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Hu J, Sun Y, Zuo X, Zou Y. Assessment of adverse events related to anti-interleukin-6 receptor monoclonal antibodies using the FDA adverse event reporting system:a real-world pharmacovigilance study. Expert Opin Drug Saf 2024:1-13. [PMID: 39049740 DOI: 10.1080/14740338.2024.2382227] [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: 05/13/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Interleukin-6 (IL-6) monoclonal antibodies are commonly acknowledged for their efficacy in managing coronavirus disease 2019 (COVID-19); however, there remains a paucity of comprehensive studies on their potential adverse effects. RESEARCH DESIGN AND METHODS This is a retrospective pharmacovigilance investigation. We employed FAERS using OpenVigil FDA to detect adverse reactions linked to the interleukin-6 antagonist tocilizumab and sarilumab. RESULTS Completely 17,037,364 reports were collected from the FAERS database, with 67,976 reports identified as 'primary suspected (PS)' adverse events (AEs) for tocilizumab, and 12,560 reports for sarilumab. AEs induced by both drugs involved 27 organ systems. 109 significant disproportionality preferred terms (PTs) of tocilizumab and 158 significant disproportionality PTs meeting the criteria of sarilumab across all four algorithms were retained simultaneously. A higher incidence of adverse reactions occurred in females aged 45-64 years, with a higher rate of subsequent hospitalization. Both drugs exhibited adverse reactions consistent with previously reported side effects, such as leukopenia, elevated liver enzymes, and hypercholesterolemia. Additionally, there was a strong correlation with gastrointestinal issues. Unexpected significant adverse events, including diabetes, fluctuations in blood pressure, drug ineffectiveness, malignancies, and disorders of the nervous system, were also observed. Gender and age differences existed in AEs signals related to IL-6RAs. CONCLUSION Our study identified significant new AE signals for interleukin-6 receptor antagonists, potentially supporting clinical monitoring and risk identification for this class of drugs.
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Affiliation(s)
- Jing Hu
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Yao Sun
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Xiangrong Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Ying Zou
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
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2
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Gridneva GI, Belov BS, Aronova ES. [Chronic hepatitis B in rheumatic diseases: issues of screening and reactivation of infection: A review]. TERAPEVT ARKH 2024; 96:523-530. [PMID: 38829815 DOI: 10.26442/00403660.2024.05.202707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 06/05/2024]
Abstract
Patients with rheumatic diseases infected with hepatitis B virus (HBV) are difficult to manage not only due to the presence of risk factors for the development and rapid progression of liver cirrhosis, but also due to the likelihood of reactivation of this infection. Despite the successes achieved in the fight against HBV, the virus cannot be completely defeated due to the presence of hidden forms of the disease, escaping the field of vision of a rheumatologist and an infectionist. Based on the results of the analysis of current publications, the paper presents the rationale for a complete immunological screening of patients with rheumatic diseases when prescribing antirheumatic therapy. The issues of the role of COVID-19 in the exacerbation of chronic viral hepatitis B, antiviral prevention and monitoring are discussed, the classification of antirheumatic drugs according to the risk of HBV reactivation is presented.
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Affiliation(s)
| | - B S Belov
- Nasonova Research Institute of Rheumatology
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3
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Ko PH, Kuo MH, Kao IT, Wu CY, Tseng CW, Shao SC. The Risk of Hepatitis B Virus Reactivation in Rheumatoid Arthritis Patients Receiving Tocilizumab: A Systematic Review and Meta-Analysis. Viruses 2024; 16:78. [PMID: 38257778 PMCID: PMC10820547 DOI: 10.3390/v16010078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Tocilizumab has demonstrated optimal efficacy and safety in patients with rheumatoid arthritis (RA) from clinical trials. However, the risk of hepatitis B virus reactivation (HBVr) in these patients remains uncertain because patients with underlying HBV have been excluded in phase III studies. METHODS Systematical reviews were conducted on PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to 21 February 2023. Random-effects meta-analysis was performed to calculate the pooled incidence of HBV reactivation. RESULTS We included 0 clinical trials and 11 observational studies with a total of 25 HBsAg+ and 322 HBsAg-/anti-HBc+ RA patients. Among the HBsAg+ patients without antiviral prophylaxis, the pooled rate was 69.4% (95% CI, 32.9-91.3), with a median time of 4 months (range, 1-8 months) from tocilizumab initiated. Half of these patients with HBVr experienced hepatitis flare-up but no deaths. HBVr was eliminated with prophylaxis in this population. Among HBsAg-/anti-HBc+ patients, the pooled incidence of reactivation was 3.3% (95% CI, 1.6-6.7), with a median time of 10 months (range, 2-43 months) from tocilizumab initiated. HBVr was not associated with hepatitis flare-up and death. HBsAg-/anti-HBc+ patients without anti-HBs antibodies had a significantly higher risk of HBVr (Odds ratio, 12.20; 95% CI, 1.16-128.06). CONCLUSIONS This systematic review indicated that the risk of HBVr in RA patients with anti-HBs-, HBsAg+, or HBsAg-/anti-HBc+ cannot be ignored but may be avoided. Clinicians should consider implementing appropriate antiviral prophylaxis and monitoring policies for RA patients to avoid unnecessary hepatic side effects from tocilizumab treatment.
