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Roberts ET, Schmajuk G, Li J, Murrill M, Yazdany J. Latent Tuberculosis Screening Among New Users of a Biologic or Targeted Synthetic Disease-Modifying Antirheumatic Drug: Gaps in Screening Overall and Among Janus Kinase Inhibitors. Arthritis Care Res (Hoboken) 2024; 76:1037-1044. [PMID: 38412872 PMCID: PMC11209809 DOI: 10.1002/acr.25318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/29/2024] [Accepted: 02/21/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE We combined claims and electronic health record (EHR) data to provide contemporary and accurate estimates of latent tuberculosis (TB) screening among new users of a biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) and assess potential gaps in testing by drug type, patient characteristics, and practice. METHODS Our denominator population was patients in the Rheumatology Informatics System for Effectiveness (RISE) registry and Medicare using a b/tsDMARD in 2018 without a claim or prescription in the year prior. TB screening was assessed in both Medicare and RISE 1 and 3 years before the medication start date. We calculated the proportion screened overall, by medication class, and by practice. We tested for demographic differences in screening using logistic regression. RESULTS In the year before drug starts, 65.6% of patients had any TB screening; in a 3-year window, 72.9% had any TB screening. Rates of screening within 1 year by drug type were greater or equal to the overall screening rate for most drugs except for JAK inhibitors (JAKis) (46%) and interleukin-17 inhibitors (IL-17is) (11.5%). A lower proportion of Hispanic and Asian patients were screened compared with White patients. Practice screening rates ranged from 20.0% to 92.9% of patients within 1 year. CONCLUSION We report higher screening rates than have previously been published because of combining claims and EHR data. However, important safety gaps remain, namely, reduced screening among new users of a JAKi or IL-17i and among Asian and Hispanic patients, as well as low-performing practices. Educational initiatives, team-based care delivery, task shifting, and technological interventions to address observed gaps in patient safety procedures are needed.
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Affiliation(s)
- Eric T Roberts
- University of California San Francisco, San Francisco, CA
| | - Gabriela Schmajuk
- University of California San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Jing Li
- University of California San Francisco, San Francisco, CA
| | | | - Jinoos Yazdany
- University of California San Francisco, San Francisco, CA
- Zuckerberg San Francisco General Hospital, San Francisco, CA
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Marijam A, Vroom N, Bhavsar A, Posiuniene I, Lecrenier N, Vroling H. Systematic Literature Review on the Incidence of Herpes Zoster in Populations at Increased Risk of Disease in the EU/EEA, Switzerland, and the UK. Infect Dis Ther 2024; 13:1083-1104. [PMID: 38656653 PMCID: PMC11098998 DOI: 10.1007/s40121-024-00963-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Older adults and patients with underlying conditions such as immunocompromised (IC) populations (e.g., due to medical conditions or immunosuppressive medication) are at increased risk for herpes zoster (HZ). The first HZ recombinant vaccine for IC patients was approved in 2020. Limited evidence exists to inform decision-makers on HZ incidence in high-risk patients in Europe. This systematic literature review (SLR) assessed HZ incidence across 14 high-risk populations in the European Union/European Economic Area, Switzerland, and the United Kingdom. METHODS An SLR (Embase, Medline, 2002-2022, observational studies) was performed to identify HZ incidence (i.e., primary outcomes: rate or cumulative; secondary: relative incidence) in type 1 and 2 diabetes mellitus (DM); chronic obstructive pulmonary disease and asthma; depression; rheumatic disorders (RD); multiple sclerosis (MS); inflammatory bowel diseases (IBD); psoriasis; lupus; human immunodeficiency virus (HIV); solid organ transplantation (SOT); solid organ malignancy (SOM); hematologic malignancy (HM); and stem cell transplantation (SCT). RESULTS Of 776 unique records screened, 59 studies were included (24 reported incidence rate per 1000 person-years; two, cumulative incidence per 1000 persons; and 33, relative incidence). The highest incidence rates were reported for SOT (12.1-78.8) and SCT (37.2-56.1); HM (2.9-32.0); RD (0.41-21.5); lupus (11.0-16.5); IC mixed population (11.3-15.5); HIV/AIDS (11.8-13.0); chronic respiratory diseases (4.7-11.4); SOM (8.8-11.0); IBD (7.0-10.8); DM (4.3-9.4); depression (7.2-7.6); MS (5.7-6.3); and psoriasis (5.3-6.1). In many high-risk populations, HZ incidence was higher for older age groups, women, and some treatments. CONCLUSIONS The HZ incidence rate in Europe increased with age and varied across high-risk populations, with high rates for solid organ and stem cell transplants, cancer, and rheumatoid arthritis. Most studies were retrospective with methodological differences affecting generalizability and comparability. Future studies should stratify data by IC population, age, sex, severity, medication, and study timeframe.
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Affiliation(s)
| | - Nikki Vroom
- Pallas Health Research & Consultancy, A P95 Company, Rotterdam, The Netherlands
| | | | | | | | - Hilde Vroling
- Pallas Health Research & Consultancy, A P95 Company, Rotterdam, The Netherlands
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Baker H, Fine R, Suter F, Allore H, Hsiao B, Chowdhary V, Lavelle E, Chen P, Hintz R, Suter LG, Danve A. Implementation of a Best Practice Advisory to Improve Infection Screening Prior to New Prescriptions of Biologics and Targeted Synthetic Drugs. Arthritis Care Res (Hoboken) 2023. [PMID: 37382043 DOI: 10.1002/acr.25181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE Use of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in patients with preexisting tuberculosis (TB), hepatitis B virus (HBV), or hepatitis C virus (HCV) infection can have serious consequences. Although various society guidelines recommend routine screening for these infections before initiating certain b/tsDMARDs, adherence to these recommendations varies widely. This quality improvement initiative evaluated local compliance with screening and assessed whether an automated computerized decision support system in the form of a best practice advisory (BPA) in the electronic health record could improve patient screening. METHODS Established patients with autoimmune rheumatic disease (ARD) aged 18 years or older with at least one visit to our rheumatology practice between October 1, 2017, and March 3, 2022, were included. When prescribing a new b/tsDMARD, clinicians were alerted via a BPA that showed the most recent results for TB, HBV, and HCV. Screening proportions for TB, HBV, and HCV before BPA initiation were compared with those of eligible patients after the BPA implementation. RESULTS A total of 711 patients pre-BPA and 257 patients post-BPA implementation were included in the study. The BPA implementation was associated with statistically significant improvement in screening for TB from 66% to 82% (P ≤ 0.001), HCV from 60% to 79% (P ≤ 0.001), hepatitis B core antibody 32% to 51% (P ≤ 0.001), and hepatitis B surface antigen from 51% to 70% (P ≤ 0.001). CONCLUSION Implementation of a BPA can improve infectious disease screening for patients with ARD who are started on b/tsDMARDs and has potential to improve patient safety.
