Patients With Connective Tissue Diseases. CLINICAL MEDICINE INSIGHTS: ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2022; 15:11795441221085141. [PMID: 35342315 PMCID: PMC8950028 DOI: 10.1177/11795441221085141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/15/2022] [Indexed: 11/16/2022]
Abstract
Objectives: At normal doses of trimethoprim-sulfamethoxazole (TMP/SMX), trimethoprim inhibits tubular creatinine secretion, leading to a rapid but reversible increase in serum creatinine (SCr). Although patients with connective tissue diseases are often in the state of immunosuppression and TMP/SMX is an important prophylactic drug, clinicians often have to stop or reduce the dosage due to concerns regarding its effect on renal function. This study aimed to evaluate the effect of a prophylactic dose of TMP/SMX on SCr in Japanese patients with connective tissue diseases, the extent of SCr level elevation and the independent risk factors for creatinine elevation. Methods: A retrospective cohort study was undertaken. Participants included patients with connective tissue diseases who were treated with a prophylactic dose of TMP/SMX between 2004 and 2018. Using single and multiple regression analyses, the risk factors that affected SCr elevation were evaluated. Results: A total of 262 patients, females, n = 181; age, median (range) = 59 (19-89) years, were included. The median baseline SCr level before treatment was 0.62 (0.16-2.1) mg/dL. The median SCr elevation value was 0.07 (−0.54 to 0.84) mg/dL in 4 weeks after TMP/SMX initiation. Five (2%) participants had ⩾0.3 mg/dL SCr elevation. Multiple regression analyses, including age, baseline SCr, diuretic use, nonsteroidal anti-inflammatory drug use and diabetes mellitus, indicated that baseline SCr and advanced age were independent risk factors of SCr elevation. Conclusions: These results demonstrated that baseline SCr and advanced age were associated with SCr elevation by a prophylactic dose of TMP/SMX. However, a prophylactic dose of TMP/SMX rarely elevated the SCr level significantly. Therefore, other causes can be considered if patients show an SCr elevation ⩾0.3 mg/dL.
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Affiliation(s)
- Rui Kawato
- Department of Rheumatology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
| | - Ryo Rokutanda
- Department of Rheumatology, Kameda Medical Center, Chiba, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
| | - Masakazu Matsushita
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
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Jinno S, Akashi K, Onishi A, Nose Y, Yamashita M, Saegusa J. Comparative effectiveness of trimethoprim-sulfamethoxazole versus atovaquone for the prophylaxis of pneumocystis pneumonia in patients with connective tissue diseases receiving prolonged high-dose glucocorticoids. Rheumatol Int 2021; 42:1403-1409. [PMID: 34263352 DOI: 10.1007/s00296-021-04945-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
We compared the prophylactic effect of trimethoprim-sulfamethoxazole (TMP-SMX) with atovaquone for pneumocystis pneumonia (PCP) in patients with connective tissue diseases (CTDs) receiving high-dose glucocorticoids. Patients with CTDs aged ≥ 18 years who were treated with a prolonged course (≥ 4 weeks) of glucocorticoids (≥ 20 mg/day prednisone) in a Japanese tertiary center between 2013 and 2017 were included. The patients were categorized into two groups: TMP-SMX and atovaquone group. Adjusted cumulative incidence of PCP was compared between the two groups after propensity score weighting for differences in confounding factors. A total of 480 patients with a prolonged high-dose glucocorticoid treatment were identified. Out of 383 patients with TMP-SMX prophylaxis, 102 (26.8%) patients experienced adverse events leading to discontinuation within 4 weeks of initiation, while no patient in the atovaquone discontinued the therapy. Two hundred eighty-one patients received TMP-SMX, while 107 received atovaquone for PCP prophylaxis. During a total of 397.0 person-years, 7 PCP cases (2 in the TMP-SMX, 5 in the atovaquone) occurred with a mortality rate of 54.5%. After adjusting for differences in baseline characteristics, the adjusted cumulative incidence of PCP was similar between the two group (HR 0.97, 95% CI 0.19-5.09, p = 0.97). Prophylactic effects for PCP in CTDs patients receiving prolonged high-dose glucocorticoids were similar between TMP-SMX and atovaquone. Atovaquone was well-tolerated with no side effects.