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Affiliation(s)
- Ping-Hung Ko
- School of Medicine, Tzuchi University, Hualien 970, Taiwan;
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi 622, Taiwan
| | - Meng Hsuan Kuo
- Department of Pharmacy, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi 622, Taiwan; (I.-T.K.); (C.-Y.W.)
| | - I-Ting Kao
- Department of Pharmacy, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi 622, Taiwan; (I.-T.K.); (C.-Y.W.)
| | - Chen-Yi Wu
- Department of Pharmacy, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi 622, Taiwan; (I.-T.K.); (C.-Y.W.)
| | - Chih-Wei Tseng
- School of Medicine, Tzuchi University, Hualien 970, Taiwan;
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi 622, Taiwan
| | - Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan;
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4
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Balsa A, Díaz Del Campo Fontecha P, Silva Fernández L, Valencia Martín J, Nistal Martínez V, León Vázquez F, Hernández Hernández MV, Corominas H, Cáliz Cáliz R, Aguado García JM, Candelas Rodríguez G, Ibargoyen Roteta N, Martí Carvajal A, Plana Farras MN, Puñal Riobóo J, Park HS, Triñanes Pego Y, Villaverde García V. Recommendations by the Spanish Society of Rheumatology on risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2023; 19:533-548. [PMID: 38008602 DOI: 10.1016/j.reumae.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/06/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE To present recommendations based on the available evidence and the consensus of experts, for risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. METHODS Clinical research questions relevant to the purpose of the document were identified. These questions were reformulated in PICO format (patient, intervention, comparison, outcome or outcome) by a panel of experts, selected based on their experience in the area. A systematic review of the evidence was carried out, grading according to the GRADE criteria (Grading of Recommendations Assessment, Development, and Evaluation). Specific recommendations were then formulated. RESULTS 6 PICO questions were proposed by the panel of experts based on their clinical relevance and the existence of recent information regarding the risk of occurrence of serious infections, the risk of reactivation of the hepatitis B virus, the risk of reactivation of the virus varicella-zoster, the risk of appearance of skin (melanoma and non-melanoma) or haematological cancer, the risk of appearance of thromboembolic disease and the risk of progression of the human papilloma virus. A total of 28 recommendations were formulated, structured by question, based on the evidence found and the consensus of the experts. CONCLUSIONS The SER recommendations on risk management of treatment with biologic therapies and JAK inhibitors in rheumatoid arthritis are presented.