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Affiliation(s)
- Hailey Baker
- Yale New Haven Health System, New Haven, Connecticut
| | - Rebecca Fine
- Yale New Haven Health System, New Haven, Connecticut
| | | | | | | | | | | | - Ping Chen
- Yale New Haven Hospital, New Haven, Connecticut
| | | | - Lisa G Suter
- Yale University and West Haven Veterans Affairs Medical Center, New Haven, Connecticut
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Jahnich N, Arkwright PD. Regional risk of tuberculosis and viral hepatitis with tumor necrosis factor-alpha inhibitor treatment: A systematic review. Front Pharmacol 2023; 14:1046306. [PMID: 36744250 PMCID: PMC9894886 DOI: 10.3389/fphar.2023.1046306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023] Open
Abstract
Background: TNFα inhibitors are regularly used to treat autoimmune diseases. Tuberculosis (TB) and viral hepatitis B are considered potential infectious complications, and screening and surveillance are therefore recommended. Current guidelines do not take into account regional differences in endemicity of these infections. Methods: A systematic literature review of TB and viral hepatitis in patients receiving TNFα-inhibitors was performed, searching in PubMed, Embase, MEDLINE and Web of Science databases. Studies were selected against predefined eligibility criteria and assessed using the Newcastle-Ottawa scale. The number of TB and viral hepatitis cases/1,000 TNFα-inhibitor patients were evaluated, and regional variation compared. Results: 105 observational studies involving over 140,000 patients were included. Overall, 1% of patients developed TB or viral hepatitis B. TB cases/1,000 TNFα-inhibitor patients were 4-fold higher in Asia, Africa, and South America than in Europe, North America, and Australasia where only 0%-0.4% of patients developed TB. Hepatitis B cases/1,000 patients were over 15-fold higher in countries with high prevalence (China, Taiwan, South Korea, Thailand) compared with low prevalence (p < 0.00001) where only 0.4% of patients developed hepatitis B. Only three of 143 patients developed viral hepatitis C, and there was insufficient data to allow regional sub-analysis. Conclusion: TB and viral hepatitis B infections in patients treated with TNFα inhibitors are largely confined to countries with high prevalence of these infections. As only 1/2,500 patients in low prevalence countries treated with TNFα inhibitors develop TB or viral hepatitis B, we suggest an individualized, risk-based approach, rather than universal screening for all patients.
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Affiliation(s)
| | - Peter D. Arkwright
- Lydia Becker Institute of Immunology and Inflammation, Manchester Incubator Building, University of Manchester, Manchester, United Kingdom
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Schmajuk G, Montgomery A, Tarasovsky G, Li J, Hauser RG, Rozenberg-Ben-Dror K, Whooley MA. Screening for Latent Infections Among Users of High-Risk Immunosuppressants: A Cross-Sectional Analysis From the Veterans Health Administration Healthcare System. J Patient Saf 2023; 19:1-7. [PMID: 36395779 DOI: 10.1097/pts.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Guidelines recommend screening for latent hepatitis B virus (HBV), hepatitis C virus (HCV), and tuberculosis (TB) before initiating biologics or targeted synthetic disease-modifying antirheumatic drugs (b/ts DMARDs) to avoid reactivation of life-threatening infections. The extent to which such screening occurs in the national Veterans Health Administration (VA) healthcare system is unknown. METHODS Using data from the Veterans Affairs' (VA) Corporate Data Warehouse, we performed a cross-sectional analysis of veterans receiving b/ts DMARDs between October 1, 2017, and September 30, 2019. We calculated the proportion of patients with screening completed for latent HBV, HCV, and TB between October 1, 1999 and September 30, 2019. Patient characteristics associated with complete screening were evaluated using mixed-effects multivariate logistic regression models. We also examined facility-level factors associated with high versus lower performance. RESULTS A total of 51,764 unique patients from 129 VA facilities received b/ts DMARDs from 2017 to 2019. Of these, 63% had complete screening. Among the 11,006 patients identified as new users, 64% had complete screening. Higher screening rates were observed among Hispanic/Latinx and Black/African American patients, users of B-cell therapies, and patients who had seen oncology subspecialists. Substantial variation was observed across facilities, with complete screening ranging from 13% to 98% of patients. Higher screening rates were associated with highly complex, urban, and higher-volume facilities. CONCLUSIONS Approximately two-thirds of veterans taking b/ts DMARDs have received guideline-recommended screening for HBV, HCV, and TB, but substantial facility variation was observed. Performance measures, robust multidisciplinary workflows, and electronic health record-based tools to feed information back to providers may improve screening rates for low-performing facilities.