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Affiliation(s)
- Sadao Jinno
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan.
| | - Kengo Akashi
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Nose
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
| | - Mai Yamashita
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
| | - Jun Saegusa
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
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Efficacy and safety of trimethoprim-sulfamethoxazole for the prevention of pneumocystis pneumonia in human immunodeficiency virus-negative immunodeficient patients: A systematic review and meta-analysis. PLoS One 2021; 16:e0248524. [PMID: 33765022 PMCID: PMC7993619 DOI: 10.1371/journal.pone.0248524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/27/2021] [Indexed: 11/29/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) has a significant impact on the mortality of immunocompromised patients. It is not known whether the prophylactic application of trimethoprim-sulfamethoxazole (TMP-SMZ) can reduce the incidence of PCP and mortality in the human immunodeficiency virus (HIV)-negative immunodeficient population. The safety profile is also unknown. There have been few reports on this topic. The aim of this study was to systematically evaluate the efficacy and safety of the use of TMP-SMZ for the prevention of PCP in this population of patients from the perspective of evidence-based medicine. Methods A comprehensive search without restrictions on publication status or other parameters was conducted. Clinical randomized controlled trials (RCTs) or case-control trials (CCSs) of TMP-SMZ used for the prevention of PCP in HIV-negative immunocompromised populations were considered eligible. A meta-analysis was performed using the Mantel-Haenszel fixed-effects model or Mantel-Haenszel random-effects model, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and reported. Results Of the 2392 records identified, 19 studies (n = 4135 patients) were included. The efficacy analysis results indicated that the PCP incidence was lower in the TMP-SMZ group than in the control group (OR = 0.27, 95% CI (0.10, 0.77), p = 0.01); however, the rate of drug discontinuation was higher in the TMP-SMZ group than in the control group (OR = 14.31, 95% CI (4.78, 42.91), p<0.00001). In addition, there was no statistically significant difference in the rate of mortality between the two groups (OR = 0.54, 95% CI (0.21, 1.37), p = 0.19). The safety analysis results showed that the rate of adverse events (AEs) was higher in the TMP-SMZ group than in the control group (OR = 1.92, 95% CI (1.06, 3.47), p = 0.03). Conclusions TMP-SMZ has a better effect than other drugs or the placebo with regard to preventing PCP in HIV-negative immunocompromised individuals, but it may not necessarily reduce the rate of mortality, the rate of drug discontinuation or AEs. Due to the limitations of the research methodologies used, additional large-scale clinical trials and well-designed research studies are needed to identify more effective therapies for the prevention of PCP.
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Havele SA, Ellis A, Chaitoff A, Khanna U, Parambil J, Langford CA, Fernandez AP. Safety of trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia prophylaxis in patients taking methotrexate. J Am Acad Dermatol 2020; 84:166-168. [PMID: 32320772 DOI: 10.1016/j.jaad.2020.04.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Sonia A Havele
- Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ariana Ellis
- Departments of Dermatology and Pathology, Cleveland Clinic, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Alex Chaitoff
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Urmi Khanna
- Departments of Dermatology and Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Joseph Parambil
- Department of Pulmonology, Allergy & Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Langford
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic, Cleveland, Ohio
| | - Anthony P Fernandez
- Departments of Dermatology and Pathology, Cleveland Clinic, Cleveland, Ohio.
