Severe pyogenic infections in patients taking infliximab

Effectiveness and drug retention of biologic disease modifying antirheumatic drugs in Korean patients with late onset ankylosing spondylitis

The clinical data on the biologic disease-modifying antirheumatic drug (bDMARD) use in late-onset ankylosing spondylitis (LOAS) is limited. Thus, this study aimed to evaluate the drug efficacy and retention rate of bDMARDs in LOAS and compare it to young-onset ankylosing spondylitis (YOAS). Data of patients with AS receiving bDMARDs were extracted from the Korean College of Rheumatology Biologics and Targeted Therapy registry. Patients whose age of onset was > 50 years and ≤ 50 years were classified as having LOAS and YOAS, respectively. Their baseline characteristics and disease-associated parameters were evaluated. Drug efficacy [Ankylosing Spondylitis Disease Activity Score (ASDAS)-clinically important improvement (CII), ASDAS-major improvement (MI), Assessment of SpondyloArthritis International Society (ASAS) 20, and ASAS 40] at 1-year follow-up and drug retention rates were assessed. A total of 1708 patients (comprising 1472 patients with YOAS and 236 patients with LOAS) were included in this analysis. The LOAS group had a lower prevalence among males, lower HLA-B27 positivity and a higher prevalence of peripheral arthritis. Patients with LOAS were more likely to have higher disease-associated parameters (inflammatory reactants, patient global assessment, ASDAS-erythrocyte sedimentation rate, and ASDAS-C-reactive protein). LOAS was negatively associated with achieving ASDAS-CII, ASAS 20, and ASAS 40. The drug retention rate was lower in LOAS; however, the propensity score-matched and covariate-adjusted hazard ratios for bDMARD discontinuation were comparable to YOAS. There were no differences in the drug retention rates based on the type of bDMARD used in LOAS. Inferior clinical efficacy and shorter drug retention time were found in patients with LOAS receiving bDMARDs using real-world nationwide data. There were no differences among each bDMARD type.

Percutaneous transforaminal endoscopic discectomy for the treatment of lateral recess stenosis secondary occurred the discal fungus infection

Background

This is a case of lateral recess stenosis secondary occurred the discal fungus infection treated with percutaneous transforaminal endoscopic discectomy (PTED). There has been no relevant reports before.

Case presentation

A 49-year-old patient who had taken itraconazole for 13 months for lateral recess stenosis secondary occurred the discal fungus infection complained of gradually worsening radiating pain and numbness in the back and inguinal and inner thigh region of right side. In order to relieve the radiating neuralgia and reduce the damage to spinal stability, the minimally invasive PTED was performed.The patient’s prognosis was assessed using Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS).

During the follow-up, the patient’s ODI and VAS scores were decreased significantly. The radiating pain in the inguinal and inner thigh region of right side were significantly alleviated and the discomfort caused by lower back instability was improved by plaster vest.

Discussion and conclusion

PTED not only avoids further damage to the stability of the lumbar spine, but also effectively relieves the symptoms of leg neuroradialgia caused by lateral recess stenosis secondary occurred the discal fungus infection.

Do model polymer therapeutics sufficiently diffuse through articular cartilage to be a viable therapeutic route?

The ability of a polymer therapeutic to access the appropriate subcellular location is crucial to its efficacy and is defined to a large part by the many and complex cellular biological and biochemical barriers such that a construct must traverse. It is shown here that model dextrin conjugates are able to pass through a cartilaginous extracellular matrix into chondrocytes, with little perturbation of the matrix structure, indicating that targeting of potential therapeutics through a cartilaginous extracellular matrix should be proven possible. Rapid chondrocytic targeting of drugs which require intra cellularisation for their activity and uniform extracellular concentrations of drugs with an extracellular target, is thus enabled though polymer conjugation.

Tumour necrosis factor inhibitors and infection: What is there to know for infectious diseases physicians?

At this year's meeting of Digestive Disease Week in Los Angeles, California, it was noted that antitumour necrosis factor (anti-TNF) inhibitors showed further evidence of efficacy in Crohn's disease (1). TNF antagonists have been used increasingly in the treatment of a number of other inflammatory diseases, especially rheumatoid arthritis (RA), where they have revolutionized treatment (2). At the same time, their use has been associated with an increased risk of serious infections (3). As more patients are treated with these agents, it is inevitable that infectious diseases physicians will see a variety of infections, both common and uncommon, requiring familiarity with this new class of drugs and their infectious complications.