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Axiaris G, Zampeli E, Michopoulos S, Bamias G. Management of hepatitis B virus infection in patients with inflammatory bowel disease under immunosuppressive treatment. World J Gastroenterol 2021; 27:3762-3779. [PMID: 34321842 PMCID: PMC8291024 DOI: 10.3748/wjg.v27.i25.3762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/26/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B remains a significant global clinical problem, despite the implementation of safe and effective vaccination programs. The prevalence of hepatitis B virus (HBV) in patients with inflammatory bowel disease (IBD) largely follows the regional epidemiologic status. Serological screening with hepatitis B surface antigen (HBsAg), and antibodies to hepatitis B surface (anti-HBs) and core (anti-HBc) proteins is a key element in the management of IBD patients and, ideally, should be performed at IBD diagnosis. Stratification of individual cases should be done according to the serologic profile and the IBD-specific treatment, with particular emphasis in patients receiving immunosuppressive regimens. In patients who have not contracted HBV, vaccination is indicated to accomplish protective immunity. Vaccination in immunosuppressed patients, however, is a challenging issue and several strategies for primary and revaccination have been proposed. The risk of HBV reactivation in patients with IBD should be considered in both HBsAg-positive and HBsAg-negative/anti-HBc-positive patients, when immunosuppressive therapies are administered. HBV reactivation is preventable via the administration of prophylactic nucleot(s)ide analogues and should be the standard approach in HBsAg-positive patients. HBsAg-negative/anti-HBc-positive patients represent a non-homogeneous group and bear a significantly lower risk of HBV reactivation. Biochemical, serological and molecular monitoring is currently the recommended approach for anti-HBc patients. Acute HBV infection is rarely reported in IBD patients. In the present review, we outline the problems associated with HBV infection in patients with IBD and present updated evidence for their management.
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Affiliation(s)
- Georgios Axiaris
- Gastroenterology Department, "Alexandra" Hospital, Athens 11528, Greece
| | - Evanthia Zampeli
- Gastroenterology Department, "Alexandra" Hospital, Athens 11528, Greece
| | | | - Giorgos Bamias
- GI Unit, 3rd Academic Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens 11526, Greece
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Fidan S, Capkın E, Arıca DA, Durak S, Okatan IE. Risk of hepatitis B reactivation in patients receiving anti-tumor necrosis factor-α therapy. Int J Rheum Dis 2020; 24:254-259. [PMID: 33244900 DOI: 10.1111/1756-185x.14034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/03/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study was to determine hepatitis B virus (HBV) screening rates in patients receiving anti-tumor necrosis factor (TNF)-α therapy and the frequency of HBV reactivation in patients with resolved hepatitis B virus infection (hepatitis B surface antigen [HBsAg] negative, hepatitis B core antibody [Anti-HBc] positive). PATIENTS AND METHODS Data from 1834 patients who underwent anti-TNF-α therapy in the Rheumatology, Gastroenterology and Dermatology Departments of our hospital between 2010 and 2020 were retrospectively analyzed. Within 6 months before the initial anti-TNF-α therapy, performing a HBsAg and/or anti-HBc test is defined as HBV screening. HBV reactivation is defined as the presence of detectable serum HBV DNA or HBsAg seroconversion from negative to positive. RESULTS The overall HBV screening rate was 82.3% before starting anti-TNF-α therapy. There was an increasing trend in HBV screening rates during the years analyzed (64% in 2010, 87.4% in 2019) (P < .001). Before anti-TNF-α therapy was initiated, 272 patients were HBsAg negative and anti-HBc positive. Among these patients, HBV reactivation did not occur in 31 patients who received antiviral prophylaxis, whereas HBV reactivation occurred in only 1 (0.4%) of the 241 patients who did not receive antiviral prophylaxis. CONCLUSION Hepatitis B virus screening rates prior to starting anti-TNF-α therapy were relatively high, and its trend was increased by year. HBV reactivation because of anti-TNF-α use rarely occurred in patients with resolved HBV infection. Further studies are needed on whether routine anti-HBc screening and/or HBV DNA follow-up are necessary in these patients aside from HBsAg.
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Affiliation(s)
- Sami Fidan
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erhan Capkın
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Deniz Aksu Arıca
- Department of Dermatology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Serdar Durak
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Ilyas Ercan Okatan
- Department of Rheumatology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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Asscher VER, Biemans VBC, Pierik MJ, Dijkstra G, Löwenberg M, van der Marel S, de Boer NKH, Bodelier AGL, Jansen JM, West RL, Haans JJL, van Dop WA, Weersma RK, Hoentjen F, Maljaars PWJ. Comorbidity, not patient age, is associated with impaired safety outcomes in vedolizumab- and ustekinumab-treated patients with inflammatory bowel disease-a prospective multicentre cohort study. Aliment Pharmacol Ther 2020; 52:1366-1376. [PMID: 32901983 PMCID: PMC7539998 DOI: 10.1111/apt.16073] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/25/2020] [Accepted: 08/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Few data are available on the effects of age and comorbidity on treatment outcomes of vedolizumab and ustekinumab in inflammatory bowel disease (IBD). AIMS To evaluate the association between age and comorbidity with safety and effectiveness outcomes of vedolizumab and ustekinumab in IBD. METHODS IBD patients initiating vedolizumab or ustekinumab in regular care were enrolled prospectively. Comorbidity prevalence was assessed using the Charlson Comorbidity Index (CCI). Association between age and CCI, both continuously assessed, with safety outcomes (any infection, hospitalisation, adverse events) during treatment, and effectiveness outcomes (clinical response and remission, corticosteroid-free remission, clinical remission combined with biochemical remission) after 52 weeks of treatment were evaluated. Multivariable logistic regression was used to adjust for confounders. RESULTS We included 203 vedolizumab- and 207 ustekinumab-treated IBD patients, mean age 42.2 (SD 16.0) and 41.6 (SD 14.4). Median treatment duration 54.0 (IQR 19.9-104.0) and 48.4 (IQR 24.4-55.1) weeks, median follow-up time 104.0 (IQR 103.1-104.0) and 52.0 weeks (IQR 49.3-100.4). On vedolizumab, CCI associated independently with any infection (OR 1.387, 95% CI 1.022-1.883, P = 0.036) and hospitalisation (OR 1.586, 95% CI 1.127-2.231, P = 0.008). On ustekinumab, CCI associated independently with hospitalisation (OR 1.621, 95% CI 1.034-2.541, P = 0.035). CCI was not associated with effectiveness, and age was not associated with any outcomes. CONCLUSIONS Comorbidity - but not age - is associated with an increased risk of hospitalisations on either treatment, and with any infection on vedolizumab. This underlines the importance of comorbidity assessment and safety monitoring of IBD patients.