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Affiliation(s)
- Alejandro Balsa
- Servicio de Reumatología, Hospital Universitario La Paz, Madrid, Spain
| | | | - Lucía Silva Fernández
- Servicio de Reumatología, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - José Valencia Martín
- Unidad de Medicina Preventiva y Salud Pública, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Fernando León Vázquez
- Medicina de Familia, Centro de Salud San Juan de la Cruz, Pozuelo de Alarcón, Madrid, Spain
| | - M Vanesa Hernández Hernández
- Servicio de Reumatología, Complejo Hospitalario Universitario de Canarias, San Cristóbal de la Laguna, Santa Cruz de Tenerife, Spain
| | - Héctor Corominas
- Servicio de Reumatología, Hospital Universitari de la Santa Creu i Sant Pau & Hospital Dos de Maig, Barcelona, Spain
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre. CIBERINFEC, ISCIII. Departamento de Medicina, UCM, Madrid, Spain
| | | | - Nora Ibargoyen Roteta
- Servicio de Evaluación de Tecnologías Sanitarias del País Vasco (Osteba). BIOEF, Barakaldo, Vizcaya, Spain
| | - Arturo Martí Carvajal
- Cátedra Rectoral de Medicina basada en la Evidencia, Universidad de Carabobo, Venezuela; Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - M Nieves Plana Farras
- Unidad de Evaluación de Tecnologías Sanitarias, Hospital Ramón y Cajal, IRYCIS. CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Janet Puñal Riobóo
- Unidad de Asesoramiento Científico-técnico, Avalia-t, Agencia Gallega para la Gestión del Conocimiento en Salud, ACIS, Santiago de Compostela, A Coruña, Spain
| | - Hye Sang Park
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Yolanda Triñanes Pego
- Unidad de Asesoramiento Científico-técnico, Avalia-t, Agencia Gallega para la Gestión del Conocimiento en Salud, ACIS, Santiago de Compostela, A Coruña, Spain
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5
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Katelani S, Fragoulis GE, Bakasis AD, Pouliakis A, Nikiphorou E, Atzeni F, Androutsakos T. HBV reactivation in patients with rheumatoid arthritis treated with anti-interleukin-6: a systematic review and meta-analysis. Rheumatology (Oxford) 2023; 62:SI252-SI259. [PMID: 37871924 DOI: 10.1093/rheumatology/kead243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/23/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVE The objective of this study was to assess the possibility of HBV reactivation (HBVr) in patients with RA under anti-IL-6 treatment. METHODS Using PubMed, Scopus and EMBASE, we performed a systematic literature search for articles related to HBVr in RA patients under anti-IL-6 treatment. The search was performed with no date limits and was last updated 28 January 2023. The results from all the databases were combined and duplicates were excluded, as were non-English articles, case reports, position articles, comments, and paediatric studies. RESULTS Our initial search led to 427 articles; 28 were duplicates, 46 non-English, 169 reviews, 31 books/letters, 25 case reports, and 88 irrelevant to the meta-analysis aim; 21 were excluded due to inadequate information, leaving 19 articles, with a sum of 372 RA patients with chronic HBV (CHB) or resolved HBV infection, for further analysis. The overall risk for HBVr in RA patients with CHB was 6.7%, increasing to 37% when only RA patients with CHB and no antiviral prophylaxis were included. On the contrary, HBVr was close to 0% in RA patients with resolved HBV infection, irrespective of antiviral prophylaxis. All RA patients experiencing HBVr in these studies were successfully managed with antiviral treatment and/or drug withdrawal. CONCLUSION Overall, anti-IL-6 treatment comes with a significant risk of HBVr in RA patients with CHB; risk is diminished when antiviral prophylaxis is used. In contrast, in RA patients with resolved HBV infection, the risk of HBVr seems to be extremely low. Large, well-designed studies (either controlled trials or multicentre/international observational studies) are warranted to further validate these results.
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Affiliation(s)
- Stamatia Katelani
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George E Fragoulis
- First Department of Internal Medicine, Propedeutic Clinic, "Laiko" Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Scotland, UK
| | | | - Abraham Pouliakis
- 2nd Department of Pathology, National and Kapodistrian University of Athens, Medical School, University General Hospital Attikon, Athens, Greece
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Theodoros Androutsakos
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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6
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Papatheodoridis GV, Lekakis V, Voulgaris T, Lampertico P, Berg T, Chan HLY, Kao JH, Terrault N, Lok AS, Reddy KR. Hepatitis B virus reactivation associated with new classes of immunosuppressants and immunomodulators: A systematic review, meta-analysis, and expert opinion. J Hepatol 2022; 77:1670-1689. [PMID: 35850281 DOI: 10.1016/j.jhep.2022.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 12/27/2022]
Abstract
HBV reactivation (HBVr) can be prevented by nucleos(t)ide analogues (NAs). We conducted a systematic review and meta-analysis on the risk of HBVr associated with new classes of immunosuppressive and immunomodulatory therapies and developed guidance on NA prophylaxis. An expert panel reviewed the data and categorised the risk of HBVr associated with each class of drugs into low (<1%), intermediate (1-10%), and high (>10%). Our search uncovered 59 studies, including 3,424 HBsAg+ and 5,799 HBsAg-/anti-HBc+ patients, which met our eligibility criteria. Based on medium-high quality evidence, immune checkpoint inhibitors, tyrosine kinase inhibitors, cytokine inhibitors, chimeric antigen receptor T-cell immunotherapies, and corticosteroids were associated with high HBVr risk in HBsAg+ patients; cytokine inhibitors, chimeric antigen receptor T-cell immunotherapies, and corticosteroids with intermediate risk in HBsAg-/anti-HBc+ patients; and anti-tumour necrosis factor agents and immune checkpoint inhibitors with low risk in HBsAg-/anti-HBc+ patients. Provisional recommendations are provided for drugs with low quality evidence. NA prophylaxis is recommended when using drugs associated with a high HBVr risk, while monitoring with on-demand NAs is recommended for low-risk drugs - either approach may be appropriate for intermediate-risk drugs. Consensus on definitions and methods of reporting HBVr, along with inclusion of HBsAg+, and HBsAg-/anti-HBc+ patients in clinical trials, will be key to gathering reliable data on the risk of HBVr associated with immunosuppressive or immunomodulatory therapies.
