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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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9
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Migita K, Arai T, Ishizuka N, Jiuchi Y, Sasaki Y, Izumi Y, Kiyokawa T, Suematsu E, Miyamura T, Tsutani H, Kawabe Y, Matsumura R, Mori S, Ohshima S, Yoshizawa S, Kawakami K, Suenaga Y, Nishimura H, Sugimoto T, Iwase H, Sawada H, Yamashita H, Kuratsu S, Ogushi F, Kawabata M, Matsui T, Furukawa H, Bito S, Tohma S. Rates of serious intracellular infections in autoimmune disease patients receiving initial glucocorticoid therapy. PLoS One 2013; 8:e78699. [PMID: 24260127 PMCID: PMC3834005 DOI: 10.1371/journal.pone.0078699] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/14/2013] [Indexed: 11/27/2022] Open
Abstract
Background/Aims The Japanese National Hospital Organization evidence-based medicine (EBM) Study group for Adverse effects of Corticosteroid therapy (J-NHOSAC) is a Japanese hospital-based cohort study investigating the safety of the initial use of glucocorticoids (GCs) in patients with newly diagnosed autoimmune diseases. Using the J-NHOSAC registry, the purpose of this observational study is to analyse the rates, characteristics and associated risk factors of intracellular infections in patients with newly diagnosed autoimmune diseases who were initially treated with GCs. Methodology/Principal Findings A total 604 patients with newly diagnosed autoimmune diseases treated with GCs were enrolled in this registry between April 2007 and March 2009. Cox proportional-hazards regression was used to determine independent risk factors for serious intracellular infections with covariates including sex, age, co-morbidity, laboratory data, use of immunosuppressants and dose of GCs. Survival was analysed according to the Kaplan-Meier method and was assessed by the log-rank test. There were 127 serious infections, including 43 intracellular infections, during 1105.8 patient-years of follow-up. The 43 serious intracellular infections resulted in 8 deaths. After adjustment for covariates, diabetes (Odds ratio [OR]: 2.5, 95% confidence interval [95% CI] 1.1–5.9), lymphocytopenia (≦1000/μl, OR: 2.5, 95% CI 1.2–5.2) and use of high-dose (≧30 mg/day) GCs (OR: 2.4, 95% CI 1.1–5.3) increased the risk of intracellular infections. Survival curves showed lower intracellular infection-free survival rate in patients with diabetes, lymphocytopaenia and high-dose GCs treatments. Conclusions/Significance Patients with newly diagnosed autoimmune diseases were at high risk of developing intracellular infection during initial treatment with GCs. Our findings provide background data on the risk of intracellular infections of patients with autoimmune diseases. Clinicians showed remain vigilant for intracellular infections in patients with autoimmune diseases who are treated with GCs.
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Affiliation(s)
- Kiyoshi Migita
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
- * E-mail:
| | - Toru Arai
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Naoki Ishizuka
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yuka Jiuchi
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yasuharu Sasaki
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yasumori Izumi
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Tetsuyuki Kiyokawa
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Eiichi Suematsu
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Tomoya Miyamura
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hiroshi Tsutani
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yojiro Kawabe
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Ryutaro Matsumura
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shunsuke Mori
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shiro Ohshima
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shigeru Yoshizawa
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Kenji Kawakami
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yasuo Suenaga
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hideo Nishimura
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Toyohiko Sugimoto
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hiroaki Iwase
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hideyuki Sawada
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Haruhiro Yamashita
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shigeyuki Kuratsu
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Fumitaka Ogushi
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Masaharu Kawabata
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Toshihiro Matsui
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hiroshi Furukawa
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Seiji Bito
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shigeto Tohma
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
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