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5
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Kitazawa T, Seo K, Yoshino Y, Asako K, Kikuchi H, Kono H, Ota Y. Efficacies of atovaquone, pentamidine, and trimethoprim/sulfamethoxazole for the prevention of Pneumocystis jirovecii pneumonia in patients with connective tissue diseases. J Infect Chemother 2019; 25:351-354. [PMID: 30711257 DOI: 10.1016/j.jiac.2019.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection in patients on steroid therapy for connective tissue diseases. The standard agent for primary PCP prophylaxis is trimethoprim/sulfamethoxazole (TMP-SMX), although this agent can cause common adverse reactions, including myelosuppression and renal toxicity, that result in cessation. Aerosolized pentamidine and oral atovaquone are alternatives for PCP prophylaxis. The efficacies of atovaquone, pentamidine, and TMP-SMX to prevent PCP in patients with connective tissue diseases have never been compared. METHODS Hospitalized patients with connective tissue diseases who started steroid therapy and PCP prophylaxis were enrolled. PCP prophylaxis regimens were oral TMP-SMX, aerosolized pentamidine, or oral atovaquone. Information was retrospectively collected from medical records about laboratory findings, duration of PCP prophylaxis, and reasons for terminating PCP prophylaxis. RESULTS Ninety-six patients received PCP prophylaxis. All of them were initially treated with TMP-SMX, but this was replaced during the study period with pentamidine in 33 patients and with atovaquone in 7. Forty-one (43%) patients discontinued TMP-SMX because of adverse events, and 5 (15%) also discontinued pentamidine. None of the patients discontinued atovaquone. The most frequent causes of TMP-SMX and pentamidine cessation were cytopenia (N = 15) and asthma (N = 2). The rates of continuing treatment with TMP-SMX, pentamidine, and atovaquone at one year after starting PCP prophylaxis were 55.3%, 68.6%, and 100%, respectively (P = 0.01). None of the patients developed PCP. CONCLUSION Although TMP-SMX for PCP prophylaxis had to be discontinued in 43% of patients with connective tissue diseases, pentamidine and atovaquone were well tolerated.
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Affiliation(s)
- Takatoshi Kitazawa
- Department of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan.
| | - Kazunori Seo
- Department of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yusuke Yoshino
- Department of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Kurumi Asako
- Department of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Hirotoshi Kikuchi
- Department of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Hajime Kono
- Department of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yasuo Ota
- Department of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
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6
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Comparisons of Guidelines and Recommendations on Managing Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Kidney Int Rep 2018; 3:1039-1049. [PMID: 30197970 PMCID: PMC6127414 DOI: 10.1016/j.ekir.2018.05.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 11/24/2022] Open
Abstract
Antineutrophil cytoplasmic antibodies−associated vasculitis (AAV) is associated with high morbidity or mortality, especially if not promptly diagnosed and treated. Many inroads have been made in the understanding of the pathophysiology that leads to exploration of novel therapies. Randomized controlled trials over the last 2 decades have better delineated and expanded therapeutic options and set the stage for an evidence-based approach. Since 2014, 4 scientific societies have systematically reviewed the existing data and have formulated evidence-based recommendations for the management of AAV. These recommendations cover diagnosis, remission induction and maintenance treatment, and prevention of long-term complications. This review is a comparative analysis of the recently published recommendations of the European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association, the British Society of Rheumatology, the Canadian Vasculitis Research Network, and the Brazilian Society of Rheumatology, and aims to determine common ground among them and highlights the differences among the recommendations.