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Affiliation(s)
- George V Papatheodoridis
- Academic Department of Gastroenterology, National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Vasileios Lekakis
- Academic Department of Gastroenterology, National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Thodoris Voulgaris
- Academic Department of Gastroenterology, National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Pietro Lampertico
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy; CRC "A. M. and A. Migliavacca" Center for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Thomas Berg
- Division of Hepatology, Department of Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Henry L Y Chan
- Division of Gastroenterology and Hepatology, Union Hospital and Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Jia-Horng Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
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7
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Săndulescu O, Streinu-Cercel A, Miron VD, Apostolescu CG, Nițescu M, Drăgănescu AC, Streinu-Cercel A. Prevalence of undiagnosed hepatitis B virus infection in patients with COVID-19A single center retrospective study. Medicine (Baltimore) 2022; 101:e31385. [PMID: 36397400 PMCID: PMC9665894 DOI: 10.1097/md.0000000000031385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
At its onset, the coronavirus disease 2019 (COVID-19) pandemic brought significant challenges to healthcare systems, changing the focus of medical care on acute illness. Disruptions in medical service provision have impacted the field of viral hepatitis, with screening programs paused throughout much of 2020 and 2021. We performed a retrospective study on consecutive outpatients with COVID-19 during the second and third wave of COVID-19 in Romania, from November 2020 to April 2021, aiming to characterize the prevalence of undiagnosed hepatitis B virus (HBV) infection among patients presenting with acute illness. Overall, 522 patients had available records during the study timespan. Their mean ± standard deviation age was 51 ± 13 years; 274 (52.5%) were male. We identified 16 (3.1%) cases of active HBV infection; only six of these patients were aware of their HBV status, and 3 of the newly diagnosed cases were identified as candidates for HBV treatment. A total of 96 patients (18.4%) had serological markers suggestive for prior HBV vaccination. A large proportion of patients (n = 120, 23.0%) had positive HBV core antibodies; among these, 90 (17.2%) had cleared a previous HBV infection (being positive for HBV surface antibodies and HBV core antibodies). We identified the following parameters that were significantly more frequent in patients with a history of HBV infection: older age (P < .001), hypoalbuminemia (P = .015), thrombocytopenia (P < .001), thrombocytopenia followed by thrombocytosis (P = .041), increased blood urea nitrogen (P < .001) and increased creatinine (P = .011). In conclusion, the COVID-19 pandemic has taught us essential lessons about the importance of maintaining access to screening programs and of ensuring active monitoring of patients with chronic infections such as hepatitis B, even during a medical crisis.
