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Sen R, Riofrio M, Singh JA. A narrative review of the comparative safety of disease-modifying anti-rheumatic drugs used for the treatment of rheumatoid arthritis. Expert Opin Drug Saf 2024; 23:687-714. [PMID: 38695151 DOI: 10.1080/14740338.2024.2348575] [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: 11/29/2023] [Accepted: 04/24/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Disease-modifying anti-rheumatic drugs (DMARDs) have improved the outcomes of patients with rheumatoid arthritis (RA). DMARDs are classified into three categories: conventional synthetic DMARDs, biological DMARDs (including biosimilars), and targeted synthetic DMARDs. DMARDs, by way of their effect on the immune system, are associated with increased risk of adverse events, including infections, malignancies, cardiovascular disease, gastrointestinal perforations, and other less common events. AREAS COVERED In this narrative literature review performed with searches of the PubMed database from 1 January 2010 through 1 January 2023, we compare the risk of safety events between DMARDs using data from both randomized clinical trials and observational studies. EXPERT OPINION DMARD use in RA is associated with higher rates of serious infections, tuberculosis reactivation, opportunistic infections, and possibly malignancies. Specific biologic DMARDs and higher doses are associated with elevated risks of various adverse events (gastrointestinal perforations, thromboembolism, serious infection). Shared decision-making is paramount when choosing a treatment regimen for patients based on their own comorbidities. JAKi are the newest class of medications used for RA with robust safety data provided in clinical trials. However, more real-world evidence and phase-IV pharmacovigilance data are needed to better understand comparative safety profile of DMARDs in RA.
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Affiliation(s)
- Rouhin Sen
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
| | - Maria Riofrio
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
| | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
- Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA
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Makimoto K, Konno R, Kinoshita A, Kanzaki H, Suto S. Incidence of severe infection in patients with rheumatoid arthritis taking biological agents: a systematic review. JBI Evid Synth 2023; 21:835-885. [PMID: 36630204 DOI: 10.11124/jbies-22-00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of this review was to estimate the population-based incidence of and determine the types of severe infection and deaths experienced by patients with rheumatoid arthritis taking biological agents. INTRODUCTION Since the late 1990s, various biological and synthetic drugs have been developed to treat rheumatoid arthritis. In recent years, the incidence of severe infection in patients with rheumatoid arthritis in Western nations has been determined by observational studies; however, no systematic review has been conducted on this topic. INCLUSION CRITERIA The following inclusion criteria were considered: i) observational studies on patients with rheumatoid arthritis treated with biological agents; ii) studies reporting the number of severe infections requiring hospitalization for treatment; iii) studies reporting person-years of observation data; and iv) studies based on rheumatoid arthritis registries, medical records from rheumatology centers, or insurance claim databases. METHODS PubMed, CINAHL, Embase, and Web of Science were searched to identify published studies. The reference lists of all studies selected for critical appraisal were screened for additional studies. Unpublished studies were searched on MedNar and OpenGrey databases. All the searches were updated on December 6, 2021. After removing the duplicates, 2 independent reviewers screened titles and abstracts against the inclusion criteria and then assessed full texts against the criteria. Two reviewers independently appraised the study and outcome levels for methodological quality using the critical appraisal instrument for cohort studies from JBI. Two reviewers extracted the relevant information related to severe infection and drugs. RESULTS Fifty-two studies from 21 countries reported severe infection rates associated with using 9 biologic agents. In total, 18,428 infections with 395,065 person-years of biologic drug exposure were included in the analysis. Thirty-five studies included infections in outpatients receiving intravenous antibiotic therapy. Fifteen studies reported the first episode of infection, and the remaining studies did not specify either the first or all of the episodes of infection. Inclusion of viral infection and/or opportunistic infection varied among studies. Fifteen studies reported the site of infection, and respiratory, skin/soft tissue, urinary tract infection, and sepsis/bacteremia were commonly reported. Ten studies reported the case fatality rates, ranging from 2.5% to 22.2%. Meta-analysis was conducted for 7 biologic agents and conventional disease-modifying antirheumatic drugs. The infection rate varied from 0.9 to 18.0/100 person-years. The meta-analysis revealed an infection rate of 4.2/100 person-years (95% CI 3.5-4.9) among patients receiving tumor necrosis factor inhibitors (heterogeneity 98.2%). The meta-analysis for the other 3 biologic agents revealed a point estimate of 5.5 to 8.7/100 person-years with high heterogeneity. Sensitivity analysis indicated that registry-based studies were less likely to have very low or very high infection rates compared with other data sources. The definition of infection, the patient composition of the cohorts, and the type of databases appeared to be the primary sources of clinical and methodological heterogeneity. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020175137. CONCLUSIONS Due to high statistical heterogeneity, the meta-analysis was not suited to estimating a summary measure of the infection rate. Developing standardized data collection is necessary to compare infection rates across studies.