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7
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Utsunomiya M, Dobashi H, Odani T, Saito K, Yokogawa N, Nagasaka K, Takenaka K, Soejima M, Sugihara T, Hagiyama H, Hirata S, Matsui K, Nonomura Y, Kondo M, Suzuki F, Tomita M, Kihara M, Yokoyama W, Hirano F, Yamazaki H, Sakai R, Nanki T, Koike R, Kohsaka H, Miyasaka N, Harigai M. Optimal regimens of sulfamethoxazole-trimethoprim for chemoprophylaxis of Pneumocystis pneumonia in patients with systemic rheumatic diseases: results from a non-blinded, randomized controlled trial. Arthritis Res Ther 2017; 19:7. [PMID: 28100282 PMCID: PMC5241919 DOI: 10.1186/s13075-016-1206-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 12/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background Sulfamethoxazole-trimethoprim (SMX/TMP) is a standard drug for the prophylaxis of Pneumocystis pneumonia (PJP) in immunosuppressed patients with systemic rheumatic diseases, but is sometimes discontinued due to adverse events (AEs). The objective of this non-blinded, randomized, 52-week non-inferiority trial was to quest an effective chemoprophylaxis regimen for PJP with a low drug discontinuation rate. Results at week 24 were reported. Methods Adult patients with systemic rheumatic diseases who started prednisolone ≥0.6 mg/kg/day were randomized into three dosage groups: a single-strength group (SS, SMX/TMP of 400/80 mg daily), half-strength group (HS, 200/40 mg daily), and escalation group (ES, started with 40/8 mg daily, increasing incrementally to 200/40 mg daily). The primary endpoint was non-incidence rates (non-IR) of PJP at week 24. Results Of 183 patients randomly allocated at a 1:1:1 ratio into the three groups, 58 patients in SS, 59 in HS, and 55 in ES started SMX/TMP. A total of 172 patients were included in the analysis. No cases of PJP were reported up to week 24. Estimated non-IR of PJP in patients who received daily SMX/TMP of 200/40 mg, either starting at this dose or increasing incrementally, was 96.8–100% using the exact confidence interval as a post-hoc analysis. The overall discontinuation rate was significantly lower with HS compared to SS (p = 0.007). The discontinuation rates due to AEs were significantly lower with HS (p = 0.006) and ES (p = 0.004) compared to SS. The IR of AEs requiring reduction in the dose of SMX/TMP (p = 0.009) and AEs of special interest (p = 0.003) were different among the three groups with significantly higher IR in SS compared to HS and ES. Conclusions Although there were no PJP cases, the combined group of HS and ES had an excellent estimated non-IR of PJP and both were superior in safety to SS. From the perspective of feasibility and drug discontinuation rates, the daily half-strength regimen was suggested to be optimal for prophylaxis of PJP in patients with systemic rheumatic diseases. Trial registration The University Hospital Medical Information Network Clinical Trials Registry number is UMIN000007727, registered 10 April 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1206-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Masako Utsunomiya
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Musashino Red Cross Hospital, 1-26-1 Kyonancho, Musashino, Tokyo, 180-0023, Japan
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kida-gun, Kagawa, 761-0793, Japan
| | - Toshio Odani
- Third Department of Internal Medicine, Obihiro-Kosei General Hospital, West-6, South-8, Obihiro, Hokkaido, 080-0016, Japan.,Department of Internal Medicine, Hokusei Hospital, 5-1-1 Seiryu, Chitose, Hokkaido, 066-0081, Japan
| | - Kazuyoshi Saito
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8524, Japan
| | - Kenji Nagasaka
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Ome Municipal General Hospital, 4-16-5 Higashi-Ome, Ome, Tokyo, 198-0042, Japan
| | - Kenchi Takenaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Ome Municipal General Hospital, 4-16-5 Higashi-Ome, Ome, Tokyo, 198-0042, Japan
| | - Makoto Soejima
- Department of Rheumatology, Ome Municipal General Hospital, 4-16-5 Higashi-Ome, Ome, Tokyo, 198-0042, Japan.,Department of Rheumatology, Soka Municipal Hospital, 2-21-1 Soka, Soka, Saitama, 340-8560, Japan
| | - Takahiko Sugihara