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Affiliation(s)
- Oana Săndulescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania
| | - Anca Streinu-Cercel
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania
| | - Victor Daniel Miron
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- *Correspondence: Victor Daniel Miron, Carol Davila University of Medicine and Pharmacy, Bucharest 050474, Romania (e-mail: ) and Cătălin Gabriel Apostolescu, Carol Davila University of Medicine and Pharmacy, Bucharest 050474, RomaniaNational Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest 021105, Romania (e-mail: )
| | - Cătălin Gabriel Apostolescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania
- *Correspondence: Victor Daniel Miron, Carol Davila University of Medicine and Pharmacy, Bucharest 050474, Romania (e-mail: ) and Cătălin Gabriel Apostolescu, Carol Davila University of Medicine and Pharmacy, Bucharest 050474, RomaniaNational Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest 021105, Romania (e-mail: )
| | - Maria Nițescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania
| | - Anca Cristina Drăgănescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania
| | - Adrian Streinu-Cercel
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania
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8
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Fragoulis GE, Nikiphorou E, Dey M, Zhao SS, Courvoisier DS, Arnaud L, Atzeni F, Behrens GM, Bijlsma JW, Böhm P, Constantinou CA, Garcia-Diaz S, Kapetanovic MC, Lauper K, Luís M, Morel J, Nagy G, Polverino E, van Rompay J, Sebastiani M, Strangfeld A, de Thurah A, Galloway J, Hyrich KL. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2022; 82:742-753. [PMID: 36328476 DOI: 10.1136/ard-2022-223335] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
ObjectivesTo develop EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD).MethodsAn international Task Force (TF) (22 members/15 countries) formulated recommendations, supported by systematic literature review findings. Level of evidence and grade of recommendation were assigned for each recommendation. Level of agreement was provided anonymously by each TF member.ResultsFour overarching principles (OAP) and eight recommendations were developed. The OAPs highlight the need for infections to be discussed with patients and with other medical specialties, in accordance with national regulations. In addition to biologic/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) for which screening for latent tuberculosis (TB) should be performed, screening could be considered also before conventional synthetic DMARDs, glucocorticoids and immunosuppressants. Interferon gamma release assay should be preferred over tuberculin skin test, where available. Hepatitis B (HBV) antiviral treatment should be guided by HBV status defined prior to starting antirheumatic drugs. All patients positive for hepatitis-C-RNA should be referred for antiviral treatment. Also, patients who are non-immune to varicella zoster virus should be informed about the availability of postexposure prophylaxis should they have contact with this pathogen. Prophylaxis againstPneumocystis jiroveciiseems to be beneficial in patients treated with daily doses >15–30 mg of prednisolone or equivalent for >2–4 weeks.ConclusionsThese recommendations provide guidance on the screening and prevention of chronic and opportunistic infections. Their adoption in clinical practice is recommended to standardise and optimise care to reduce the burden of opportunistic infections in people living with AIIRD.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Rheumatology Department, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
| | | | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), University Hospitals Strasbourg, Strasbourg, France
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Georg Mn Behrens
- Department for Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Johannes Wj Bijlsma
- Dept of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Peter Böhm
- Forschungspartner, German League against rheumatism, Bonn, Germany
| | | | - Silvia Garcia-Diaz
- Rheumatology Department, Complex Hospitalari Moises Broggi, Barcelona, Spain
| | | | - Kim Lauper
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- Division of Rheumatology, University of Geneva, Geneva, Switzerland
| | - Mariana Luís
- Rheumatology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Jacques Morel
- Department of Rheumatology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - György Nagy
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias CIBERES, Barcelona, Spain
| | - Jef van Rompay
- Belgium Patient Partner Program, EULAR People with Arthritis/Rheumatism across Europe (PARE), Antwerpen, Belgium
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Centre (DRFZ) Berlin and Charite University Medicine, Berlin, Germany
| | - Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester NHS Foundation Trust, Manchester, UK
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Fragoulis GE, Dey M, Zhao S, Schoones J, Courvoisier D, Galloway J, Hyrich KL, Nikiphorou E. Systematic literature review informing the 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. RMD Open 2022; 8:rmdopen-2022-002726. [PMID: 36323488 PMCID: PMC9639159 DOI: 10.1136/rmdopen-2022-002726] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To conduct a systematic literature review (SLR) on the screening and prophylaxis of opportunistic and chronic infections in autoimmune inflammatory rheumatic diseases (AIIRD). METHODS SLR (inception-12/2021) based on the following search domains: (1) infectious agents, (2) AIIRD, (3) immunosuppressives/immunomodulators used in rheumatology, (4) screening terms and (5) prophylaxis terms. Articles were retrieved having the terms from (1) AND (2) AND (3) plus terms from (4) OR(5). Databases searched: PubMed, Embase and Cochrane Library. EXCLUSION