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Schmajuk G, Li J, Evans M, Anastasiou C, Izadi Z, Kay JL, Hammam N, Yazdany J. RISE registry reveals potential gaps in medication safety for new users of biologics and targeted synthetic DMARDs. Semin Arthritis Rheum 2020; 50:1542-1548. [PMID: 32234243 DOI: 10.1016/j.semarthrit.2020.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/12/2020] [Accepted: 03/13/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Immunosuppressant drugs can increase the risk of hepatitis B virus (HBV) and hepatitis C virus (HCV) and tuberculosis (TB) reactivation. Using the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry, we examined pre-treatment screening among new users of biologic or targeted synthetic disease modifying drugs (DMARDs). METHODS Data, derived from RISE, included patients ≥ 18 years old who were new users of biologic or targeted synthetic DMARDs. We developed quality measures related to pre-treatment screening for HBV, HCV, and TB in addition to a "composite" measure for all applicable tests. We assessed patient-level screening rates, practice-level variation among practices reporting on ≥ 20 patients, and the frequency of positive results. RESULTS We included 26,802 patients across 213 rheumatology practices nationwide. Patients were 58 (14) years old, 75.9% female; 59.6% had rheumatoid arthritis, and TNFi were the most common index DMARDs (64.9%). Overall, 44.8% and 40.5% patients had any documented HBV or HCV screening, respectively, prior to the index date; 29.7% had TB screening in the year prior to drug start. Only 15.5% had documentation of screening for all appropriate infections prior to drug start. Practice-level performance on the composite measure was low (range 0 to 48.3%). 2.4% of screening tests were positive. CONCLUSION We found gaps in documentation of key safety measures among practices participating in RISE. Given the small but significant number of patients with active or latent infections that pose safety risks, developing standardized and reliable strategies to capture safety screening measures is paramount.
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Affiliation(s)
- Gabriela Schmajuk
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States; Philip R. Lee Institute for Health Policy Research, University of California - San Francisco, 3333 California St San Francisco, CA 94118, United States; San Francisco VA Medical Center, 4150 Clement St 111R, San Francisco, CA 94121, United States.
| | - Jing Li
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Michael Evans
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Christine Anastasiou
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Zara Izadi
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Julia L Kay
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Nevin Hammam
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Jinoos Yazdany
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
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Singh S, Facciorusso A, Dulai PS, Jairath V, Sandborn WJ. Comparative Risk of Serious Infections With Biologic and/or Immunosuppressive Therapy in Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2020; 18:69-81.e3. [PMID: 30876964 PMCID: PMC8011651 DOI: 10.1016/j.cgh.2019.02.044] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/29/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a systematic review and meta-analysis to evaluate the comparative risk of serious infections with tumor necrosis factor (TNF) antagonists, non-TNF targeted biologics, tofacitinib, and immunosuppressive agents in patients with inflammatory bowel diseases (IBDs). METHODS In a systematic search of publications, through March 18, 2018, we identified 15 observational studies (>500 person-years) of patients with IBD treated with TNF antagonists, non-TNF targeted biologics, tofacitinib, and/or immunosuppressive agents (thiopurines, methotrexate) that reported risk of serious infections. Only studies with active comparators were included, to allow appropriate comparative synthesis. We performed random-effects meta-analysis and estimated relative risk (RR) and 95% CIs. RESULTS Compared with anti-TNF monotherapy, risk of serious infection increased with the combination of anti-TNF and an immunosuppressive agent (in 6 cohorts: RR, 1.19; 95% CI, 1.03-1.37), with anti-TNF and a corticosteroid (in 4 cohorts: RR, 1.64; 95% CI, 1.33-2.03), or with all 3 drugs (in 2 cohorts: RR, 1.35; 95% CI, 1.04-1.77); there was minimal heterogeneity among studies. In contrast, monotherapy with an immunosuppressive agent was associated with a lower risk of serious infections than monotherapy with a TNF antagonist (7 cohorts: RR, 0.61; 95% CI 0.44-0.84) or a TNF antagonist with an immunosuppressive agent (2 cohorts: RR, 0.56; 95% CI, 0.39-0.81). Infliximab-based therapy was associated with a lower risk of serious infections compared with adalimumab-based therapy in patients with ulcerative colitis (4 cohorts: RR, 0.57; 95% CI, 0.33-0.97), but not Crohn's disease (4 cohorts: RR, 0.91; 95% CI, 0.49-1.70). Few data were available on the comparative safety of biologic agents that do not inhibit TNF and tofacitinib. CONCLUSIONS Combination therapies for IBD that include TNF antagonists, especially with corticosteroids, are associated with a higher risk of serious infection, whereas monotherapy with an immunosuppressive agent is associated with a lower risk, compared with monotherapy with a TNF antagonist. Studies are needed to evaluate the comparative safety of non-TNF targeted biologics and small molecules for treatment of IBD.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, University Hospital, Ontario, Canada,Division of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1282] [Impact Index Per Article: 256.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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12
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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13
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Zabana Y, Rodríguez L, Lobatón T, Gordillo J, Montserrat A, Mena R, Beltrán B, Dotti M, Benitez O, Guardiola J, Domènech E, Garcia-Planella E, Calvet X, Piqueras M, Aceituno M, Fernández-Bañares F, Esteve M. Relevant Infections in Inflammatory Bowel Disease, and Their Relationship With Immunosuppressive Therapy and Their Effects on Disease Mortality. J Crohns Colitis 2019; 13:828-837. [PMID: 30668662 DOI: 10.1093/ecco-jcc/jjz013] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/12/2019] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS There is controversy as to whether the risk of relevant infection in IBD is related to immunosuppressants or the disease itself. The aims of this study were to evaluate: [1] the life-long prevalence and types of relevant infections in patients with IBD related to immunosuppressive treatment, and [2] the relationship of both infection and patient comorbidity to mortality. METHODS Observational multicentre retrospective study of IBD patients that presented a relevant infection. For each case, four periods of infection exposure were analysed: P1: pre-IBD diagnosis, P2: from IBD diagnosis to immunosuppressant initiation, P3: during immunosuppressant therapy, and P4: after treatment withdrawal. RESULTS The life-long prevalence of relevant infection in the total cohort of patients [6914] was 3%, and 5% in immunosuppressed patients [4202]. 366 relevant infections were found in 212 patients [P1: 9, P2: 17, P3: 334, and P4: 6]. Differences between periods were significant [p < 0.0001]. The most frequent types of infection were respiratory, intestinal and urinary. The most frequent opportunistic infections were tuberculosis [prevalence: 2.6/1000] and herpes zoster [prevalence: 3.9/1000]. Herpes zoster infection was associated with thiopurines alone or in combination with anti-TNF in 75% of the cases, whereas tuberculosis was associated with anti-TNF in 94% of patients. The overall mortality was 4.2%. Infection-related mortality was 2.8% and it was not influenced by comorbidity. CONCLUSIONS Relevant infections in IBD patients are rare and appear to be related to immunosuppression. Relevant infection is a major cause of death in IBD.