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakaecho, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Hiroyuki Hagiyama
- Department of Rheumatology, Yokohama City Minato Red Cross Hospital, 3-12-1, Shinyamashita, Naka-ku, Yokohama, Kanagawa, 231-8682, Japan
| | - Shinya Hirata
- Department of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Kumamoto, Kumamoto, 860-8556, Japan
| | - Kazuo Matsui
- Department of Rheumatology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan.,Department of Internal Medicine, Takikawa Municipal Hospital, 2-2-34 Oh-machi, Takikawa, Hokkaido, 073-0022, Japan
| | - Yoshinori Nonomura
- Department of Rheumatology, Tokyo Kyosai Hospital, 2-3-8 Nakameguro, Meguro-ku, Tokyo, 153-8934, Japan
| | - Masahiro Kondo
- Department of Rheumatology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Fumihito Suzuki
- Department of Rheumatology, Soka Municipal Hospital, 2-21-1 Soka, Soka, Saitama, 340-0043, Japan.,Department of Rheumatology, JA Toride Medical Center, 2-1-1 Hongo, Toride, Ibaraki, 302-0022, Japan
| | - Makoto Tomita
- Clinical Research Center, Medical Hospital of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Mari Kihara
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Waka Yokoyama
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Fumio Hirano
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hayato Yamazaki
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ryoko Sakai
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Toshihiro Nanki
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Ryuji Koike
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Nobuyuki Miyasaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masayoshi Harigai
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan.
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8
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McGeoch L, Twilt M, Famorca L, Bakowsky V, Barra L, Benseler SM, Cabral DA, Carette S, Cox GP, Dhindsa N, Dipchand CS, Fifi-Mah A, Goulet M, Khalidi N, Khraishi MM, Liang P, Milman N, Pineau CA, Reich HN, Samadi N, Shojania K, Taylor-Gjevre R, Towheed TE, Trudeau J, Walsh M, Yacyshyn E, Pagnoux C. CanVasc Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitides. J Rheumatol 2015; 43:97-120. [DOI: 10.3899/jrheum.150376] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2015] [Indexed: 01/14/2023]
Abstract
Objective.The Canadian Vasculitis research network (CanVasc) is composed of physicians from different medical specialties and researchers with expertise in vasculitis. One of its aims is to develop recommendations for the diagnosis and management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada.Methods.Diagnostic and therapeutic questions were developed based on the results of a national needs assessment survey. A systematic review of existing non-Canadian recommendations and guidelines for the diagnosis and management of AAV and studies of AAV published after the 2009 European League Against Rheumatism/European Vasculitis Society recommendations (publication date: January 2009) until November 2014 was performed in the Medline database, Cochrane library, and main vasculitis conference proceedings. Quality of supporting evidence for each therapeutic recommendation was graded. The full working group as well as additional reviewers, including patients, reviewed the developed therapeutic recommendations and nontherapeutic statements using a modified 2-step Delphi technique and through discussion to reach consensus.Results.Nineteen recommendations and 17 statements addressing general AAV diagnosis and management were developed, as well as appendices for practical use, for rheumatologists, nephrologists, respirologists, general internists, and all other healthcare professionals more occasionally involved in the management of patients with AAV in community and academic practice settings.Conclusion.These recommendations were developed based on a synthesis of existing international guidelines, other published supporting evidence, and expert consensus considering the Canadian healthcare context, with the intention of promoting best practices and improving healthcare delivery for patients with AAV.