CRITERIA studies on postoperative infections, paediatric AIIRD, COVID-19, vaccinations and non-Εnglish literature. Study quality was assessed with Newcastle-Ottawa scale for non-randomised controlled trials (RCTs), RoB-Cochrane for RCTs, AMSTAR2 for SLRs. RESULTS From 5641 studies were retrieved, 568 full-text articles were assessed for eligibility, with 194 articles finally included. For tuberculosis, tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. For hepatitis B virus (HBV): risk of reactivation is increased in patients positive for hepatitis B surface antigen. Anti-HBcore positive patients are at low risk for reactivation but should be monitored periodically with liver function tests and/or HBV-viral load. Risk for Hepatitis C reactivation is existing but low in patients treated with biological DMARDs. For Pneumocystis jirovecii, prophylaxis treatment should be considered in patients treated with prednisolone ≥15-30 mg/day for >2-4 weeks. CONCLUSIONS Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Zhao
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Jan Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | | | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
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10
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COVID-19 as Another Trigger for HBV Reactivation: Clinical Case and Review of Literature. Pathogens 2022; 11:pathogens11070816. [PMID: 35890060 PMCID: PMC9318431 DOI: 10.3390/pathogens11070816] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 02/07/2023] Open
Abstract
Universal hepatitis B virus (HBV) vaccination has been applied for years in most countries, but HBV infection remains an unresolved public health problem worldwide, with over one-third of the world’s population infected during their lifetime and approximately 248 million hepatitis B surface antigen (HBsAg) chronic carriers. HBV infection may reactivate with symptomatic and sometimes life-threatening clinical manifestations due to a reduction in the immune response of various origins, due to chemotherapy or immunosuppressive therapy, treatments increasingly practiced worldwide. SARS-CoV-2 and its COVID-19 associated disease have introduced new chances for HBV reactivation due to the use of dexamethasone and tocilizumab to counteract the cytokine storm. This could and should be prevented by accurate screening of HBV serologic markers and adequate pharmacologic prophylaxis. This article describes the case of a patient with COVID-19 who developed HBV reactivation and died of liver failure and analyzes published data on this setting to provide useful information to physicians who manage these patients during the SARS-CoV-2 pandemic.
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11
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Minihan B, McAuliffe E, Powell J, Wong SL, Wilkie K, Murphy C, Maher A, Power L, O'Connell NH, Dunne CP. Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections. J Hosp Infect 2022; 126:29-36. [PMID: 35472487 PMCID: PMC9033628 DOI: 10.1016/j.jhin.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022]
Abstract
Background Tocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously. Aim To describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33). Methods Retrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1st January to 31st December 2021. Findings Amongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04–6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08–9.00; P<0.0001). Conclusions In this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.
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Affiliation(s)
- B Minihan
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - E McAuliffe
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - J Powell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - S L Wong
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - K Wilkie
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - C Murphy
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - A Maher
- Department of Pharmacy, University Hospital Limerick, Limerick, Ireland
| | - L Power
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - N H O'Connell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland; School of Medicine, University of Limerick, Limerick, Ireland
| | - C P Dunne
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland; School of Medicine, University of Limerick, Limerick, Ireland.
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12
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Abstract
The world has made significant progress in developing novel treatments for COVID-19 since the pandemic began. Some treatments target the patient's dysregulated inflammatory response during COVID-19 infection and may cause hepatitis B reactivation (HBVr) in patients with current or past hepatitis B virus (HBV) infection. This review summarizes the risk and management of HBVr due to different treatments of COVID-19 in patients who have current or past HBV infection. Abnormal liver function tests are common during COVID-19 infection. Current evidence suggests that current or past HBV infection is not associated with an increased risk of liver injury and severe disease in COVID-19 patients. Among patients who received high-dose corticosteroids, various immunosuppressive monoclonal antibodies and inhibitors of Janus kinase, the risk of HBVr exists, especially among those without antiviral prophylaxis. Data, however, remain scarce regarding the specific use of immunosuppressive therapies in COVID-19 patients with HBV infection. Some results are mainly extrapolated from patients receiving the same agents in other diseases. HBVr is a potentially life-threatening event following profound immunosuppression by COVID-19 therapies. Future studies should explore the use of immunosuppressive therapies in COVID-19 patients with HBV infection and the impact of antiviral prophylaxis on the risk of HBVr.