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Affiliation(s)
- Yamile Zabana
- Gastroenterology and Inflammatory Bowel Disease Unit, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, Spain
| | | | - Triana Lobatón
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | | | - Raquel Mena
- Consorci Sanitari de Terrassa, Terrassa, Spain
| | - Belén Beltrán
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, Spain.,Hospital Universitari i Policlínic La Fe, Valencia, Spain
| | - Marina Dotti
- Gastroenterology and Inflammatory Bowel Disease Unit, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Olga Benitez
- Gastroenterology and Inflammatory Bowel Disease Unit, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | | | - Eugeni Domènech
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, Spain.,Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Xavier Calvet
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, Spain.,Corporació Sanitària Parc Taulí, Sabadell, Spain
| | | | - Montserrat Aceituno
- Gastroenterology and Inflammatory Bowel Disease Unit, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, Spain
| | - Fernando Fernández-Bañares
- Gastroenterology and Inflammatory Bowel Disease Unit, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, Spain
| | - Maria Esteve
- Gastroenterology and Inflammatory Bowel Disease Unit, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, Spain
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14
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Patterson S, Schmajuk G, Evans M, Aggarwal I, Izadi Z, Gianfrancesco M, Yazdany J. Gaps in Ambulatory Patient Safety for Immunosuppressive Specialty Medications. Jt Comm J Qual Patient Saf 2019; 45:348-357. [PMID: 30686706 PMCID: PMC7433663 DOI: 10.1016/j.jcjq.2018.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES New specialty drugs such as biologics are now available in record numbers, presenting increased safety risks for people with immune-mediated diseases. However, comprehensive assessments of patient safety for these drugs are lacking. We examined performance on key patient safety measures, such as screening for latent tuberculosis (LTBI), hepatitis B virus (HBV), and hepatitis C virus (HCV), for new users of a broad group of specialty medications. METHODS Data were extracted via electronic health record data warehouses of a large university health system using structured queries, and extensive chart review was performed to confirm measure elements. We included all new users of immunosuppressive specialty drugs between 2013 and 2017. We assessed screening for LTBI, HBV, and HCV from 12 months before through 60 days after medication initiation, and calculated performance on a composite measure that required screening for all three infections. Multivariable logistic regression was used to assess differences in screening across specialties, adjusting for patient race, sex, age, and comorbidities. RESULTS Among 2027 patients, the most common drugs prescribed were adalimumab (32%), etanercept (24%), infliximab (19%), and ustekinumab (9%). Overall, 62% of patients were screened for LTBI, 42% for HBV, and 33% for HCV. Only 26% of patients were screened appropriately for all three infections. Screening patterns differed significantly according to treating specialty. CONCLUSIONS We found gaps in ambulatory safety for patients treated with immunosuppressive specialty drugs for diverse inflammatory conditions across all relevant treating specialties. More robust safety protocols are urgently needed to prevent serious patient safety events in this high-risk population.
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Affiliation(s)
- Sarah Patterson
- Department of Medicine, Division of Rheumatology, University of California, San Francisco.
| | - Gabriela Schmajuk
- Department of Medicine, University of California, San Francisco, and the Department of Veterans Affairs Medical Center, San Francisco, USA
| | - Michael Evans
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
| | - Ishita Aggarwal
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
| | - Zara Izadi
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Milena Gianfrancesco
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
| | - Jinoos Yazdany
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
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15
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Abubakar I, Lalvani A, Southern J, Sitch A, Jackson C, Onyimadu O, Lipman M, Deeks JJ, Griffiths C, Bothamley G, Kon OM, Hayward A, Lord J, Drobniewski F. Two interferon gamma release assays for predicting active tuberculosis: the UK PREDICT TB prognostic test study. Health Technol Assess 2019; 22:1-96. [PMID: 30334521 DOI: 10.3310/hta22560] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Despite a recent decline in the annual incidence of tuberculosis (TB) in the UK, rates remain higher than in most Western European countries. The detection and treatment of latent TB infection (LTBI) is an essential component of the UK TB control programme. OBJECTIVES To assess the prognostic value and cost-effectiveness of the current two interferon gamma release assays (IGRAs) compared with the standard tuberculin skin test (TST) for predicting active TB among untreated individuals at increased risk of TB: (1) contacts of active TB cases and (2) new entrants to the UK from high-TB-burden countries. DESIGN A prospective cohort study and economic analysis. PARTICIPANTS AND SETTING Participants were recruited in TB clinics, general practices and community settings. Contacts of active TB cases and migrants who were born in high-TB-burden countries arriving in the UK were eligible to take part if they were aged ≥ 16 years. MAIN OUTCOME MEASURES Outcomes include incidence rate ratios comparing the incidence of active TB in those participants with a positive test result and those with a negative test result for each assay, and combination of tests and the cost per quality-adjusted life-year (QALY) for each screening strategy. RESULTS A total of 10,045 participants were recruited between May 2010 and July 2015. Among 9610 evaluable participants, 97 (1.0%) developed active TB. For the primary analysis, all test data were available for 6380 participants, with 77 participants developing active TB. A positive result for TSTa (positive if induration is ≥ 5 mm) was a significantly poorer predictor of progression to active TB than a positive result for any of the other tests. Compared with TSTb [positive if induration is ≥ 6 mm without prior bacillus Calmette-Guérin (BCG) alone, T-SPOT®.TB (Oxford Immunotec Ltd, Oxford, UK), TSTa + T-SPOT.TB, TSTa + IGRA and the three combination strategies including TSTb were significantly superior predictors of progression. Compared with the T-SPOT.TB test alone, TSTa + T-SPOT.TB, TSTb + QuantiFERON® TB Gold In-Tube (QFT-GIT; QIAGEN GmbH, Hilden, Germany) and TSTb + IGRA were significantly superior predictors of progression and, compared with QFT-GIT alone, T-SPOT.TB, TSTa + T-SPOT.TB, TSTa + QFT-GIT, TSTa + IGRA, TSTb + T-SPOT.TB, TSTb + QFT-GIT and TSTb + IGRA were significantly superior predictors of progression. When evaluating the negative predictive performance