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Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: Risks and Prophylaxis Recommendations. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:29-40. [PMID: 26396551 PMCID: PMC4562607 DOI: 10.4137/ccrpm.s23286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 01/05/2023]
Abstract
Pneumocystis jirovecii infection causes fulminant interstitial pneumonia (Pneumocystis pneumonia, PCP) in patients with rheumatoid arthritis (RA) who are receiving biological and/or nonbiological antirheumatic drugs. Recently, we encountered a PCP outbreak among RA outpatients at our institution. Hospital-acquired, person-to-person transmission appears to be the most likely mode of this cluster of P. jirovecii infection. Carriage of P. jirovecii seems a time-limited phenomenon in immunocompetent hosts, but in RA patients receiving antirheumatic therapy, clearance of this organism from the lungs is delayed. Carriers among RA patients can serve as sources and reservoirs of P. jirovecii infection for other susceptible patients in outpatient facilities. Development of PCP is a matter of time in such carriers. Considering the poor survival rates of PCP cases, prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy. Once a new case of PCP occurs, we should take prompt action not only to treat the PCP patient but also to prevent other patients from becoming new carriers of P. jirovecii. Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, Social Insurance Omuta Tenryo Hospital, Fukuoka, Japan
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Haddad TM, Vallabhajosyula S, Nawaz MS, Vivekanandan R. Fatal Pneumocystis jirovecii pneumonia in a HIV-negative adult. BMJ Case Rep 2015; 2015:bcr-2015-210117. [PMID: 26311008 DOI: 10.1136/bcr-2015-210117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pneumocystis jirovecii is responsible for P. jirovecii pneumonia (PJP) in immunocompromised individuals, with a recent rise of cases noted in non-HIV patients. A middle-aged man presented with new-onset cough, fever, hypoxia and tachypnoea. He was on a tapering course of dexamethasone for amiodarone-induced thyrotoxicosis. He developed worsening airspace disease necessitating mechanical ventilation. Bronchoalveolar lavage (BAL) fluid was positive for P. jirovecii and he was managed with trimethoprim/sulfamethoxazole and pentamidine, but succumbed to cardiorespiratory arrest. One-third of PJP cases occur in non-HIV patients, and have a higher morbidity and mortality. Most immunocompromised patients typically exhibit PJP during a corticosteroid taper. The accurate dose, duration or frequency of steroid use in not well established. Diagnosis of PJP in this population is more challenging due to lower BAL yield with alternate modalities such as serum/BAL β-d-glucan and PCR enhancing the yield. Further studies are needed to highlight PJP prophylaxis in patients with steroid use.
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Affiliation(s)
- Toufik Mahfood Haddad
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Saraschandra Vallabhajosyula
- Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Muhammad Sarfraz Nawaz
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Renuga Vivekanandan
- Division of Infectious Diseases, Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
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Maezawa R, Kurasawa K, Arai S, Okada H, Owada T, Fukuda T. Positivity for anti-RNP antibody is a risk factor for adverse effects caused by trimethoprim–sulfamethoxazole, a prophylactic agent for P. jiroveci pneumonia, in patients with connective tissue diseases. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0625-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Reika Maezawa
- Clinical Immunology, Dokkyo Medical University,
880 Kita-Kobayashi, Mibu, Tochigi 321-0293, Japan
| | - Kazuhiro Kurasawa
- Clinical Immunology, Dokkyo Medical University,
880 Kita-Kobayashi, Mibu, Tochigi 321-0293, Japan
| | - Satoko Arai
- Clinical Immunology, Dokkyo Medical University,
880 Kita-Kobayashi, Mibu, Tochigi 321-0293, Japan
| | - Harutsugu Okada
- Clinical Immunology, Dokkyo Medical University,
880 Kita-Kobayashi, Mibu, Tochigi 321-0293, Japan
| | - Takayoshi Owada
- Clinical Immunology, Dokkyo Medical University,
880 Kita-Kobayashi, Mibu, Tochigi 321-0293, Japan
| | - Takeshi Fukuda
- Clinical Immunology, Dokkyo Medical University,
880 Kita-Kobayashi, Mibu, Tochigi 321-0293, Japan
