A retrospective study on the risk of tuberculosis in patients with rheumatoid arthritis

Risk of tuberculosis in patients with rheumatoid arthritis treated with biological and targeted drugs: meta-analysis of randomized clinical trials

BACKGROUND

Concerns exist regarding the potential development of tuberculosis in patients with rheumatoid arthritis (RA) treated with biological and targeted drugs. We assessed systematically whether biological therapy increased the risk of tuberculosis in patients with RA by meta-analysis of randomized controlled trials (RCTs).

METHODS

A systematic literature search was conducted in PubMed, Embase, the Cochrane Library, and China Biology Medicine disc for RCTs evaluating biological therapy in patients with RA from inception through August 2021. Traditional meta-analysis and network meta-analysis were performed to compare the risk of tuberculosis for each biologics class in patients with RA. Peto odds ratio (Peto OR) and its 95% confidence interval (CI) were calculated as the primary effect measure.

RESULTS

In total, 39 studies with 20,354 patients were included in this meta-analysis, and 82 patients developed tuberculosis. The risk of tuberculosis was increased in patients treated with biologics compared with non-biologics (Peto OR: 3.86, 95% CI: 2.36-6.32, P < 0.001). Also, tumor necrosis factor-α (TNF-α) inhibitors had a higher probability of developing tuberculosis than placebo (Peto OR: 3.98, 95% CI: 2.30-6.88, P < 0.001). However, network meta-analysis demonstrated that there was no significant difference in the risk of tuberculosis for each biologics class in patients with RA. Noticeably, tuberculosis was significantly more common in patients treated with a high dose compared with patients receiving a low dose of tofacitinib (Peto OR: 7.39, 95% CI: 2.00-27.31, P = 0.003).

CONCLUSION

This meta-analysis demonstrates the evidence of an elevated risk of tuberculosis in patients with RA treated with TNF-α inhibitors, and a dose-dependent elevated risk of tuberculosis in patients treated with tofacitinib.

Frecuencia de positividad de la prueba de intradermorreacción a tuberculina en una cohorte de pacientes con artritis reumatoide

Introducción.

La artritis reumatoide es una enfermedad autoinmunitaria, crónica y deformante asociada con discapacidad. Quienes la padecen reciben inmunosupresores y tienen un gran riesgo de desarrollar tuberculosis. La prueba de intradermorreacción a la tuberculina se utiliza como tamización en quienes van a recibir terapia biológica.

Objetivo.

Evaluar la frecuencia de positividad en la prueba de intradermorreacción a la tuberculina en una cohorte de pacientes con artritis reumatoide.

Materiales y métodos.

Se hizo un estudio descriptivo de corte transversal de una cohorte de pacientes con artritis reumatoide a quienes se les practicó la prueba de tuberculina antes de iniciar la terapia biológica o en el momento del cambio de tratamiento. Los pacientes presentaban enfermedad moderada o grave y eran candidatos para iniciar o cambiar de terapia biológica. Se definió el valor de ≥6 mm como punto de corte para la positividad de la prueba y se hizo un análisis descriptivo de cada una de las variables.

Resultados.

Se incluyeron 261 pacientes con artritis reumatoide, 92 % de ellos eran mujeres, la edad promedio fue de 55 años (desviación estándar, DE=13,92) y el tiempo desde el diagnóstico era de 12,3 años (DE=8,54). La frecuencia de positividad de la prueba fue de 15,71 % (n=41). Nueve de los 41 pacientes positivos habían recibido la prueba previamente (entre 1 y 6 años antes), todos con resultado negativo; 18 (43,9 %) de ellos venían recibiendo tratamiento con glucocorticoides y todos los 41 (100 %) recibían metotrexate.

Conclusiones.

La frecuencia de positividad de la prueba de tuberculina en pacientes colombianos con artritis reumatoide fue de aproximadamente 16 %. Se recomienda optimizar las estrategias para detectar esta condición y darle un tratamiento oportuno y, así, disminuir el riesgo de reactivación de la tuberculosis.

Risk of tuberculosis in patients with spondyloarthritis: data from a centralized electronic database in Hong Kong

BACKGROUND/ OBJECTIVE

Tuberculosis (TB) is one of the most infectious comorbidities in spondyloarthritis (SpA). Our goals were to determine the crude incidence rate of and risk factors for TB in SpA.

METHOD

Clinical data of 2984 patients with SpA from 11 rheumatology centres were reviewed. This included demographics, duration of follow-up, comorbidities including diabetes, chronic kidney disease, chronic heart disease, chronic lung disease, stroke and malignancies, date of diagnosis of tuberculosis, use of non-steroidal anti-inflammatory drugs, duration of glucocorticoid therapy for more than 6 months, conventional (cDMARD) and biological (bDMARD) disease modifying anti-rheumatic drug therapies. Crude incidence rates were reported. Cox regression models were used to determine the risk factors for TB in patients with SpA.

RESULTS

Forty-three patients had TB, of which 4 (9.3%) were extra-pulmonary. The crude incidence rate of TB was 1.57 in patients with SpA, compared with 0.58 in the general population in Hong Kong. Independent risk factors identified from the multivariate Cox regression model were: alcohol use (HR 2.62; p = 0.03), previous TB (HR 13.62; p < 0.001), chronic lung disease (HR 3.39; p = 0.004), duration of glucocorticoid therapy greater than 6 months (HR 3.25; p = 0.01) and infliximab therapy (HR 5.06; p < 0.001). Age was associated with decreased risk (HR 0.93; p < 0.001).

CONCLUSION

Incidence of TB was higher in patients with SpA. Glucocorticoid therapy beyond 6 months and infliximab therapy increased the risk of TB. Rheumatologists should avoid prolonged use of glucocorticoids and consider DMARDs other than infliximab in the treatment of at-risk patients.

Tuberculosis comorbidity with rheumatoid arthritis: Gene signatures, associated biomarkers, and screening

Rheumatoid arthritis (RA) is known to be related to an elevated risk of infections because of its pathobiology and the use of immunosuppressive therapies. Reactivation of latent tuberculosis (TB) infection is a serious issue in patients with RA, especially after receiving anti-TNFs therapy. TNF blocking reinforces the TB granuloma formation and maintenance and the growth of Mycobacterium tuberculosis (Mtb). After intercurrent of TB infection, the standard recommendation is that the treatment with TNF inhibitors to be withheld despite its impressive effect on suppression of inflammation until the infection has resolved. Knowing pathways and mechanisms that are common between two diseases might help to find the mechanistic basis of this comorbidity, as well as provide us a new approach to apply them as therapeutic targets or diagnostic biomarkers. Also, screening for latent TB before initiation of an anti-TNF therapy can minimize complications. This review summarizes the shared gene signature between TB and RA and discusses the biomarkers for early detection of this infection, and screening procedures as well.