of tests and strategies, negative results for TSTa + QFT-GIT were significantly poorer predictors of non-progression than negative results for TSTa, T-SPOT.TB and TSTa + IGRA. The most cost-effective LTBI testing strategies are the dual-testing strategies. The cost and QALY differences between the LTBI testing strategies were small; in particular, QFT-GIT, TSTb + T-SPOT.TB and TSTb + QFT-GIT had very similar incremental net benefit estimates. CONCLUSION This study found modest differences between tests, or combinations of tests, in identifying individuals who would go on to develop active TB. However, a two-step approach that combined TSTb with an IGRA was the most cost-effective testing option. IMPLICATIONS FOR PRACTICE AND FUTURE RESEARCH The two-step TSTb strategy, which stratified the TST by prior BCG vaccination followed by an IGRA, was the most cost-effective approach. The limited ability of current tests to predict who will progress limits the clinical utility of tests. The implications of these results for the NHS England/Public Health England national TB screening programme for migrants should be investigated. STUDY REGISTRATION This study is registered as NCT01162265. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Ajit Lalvani
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jo Southern
- National Infection Service, Public Health England, London, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Oluchukwu Onyimadu
- Southampton Health Technology Assessment Centre, University of Southampton, Southampton, UK
| | - Marc Lipman
- Respiratory Medicine, University College London, London, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chris Griffiths
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Onn Min Kon
- Imperial College Healthcare NHS Trust, London, UK
| | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Joanne Lord
- Southampton Health Technology Assessment Centre, University of Southampton, Southampton, UK
| | - Francis Drobniewski
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
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16
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Schwaneck EC, Krone M, Kreissl-Kemmer S, Weißbrich B, Weiss J, Tony HP, Gadeholt O, Schmalzing M, Geier A. Management of anti-HBc-positive patients with rheumatic diseases treated with disease-modifying antirheumatic drugs-a single-center analysis of 2054 patients. Clin Rheumatol 2018; 37:2963-2970. [PMID: 30238380 DOI: 10.1007/s10067-018-4295-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/05/2018] [Accepted: 09/10/2018] [Indexed: 12/14/2022]
Abstract
Hepatitis B virus (HBV) reactivation is a common complication of immunosuppressive treatment in high prevalence countries. Biological disease-modifying antirheumatic drugs (bDMARDs) cause this adverse event more often than conventional immunosuppressants. The incidence of HBV reactivation during treatment for rheumatic diseases in Germany is unclear. Furthermore, it remains open how to treat and monitor patients at risk during immunosuppressive therapy with bDMARDs. We examined 2054 patients from a German tertiary rheumatology center in order to analyze the prevalence of HBc-antibody-positivity and the incidence of HBV reactivation in German rheumatology patients treated with immunosuppressants. Of 1317 patients treated with bDMARDs and 737 conventional synthetic DMARD (csDMARDs) patients between 2008 and 2017, 86 had a history of HBV infection (anti-HBc positive). Only two patients were suffering from chronic infection (HBsAg positive). Three patients were treated pre-emptively with entecavir, and eight patients after HBV DNA reappearance. No liver failure occurred due to HBV reactivation. Compared to anti-HBc-positive patients without reactivation, the reactivation group included more patients exposed to three or more classes of bDMARDs (p = 0.017). The median HBs antibody titer was significantly lower in the reactivation group (15.0 IU/l vs. 293.5 IU/l; p = 0.001). This study shows that bDMARDs and csDMARDs can safely be administered to patients with a history of HBV, provided they are closely monitored. Low titers of anti-HBs antibodies and a history of ≥ 3 classes of immunosuppressants increase the risk of HBV reactivation. These data highlight major differences to high prevalence regions.
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Affiliation(s)
- Eva C Schwaneck
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany.
| | - Manuel Krone
- Institute for Hygiene and Microbiology, University of Wuerzburg, Würzburg, Germany
| | | | - Benedikt Weißbrich
- Institute for Virology and Immunobiology, University of Wuerzburg, Würzburg, Germany
| | - Johannes Weiss
- Division of Hepatology, University Hospital Wuerzburg, Würzburg, Germany
| | - Hans-Peter Tony
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Ottar Gadeholt
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Marc Schmalzing
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Andreas Geier
- Division of Hepatology, University Hospital Wuerzburg, Würzburg, Germany
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17
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Hepatitis B Virus Screening and Reactivation in a National VA Cohort of Patients with Inflammatory Bowel Disease Treated with Tumor Necrosis Factor Antagonists. Dig Dis Sci 2018; 63:1551-1557. [PMID: 29663266 DOI: 10.1007/s10620-018-5042-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 03/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Practice guidelines recommend screening for hepatitis B virus (HBV) infection prior to initiating treatment of inflammatory bowel disease (IBD) with anti-tumor necrosis factor (anti-TNF) therapy. However, the adherence to these screening guidelines and the clinical outcomes of HBV reactivation following anti-TNF use are not well known. METHODS This is a retrospective cohort study using the Veterans Health Administration datasets for IBD patients with filled prescriptions for anti-TNFs from 2003 to 2011. Laboratory testing was used to define HBV screening status in the 12 months preceding anti-TNF initiation. Logistic regression models were used to identify predictors of HBV screening. Cases of potential HBV reactivation were identified using ICD-9 codes for HBV infection or acute liver failure or by medications used for HBV infection treatment, and manually reviewed for verification. RESULTS We identified 3357 IBD patients with filled prescriptions for anti-TNF medications. The HBV testing prior to anti-TNF initiation was 8.1% in 2003 and increased to 43.2% by 2011, with an overall rate of 23.7%. In multivariate analysis, African-American race, facilities with a higher volume of IBD patients, and facilities with an academic affiliation were associated with a higher probability of HBV screening. We did not identify a single case of confirmed clinically relevant HBV reactivation after anti-TNF initiation during 7210 patient-years of medication use. CONCLUSIONS HBV screening rates prior to anti-TNF initiation are low among IBD patients, but have increased over time. Despite low rates of screening, clinically significant HBV reactivation after anti-TNF initiation in this US cohort was nonexistent.