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Mitsides N, Green D, Middleton R, New D, Lamerton E, Allen J, Redshaw J, Chadwick PR, Subudhi CPK, Wood G. Dapsone-induced methemoglobinemia in renal transplant recipients: more prevalent than previously thought. Transpl Infect Dis 2013; 16:37-43. [PMID: 24215452 DOI: 10.1111/tid.12161] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 03/01/2013] [Accepted: 04/23/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND After an outbreak of Pneumocystis pneumonia (PCP) in our nephrology unit, dapsone was used as the second-line chemoprophylactic agent. Dapsone is the most common cause of drug-induced methemoglobinemia (MHb). Its prevalence is poorly described in the renal transplant population. Because dapsone is excreted by the kidneys, we hypothesized that the rate of MHb in these patients would be higher than previously reported. We aimed to describe the demographics, risk factors, and presenting features of MHb in these renal transplant patients. METHODS Twenty-six transplant recipients commenced on dapsone for chemoprophylaxis against PCP from February to September 2011. All patients had normal glucose-6-phosphate dehydrogenase levels before treatment. Characteristics of patients with MHb were compared with those of the rest of the cohort to determine potential risk factors. RESULTS Twelve (46%) patients developed MHb (levels 6.4 ± 4.1%). Six (50%) of the patients with MHb were asymptomatic on presentation. Cases had a mean drop in hemoglobin of 19 ± 7%. MHb led to five admissions (median length of stay 5 days, range 1-10 days). MHb level showed a strong correlation with the length of stay (correlation coefficient 0.762, P = 0.002). CONCLUSION This is the highest reported prevalence of MHb, to our knowledge, in patients receiving dapsone, and its use led to significant hospitalization in this population. This study raises concerns about the use of dapsone as chemoprophylaxis in renal transplant recipients.
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Affiliation(s)
- N Mitsides
- Nephrology Department, Salford Royal NHS Foundation Trust, Salford, UK
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Wey MT, Lyu PC, Kan LS. Thermodynamic and Kinetic Studies of a Stable Imperfect DNA Triplex by Spectroscopic and Calorimetric Methods. J CHIN CHEM SOC-TAIP 2013. [DOI: 10.1002/jccs.201000072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Enquête sur l’utilisation des nébulisations de pentamidine en pédiatrie. Rev Mal Respir 2012; 29:656-63. [DOI: 10.1016/j.rmr.2012.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 11/02/2011] [Indexed: 11/23/2022]
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Positivity for anti-RNP antibody is a risk factor for adverse effects caused by trimethoprim-sulfamethoxazole, a prophylactic agent for P. jiroveci pneumonia, in patients with connective tissue diseases. Mod Rheumatol 2012; 23:62-70. [PMID: 22466117 DOI: 10.1007/s10165-012-0625-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Trimethoprim-sulphamethoxazole (TMP-STX), an agent used for prophylaxis against pneumocystis pneumonia (PCP) in immunocompromised hosts, causes serious adverse effects (AEs) in some patients. The objective of this study was to identify the risk factors for AEs caused by TMP-STX in connective tissue disease (CTD) patients and to describe the clinical features of the AEs. METHODS The medical records of 539 patients (CTDs 312, pulmonary diseases 227) receiving TMP-STX for prophylaxis against PCP were reviewed retrospectively. Patients with human immunodeficiency virus were excluded. Univariate and multivariate analyses were conducted to identify the risk factors. RESULTS Adverse events caused by TMP-STX occurred in 22 of 312 (7.05 %) CTD patients, while only six of 227 (2.64 %) pulmonary disease patients developed AEs. The incidence of AEs was significantly higher in systemic lupus erythematosus (SLE) (11.0 %) and mixed connective tissue disease (MCTD) (33.3 %) patients than in other CTD patients. AEs occurred in 25 % of patients with anti-RNP antibody. Univariate analysis revealed that SLE, MCTD, and anti-RNP antibody were risk factors for AEs in CTD patients. Further multivariate analyses demonstrated that only anti-RNP antibody positivity was a risk factor for AEs. Systemic inflammation, including fever, was a characteristic manifestation of the AEs in CTD patients, particularly those with anti-RNP antibody. CONCLUSIONS Positivity for anti-RNP antibody is a risk factor for AEs caused by TMP-STX in CTD patients. Systemic inflammation, including fever, might be a characteristic feature of the AEs in CTD patients, particularly those with anti-RNP antibody.