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13
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Wu YL, Ke J, Zhang BY, Zhao D. Hepatitis B virus reactivation in rheumatoid arthritis. World J Clin Cases 2022; 10:12-22. [PMID: 35071501 PMCID: PMC8727249 DOI: 10.12998/wjcc.v10.i1.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/16/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease characterized by proliferative synovitis, which can cause cartilage and bone damage as well as functional limitations. Disease-modifying anti-rheumatic drugs have significantly improved the prognosis of RA patients. However, people with RA, when combined with hepatitis B virus (HBV) infection, may experience reactivation of HBV during treatment with anti-rheumatic drugs. The outcome of HBV reactivation (HBVr) varies from liver inflammation to liver failure, while insufficient HBV screening in RA patients has been reported in various countries. Therefore, it is necessary to identify patients at high risk before starting immunosuppressive therapy. The immune response plays an important role in anti-HBV infection. However, most anti-rheumatic drugs exert an inhibitory effect on the body's immune system, resulting in HBVr. Therefore, it is necessary to conduct a comprehensive evaluation based on host factors, viral factors, and drug factors. In this paper, we summarize the mechanism of HBVr, the risk of HBVr caused by anti-rheumatic drugs, and the appropriate diagnosis and treatment process for RA patients so that clinicians can have a more comprehensive understanding of HBVr in RA patients.
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Affiliation(s)
- Ya-Li Wu
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing 101149, China
| | - Jing Ke
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing 101149, China
| | - Bao-Yu Zhang
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing 101149, China
| | - Dong Zhao
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing 101149, China
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14
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Aguirre A, Yazdany J. Hepatitis B Screening Before Biologic or Targeted Synthetic Disease-modifying Antirheumatic Drug Therapy: Many Roads to Improvement. J Rheumatol 2021; 49:1-4. [PMID: 34725177 DOI: 10.3899/jrheum.211000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Alfredo Aguirre
- A. Aguirre, MD, Clinical Fellow, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, University of California, San Francisco, California, USA.
| | - Jinoos Yazdany
- A. Aguirre, MD, Clinical Fellow, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, University of California, San Francisco, California, USA
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Oikonomou KG, Papamichalis P, Zafeiridis T, Xanthoudaki M, Papapostolou E, Valsamaki A, Bouliaris K, Papamichalis M, Karvouniaris M, Vlachostergios PJ, Skoura AL, Komnos A. Gastroenterology and liver disease during COVID-19 and in anticipation of post-COVID-19 era: Current practice and future directions. World J Clin Cases 2021; 9:4918-4938. [PMID: 34307544 PMCID: PMC8283616 DOI: 10.12998/wjcc.v9.i19.4918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/10/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as a major threat to global public health. The virus causes the clinical syndrome known as coronavirus disease 2019 (COVID-19), in which multiple organs can get affected. Apart from manifestations of the respiratory system, which predominate, its clinical presentation is frequently accompanied by symptoms of the gastro-intestinal (GI) tract and liver abnormalities. The correlation of symptoms and abnormalities with disease severity is discussed, leading to ambiguous results from international literature. Moreover, the disease infects patients with co-existing liver and GI disorders affecting both their health status and the availability of healthcare services provided to them. The risk of transmission of the disease during aerosol-generating procedures has changed the diagnostic approach and follow-up algorithms for liver and GI diseases. For the safety of both doctors and patients, telemedicine and distant evaluation have become everyday practice, whereas several routines and emergency visits at outpatient and emergency departments have been postponed or delayed. Vaccination against SARS-CoV-2 is underway, providing hope to humanity and the expectation that the post-COVID-19 era is near. This review aims to update knowledge about the manifestations of COVID-19 related to liver and GI diseases and the effect of the pandemic on the diagnostic and therapeutic procedures for these diseases with a special focus on how current practices have changed and what changes will possibly remain in the future.
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Affiliation(s)
- Katerina G Oikonomou
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | | | | | - Maria Xanthoudaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | | | - Asimina Valsamaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | | | - Michail Papamichalis
- Department of Cardiology, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | - Marios Karvouniaris
- Intensive Care Unit, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | - Panagiotis J Vlachostergios
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, United States
| | - Apostolia-Lemonia Skoura
- Intensive Care Unit, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
- Transfusion Medicine Department, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | - Apostolos Komnos
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
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