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18
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Torres-Castiblanco JL, Carrillo JA, Hincapié-Urrego D, Rojas-Villarraga A. [Tuberculosis in the era of anti-TNF-alpha therapy: Why does the risk still exist?]. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2018; 38:17-26. [PMID: 29668129 DOI: 10.7705/biomedica.v38i0.3458] [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: 07/25/2016] [Revised: 11/15/2016] [Accepted: 03/28/2017] [Indexed: 06/08/2023]
Abstract
Rheumatoid arthritis is an autoimmune systemic disease characterized mainly by inflammatory compromise of diarthrodial joints. Multiple drug therapies have been developed to control the activity of rheumatoid arthritis, among them, the first line of disease-modifying antirheumatic drugs (DMARD), and novel drug therapies such as the anti-TNF alpha therapy, with satisfactory clinical outcomes.Despite this positive fact, the use of this therapy implies the risk of producing negative effects due to its mechanism of action, which has been associated with multiple infections, especially tuberculosis, making it necessary to use screen tests before resorting to this kind of drugs.We present the case of a 58-year-old female patient, with a six-year history of rheumatoid arthritis.The patient developed disseminated tuberculosis with compatible radiological and histological findings after receiving treatment with infliximab (anti-TNF therapy). No test was performed to screen for latent tuberculosis infection prior to the administration of infliximab.The performance of routine screenings tests for tuberculosis prior to anti-TNF alpha therapy plays an essential role in the detection of asymptomatic patients with latent tuberculosis. This is the only way to identify those patients who would benefit from anti-tuberculosis drugs before the initiation of anti-TNF alpha therapy, which makes the difference in the search of a significant reduction in the incidence of tuberculosis and its associated morbidity and mortality.
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Affiliation(s)
- John-Leonardo Torres-Castiblanco
- Centro de Estudio de Enfermedades Autoinmunes (CREA), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, D.C., Colombia.
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19
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Screening and Treatment of Latent Tuberculosis Among Patients Receiving Biologic Agents: A National and International Survey of Rheumatologists. J Clin Rheumatol 2017; 23:6-11. [PMID: 28002150 DOI: 10.1097/rhu.0000000000000466] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We sought to understand the current practice patterns of both US and international members of the American College of Rheumatology (ACR) in this regard. METHODS A set of questionnaires developed by a focus group of faculties and fellows of the Rheumatology Division of University of Tennessee Health Science Center, Memphis, TN, was sent electronically using an online survey tool to 4433 rheumatologists who are ACR members in the United States and internationally. RESULTS Seven hundred sixty-eight physicians out of 4433 ACR members responded to the electronic survey, with a response rate of 17.32%. The preferred screening method by most of the respondents was either tuberculin skin test (19%) or interferon γ release assay (32%) or both. For treatment of latent tuberculosis infection (LTBI) overall, 49% of the respondents would refer management to infectious disease specialist or the health department, 37% would initiate isoniazid for 9 or 12 months, and 14% would use isoniazid for 6 months. Approximately 60% of respondents would initiate anti-tumor necrosis factor therapy after being on LTBI treatment for 1 month. The other respondents were almost equally divided among the 3 responses: 2, 3, 6, or 9 months. CONCLUSIONS There is a large disagreement regarding the method used and how often to screen for LTBI after initiating biologic therapy and how soon biologic treatment would be started after initiating LTBI therapy. Another disagreement exists regarding the duration of LTBI therapy. The information obtained from the survey can be taken into account when ACR or other international member organizations formulate future recommendations regarding screening and treatment of LTBI.
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20
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Schmajuk G, Tonner C, Trupin L, Li J, Sarkar U, Ludwig D, Shiboski S, Sirota M, Dudley RA, Murray S, Yazdany J. Using health-system-wide data to understand hepatitis B virus prophylaxis and reactivation outcomes in patients receiving rituximab. Medicine (Baltimore) 2017; 96:e6528. [PMID: 28353614 PMCID: PMC5380298 DOI: 10.1097/md.0000000000006528] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hepatitis B virus (HBV) reactivation in the setting of rituximab use is a potentially fatal but preventable safety event. The rate of HBV screening and proportion of patients at risk who receive antiviral prophylaxis in patients initiating rituximab is unknown.We analyzed electronic health record (EHR) data from 2 health systems, a university center and a safety net health system, including diagnosis grouper codes, problem lists, medications, laboratory results, procedures codes, clinical encounter notes, and scanned documents. We identified all patients who received rituximab between 6/1/2012 and 1/1/2016. We calculated the proportion of rituximab users with inadequate screening for HBV according to the Centers for Disease Control guidelines for detecting latent HBV infection before their first rituximab infusion during the study period. We also assessed the proportion of patients with positive hepatitis B screening tests who were prescribed antiviral prophylaxis. Finally, we characterized safety failures and adverse events.We included 926 patients from the university and 132 patients from the safety net health system. Sixty-one percent of patients from the university had adequate screening for HBV compared with 90% from the safety net. Among patients at risk for reactivation based on results of HBV testing, 66% and 92% received antiviral prophylaxis at the university and safety net, respectively.We found wide variations in hepatitis B screening practices among patients receiving rituximab, resulting in unnecessary risks to patients. Interventions should be developed to improve patient safety procedures in this high-risk patient population.