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Abstract
BACKGROUND Immunobullous dermatoses are usually treated with immunosuppressive agents, which make patients susceptible to pneumocystis pneumonia (PCP). The aim of this study was to evaluate the incidence and clinical characteristics of PCP in patients with immunobullous diseases. METHODS We analyzed computerized medical records to obtain a retrospective evaluation of the incidence and clinical characteristics of PCP in patients with immunobullous diseases, hospitalized at the Peking Union Medical College Hospital from January 2004 to December 2009. RESULTS Of 202 patients with immunobullous disorders, four (1.9%) had PCP; two of them had pemphigus vulgaris (PV), one had pemphigus foliaceus (PF), and one suffered from bullous pemphigoid (BP). All four patients had been treated with corticosteroids and a cytotoxic agent before diagnosis of PCP. Three of the four patients developed PCP within 14 weeks of the diagnosis of an immunobullous disease. Average and maximal prednisone doses were 0.98 mg/kg per day and 1.8 mg/kg per day, respectively. The median durations of prednisone doses >1.0 mg/kg per day and >1.5 mg/kg per day were 6.5 weeks and 4 weeks, respectively. Lymphocyte counts ranged from 330/μl to 1200/μl at the time of diagnosis of PCP. Additional complicating infections were found in three of the four patients. In all four patients, PCP was treated with trimethoprim-sulfamethoxazole and corticosteroids. Skin lesions were under control at the onset of PCP and did not flare during the treatment of PCP; however, two of the four patients died. CONCLUSIONS Fewer than 2% of subjects in our large series of patients with immunobullous diseases contracted PCP. Nevertheless, it is important to remain alert for PCP in patients with immunobullous diseases who are undergoing treatment with prednisone and cytotoxic agent(s).
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Affiliation(s)
- Feng Li
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Vananuvat P, Suwannalai P, Sungkanuparph S, Limsuwan T, Ngamjanyaporn P, Janwityanujit S. Primary Prophylaxis for Pneumocystis jirovecii Pneumonia in Patients with Connective Tissue Diseases. Semin Arthritis Rheum 2011; 41:497-502. [DOI: 10.1016/j.semarthrit.2011.05.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 05/13/2011] [Accepted: 05/22/2011] [Indexed: 11/28/2022]
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Role of primary prophylaxis for pneumocystis pneumonia in patients treated with systemic corticosteroids or other immunosuppressive agents for immune-mediated dermatologic conditions. J Am Acad Dermatol 2010; 63:815-23. [DOI: 10.1016/j.jaad.2009.11.588] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 11/17/2009] [Accepted: 11/22/2009] [Indexed: 11/20/2022]
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Pneumocystose au cours des maladies systémiques. Presse Med 2009; 38:251-9. [DOI: 10.1016/j.lpm.2008.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 10/28/2008] [Accepted: 11/03/2008] [Indexed: 11/18/2022] Open
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Smyth A, Garovic VD. 25-year-old man with flank pain, hematuria, and proteinuria. Mayo Clin Proc 2009; 84:72-5. [PMID: 19121256 PMCID: PMC2664573 DOI: 10.1016/s0025-6196(11)60810-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew Smyth
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Vesna D. Garovic
- Adviser to resident and Consultant in Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Individual reprints of this article are not available. Address correspondence to Vesna D. Garovic, MD, Division of Nephrology and Hypertension, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Smyth A, Garovic VD. 25-year-old man with flank pain, hematuria, and proteinuria. Mayo Clin Proc 2009; 84:72-5. [PMID: 19121256 PMCID: PMC2664573 DOI: 10.4065/84.1.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Andrew Smyth
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Vesna D. Garovic
- Adviser to resident and Consultant in Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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