The risk of infections with biologic therapies for rheumatoid arthritis

OBJECTIVES

To assess the risk of serious and nonserious bacterial and viral infections associated with the use of biologic therapy (abatacept, adalimumab, anakinra, etanercept, infliximab, and rituximab) in patients with rheumatoid arthritis (RA).

METHODS

Information was derived from PubMed, EMBASE, and the Cochrane clinical trials register and database of systematic reviews and relevant congress abstracts up to and including February 2008.

RESULTS

Compared with the general population, patients with RA have a heightened risk of infection, including tuberculosis. Long-term clinical trials and postmarketing studies indicate that anakinra and the tumor necrosis factor (TNF) inhibitors are associated with an increased risk of infections versus conventional disease-modifying antirheumatic drugs (DMARDs), especially early in the course of treatment. The most common sites of infection are the respiratory tract (including pneumonia), skin and soft tissue, and the urinary tract. The risk of tuberculosis also appears higher with TNF inhibitors (in particular, infliximab) versus DMARDs, although this can be reduced by screening and prophylaxis. TNF inhibitors do not appear to significantly increase the risk of reactivating chronic viral infections. Influenza and pneumococcal vaccinations are generally effective in the face of TNF inhibitors or abatacept. Available data suggest that the risk of infections and serious infections with abatacept and rituximab may be similar to that of the TNF inhibitors. To date, there have been no reports from clinical trials of increased tuberculosis or opportunistic infections with abatacept or rituximab.

CONCLUSIONS

All marketed TNF inhibitors for compared to control RA appear to increase the risk of serious and nonserious infections compared with DMARDs. Although suggestive, data for abatacept and rituximab are less definitive and longer periods of patient exposure to these agents are needed before an assessment of their risks can be made.

Clinical evaluation of a cohort of patients with rheumatoid arthritis treated with anti-TNF-alpha in the community

OBJECTIVES

TNF-alpha inhibitors have been effective in randomized controlled studies for the treatment of RA. The purpose of this study was to evaluate the clinical, laboratory, and radiological responses in a cohort of unselected patients with RA treated with TNF-alpha inhibitors in the community.

METHODS

Using the Swiss Clinical Quality Management in Rheumatoid Arthritis, a centralized system of data gathering for RA patients, we obtained the following information regarding patients treated with a TNF-alpha inhibitor in the Geneva Canton before 02/2003: demographics; clinical data (disease activity, functional status, treatments received and type of TNF-alpha inhibitor used); laboratory and radiographic data.

RESULTS

A total of 66 patients (mean age = 60.5 years) with long-standing disease (mean duration = 12.5 years) were analyzed. Sixteen patients (24%) discontinued anti-TNF-alpha, half within the first 6 months of the study. Mean DAS score decreased from 4.8+ /- 0.4 to 3.8 +/- 0.4 (P < 0.01); HAQ scores (mean = 1.35) remained unchanged; pain, evaluated on a 10-point scale, decreased from 5.0 at baseline to 3.3 (P < 0.001). CRP values decreased steadily from 17.9 at baseline to 5.6 at 20 months or later. The progression of radiographic damage decelerated in 30 patients, accelerated in 12, and remained unchanged in one.

CONCLUSIONS

The responses of this community-based group of patients with severe, long-standing RA to TNF-alpha inhibitors revealed a reassuring similarity to those of patients enrolled in controlled clinical trials.

Anti-Tumour Necrosis Factor-?? Therapy for Rheumatoid and Other Inflammatory Arthropathies

Anti-tumour necrosis factor (TNF)-alpha represents a major advance in the treatment of rheumatoid arthritis (RA), ankylosing spondylitis and psoriatic arthritis. It is usually well tolerated, but a potential increase in the incidence of some infections in patients taking anti-TNFalpha agents has been reported. Compared with younger people, elderly patients have more co-morbidities and are likely to be taking more medications. Moreover, the aging process induces an increase in the rate of infections. Nevertheless, in recent studies analysing the databases of etanercept trials, the normalised incidence of adverse events, serious adverse events, medically important infections and deaths was not increased in patients aged >or=65 years. However, these trials included patients who might have been healthier than elderly RA patients in the general population and therefore not truly representative. Conflicting results have been reported in several 'real-life' observational studies. Taken together, the available data are reassuring for carefully selected populations, at least for etanercept, but it is not possible to claim that anti-TNFalpha agents do, or do not, pose a particular risk for the general population of older patients. Additional studies aiming at determining the safety and benefit-risk ratio of anti-TNFalpha agents in elderly patients are needed. In addition, since the benefit-risk ratio of anti-TNFalpha agents might be different in patients aged 65, 75 or >80 years, when possible, subgroup analysis might also be useful.