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Affiliation(s)
- Gabriela Schmajuk
- Division of Rheumatology, University of California-San Francisco
- Veterans Affairs Medical Center – San Francisco
| | - Chris Tonner
- Division of Rheumatology, University of California-San Francisco
| | - Laura Trupin
- Division of Rheumatology, University of California-San Francisco
| | - Jing Li
- Division of Rheumatology, University of California-San Francisco
| | - Urmimala Sarkar
- Center for Vulnerable Populations & Division of General Internal Medicine at the Zuckerberg San Francisco General Hospital, Department of Medicine, University of California-San Francisco
| | - Dana Ludwig
- University of California-San Francisco , Enterprise Information and Analytics
| | - Stephen Shiboski
- Department of Epidemiology and Biostatistics, University of California-San Francisco
| | - Marina Sirota
- Institute for Computational Health Sciences, University of California-San Francisco
| | - R. Adams Dudley
- Center for Healthcare Value, Philip R. Lee Institute for Health Policy Studies, University of California-San Francisco
| | - Sara Murray
- Department of Medicine, University of California-San Francisco
| | - Jinoos Yazdany
- Division of Rheumatology, University of California-San Francisco
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21
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Tuberculosis Screening and Reactivation Among a National Cohort of Patients with Inflammatory Bowel Disease Treated with Tumor Necrosis Factor Alpha Antagonists. Inflamm Bowel Dis 2017; 23:254-260. [PMID: 27997433 DOI: 10.1097/mib.0000000000001003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tumor necrosis factor antagonists (anti-TNFs) are effective in treating inflammatory bowel disease (IBD) but may cause reactivation of tuberculosis (TB). TB screening rates and related outcomes are not well described among patients with IBD. This study aims to evaluate the prevalence and determinants of TB screening before anti-TNF initiation and related outcomes among patients with IBD. METHODS We identified patients with IBD with filled prescriptions for anti-TNFs using the National Veterans Affairs administrative data sets. Determinants of TB screening were identified by univariate and multivariate analyses. Patients with TB reactivation were identified by ICD9 codes or prescriptions for isoniazid, and confirmed by chart review. RESULTS A total of 3357 patients with IBD were identified with filled anti-TNF prescriptions. Approximately 72% to 86% of patients received TB screening. In multivariate analyses, patients in rural areas were less likely to be screened for TB compared with those in urban areas (odds ratio 0.72, 95% confidence ratio 0.54-0.95). Patients who received care at academically affiliated facilities were more likely to have received screening for TB (odds ratio 1.49, 95% confidence ratio 1.31-1.95). In 7210 patient-years of follow-up on anti-TNF, TB reactivation was confirmed in 2 patients, both of whom had a history and treatment of latent TB before anti-TNF initiation. CONCLUSIONS TB screening before anti-TNF is estimated to be between 72% and 86%. Receipt of care at urban, academic-affiliated, high-volume IBD facilities is associated with higher rates of screening. Reactivation of TB in a highly screened cohort is estimated to be 2.8 per 10,000 patient-years.
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Paul S, Shuja A, Tam I, Kim EM, Kang S, Kapulsky L, Viveiros K, Lee H. Gastroenterologists Have Suboptimal Hepatitis B Virus Screening Rates in Patients Receiving Immunosuppressive Therapy. Dig Dis Sci 2016; 61:2236-2241. [PMID: 26993822 PMCID: PMC6484859 DOI: 10.1007/s10620-016-4118-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 03/06/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS Hepatitis B reactivation in patients undergoing immunosuppressive therapy can lead to liver failure and death. Prior studies have shown suboptimal hepatitis B screening rates, but few have compared screening rates across specialties or factors associated with screening. METHODS A retrospective study was performed using a hospital-based chemotherapy database and outpatient pharmacy records from January 1999 to December 2013. HBV screening rates prior to initiation of immunosuppression were determined. Multivariate analysis was used to determine predictors of HBV screening. RESULTS Of the 4008 study patients, 47 % were screened prior to receiving immunosuppressive therapy; only 48 % on rituximab and 45 % of those on anti-TNF therapy were screened. Transplant specialists screened most frequently (85 %) while gastroenterologists screened the least (34 %). Factors significantly associated with HBV screening were younger age, Asian race, use of anti-rejection therapy, and treatment by a transplant specialist (p < 0.001). CONCLUSION HBV screening prior to immunosuppressive therapy is suboptimal, especially among gastroenterologists. Efforts to improve screening rates in at risk populations are needed.
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Affiliation(s)
- Sonali Paul
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, 55 Fruit Street, Blake 4, Boston, MA 02114,
| | - Asim Shuja
- Department of Gastroenterology, University of Florida College of Medicine, 655 West 8 Street, Jacksonville, FL 23309,
| | - Idy Tam
- Division of Gastroenterology and Hepatology, Tufts Medical Center, 800 Washington Street, Box #233, Boston, MA 02111,
| | - Eun Min Kim
- Division of Gastroenterology and Hepatology, Tufts Medical Center, 800 Washington Street, Box #233, Boston, MA 02111,
| | - Sandra Kang
- Tufts University School of Medicine, 145 Harrison Street, Boston, MA 02111,
| | - Leonid Kapulsky
- Tufts University School of Medicine, 145 Harrison Street, Boston, MA 02111,
| | - Kathleen Viveiros
- Division of Gastroenterology and Hepatology, Tufts Medical Center, 800 Washington Street, Box #233 Boston, MA 02111,
| | - Hannah Lee
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University Medical Center, 1101 East Marshall Street Richmond, Virginia 23298-0663,
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Abstract
PURPOSE OF REVIEW The treatment of inflammatory bowel disease (IBD) in the modern area has improved with more biological agents available. Although the efficacy of these drugs has been demonstrated, concerns about their safety profile have been raised, and new data have emerged in the past year. RECENT FINDINGS New data regarding the safety profile of anti-TNF were published over the last year, with a better identification of patients at risk of infection, and specific recommendations for the prevention of infections. There is a mild increase in malignancy in patients receiving anti-TNF, mainly lymphoma and skin cancer, which seems mainly attributable to combination with thiopurines. Specific recommendations for management of pregnancy were published. SUMMARY Biological treatments are effective and safe in the treatment of IBD, provided that the recommendations for their use and monitoring are followed.
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