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Affiliation(s)
- Kiyoko Makimoto
- Osaka University, Suita, Osaka, Japan.,The Japan Centre for Evidence Based Practice: A JBI Centre of Excellence, Osaka University, Suita, Osaka, Japan
| | - Rie Konno
- Hyogo Medical University, Hypgo, Kobe, Japan
| | | | | | - Shunji Suto
- Nara Medical University, Kashihara, Nara, Japan
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Grøn KL, Glintborg B, Nørgaard M, Mehnert F, Østergaard M, Dreyer L, Krogh NS, Hetland ML. Overall infection risk in rheumatoid arthritis during treatment with abatacept, rituximab and tocilizumab; an observational cohort study. Rheumatology (Oxford) 2021; 59:1949-1956. [PMID: 31764977 DOI: 10.1093/rheumatology/kez530] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/01/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Most infections in patients with RA are treated in primary care with antibiotics. A small fraction require hospitalization. Only a few studies exist regarding the overall risk of infection (i.e. prescription of antibiotics or hospitalization due to infection) in patients initiating non-TNF-inhibitor therapy. In Danish RA patients initiating abatacept, rituximab and tocilizumab treatment in routine care, the aims were to compare adjusted incidence rates (IR) of infections and to estimate relative risk of infections across the drugs during 0-12 and 0-24 months. METHODS This was an observational cohort study including all RA patients in the DANBIO registry starting a non-TNF-inhibitor from 2010 to 2017. Infections were defined as a prescription of antibiotics or hospitalization due to infection. Prescriptions, comorbidities and infections were captured through linkage to national registries. IRs of infections (age, gender adjusted) and rate ratios (as estimates of RR (relative risk)), adjusted for additional covariates) (Poisson regression) were calculated. RESULTS We identified 3696 treatment episodes (abatacept 1115, rituximab 1017, tocilizumab 1564). At baseline, rituximab users were older and had more previous cancer. During 0-12 months, 1747 infections occurred. Age and gender-adjusted IRs per 100 person-years were as follows: abatacept: 76 (95% CI: 69, 84); rituximab: 87 (95% CI: 79, 96); tocilizumab: 77 (95% CI: 71, 84). Adjusted RRs were 0.94 (95% CI: 0.81, 1.08) for abatacept and 0.94 (95% CI: 0.81, 1.03) for tocilizumab compared with rituximab and 1.00 (95% CI: 0.88, 1.14) for abatacept compared with tocilizumab. RRs around 1 were observed after 24 months. Switchers and ever smokers had higher risk compared with biologic-naïve and never smokers, respectively. CONCLUSION Overall infections were common in non-TNF-inhibitor-treated RA patients, with a tendency towards rituximab having the highest risk, but CIs were wide in all analyses. Confounding by indication may at least partly explain any differences.
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Affiliation(s)
- Kathrine L Grøn
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus
| | - Mikkel Østergaard
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Lene Dreyer
- Departments of Clinical Medicine and Rheumatology, Aalborg University and Aalborg University Hospital, Aalborg
| | | | - Merete L Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
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Chiu YM, Chen DY. Infection risk in patients undergoing treatment for inflammatory arthritis: non-biologics versus biologics. Expert Rev Clin Immunol 2020; 16:207-228. [PMID: 31852268 DOI: 10.1080/1744666x.2019.1705785] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Despite the therapeutic effectiveness of biologics targeting immune cells or cytokines in patients with inflammatory arthritis, which reflects their pathogenic roles, an increased infection risk is observed in those undergoing biological treatment. However, there are limited data regarding the comparison of infection risks in inflammatory arthritis patients treated with non-biologics (csDMARDs), biologics (bDMARDs), including tumor necrosis factor (TNF) inhibitors and non-TNF inhibitors, or targeted synthetic (ts)DMARDs.Areas covered: Through a review of English-language literature as of 30 June 2019, we focus on the existing evidence on the risk of infections caused by bacteria, Mycobacterium tuberculosis, and hepatitis virus in inflammatory arthritis patients undergoing treatment with csDMARDs, bDMARDs, or tsDMARDs.Expert opinion: While the risks of bacterial and mycobacterial infection are increased in arthritis patients treated with csDMARDs, the risks are further higher in those receiving bDMARDs therapy, particularly TNF inhibitors. Regarding HBV infection, antiviral therapy may effectively prevent HBV reactivation in patients receiving bDMARDs, especially rituximab. However, more data are needed to establish effective preventive strategies for HBsAg-negative/HBcAb-positive patients. It seems safe to use cyclosporine and TNF inhibitors in patients with HCV infection, while those undergoing rituximab therapies should be frequently monitored for HCV activity.Abbreviations: ABT: abatacept; ADA: adalimumab; AS: ankylosing spondylitis; bDMARDs: biologic disease-modifying anti-rheumatic drugs; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; CS: corticosteroids; CsA: cyclosporine A; csDMARDs: conventional synthetic disease-modifying anti-rheumatic drugs; CZP: certolizumab; DAAs: direct-acting antiviral agents; DM: diabetes mellitus; DOT: directly observed therapy; EIN: Emerging Infections Network; ETN: etanercept; GOL: golimumab; GPRD: General Practice Research Database; HBV: hepatitis B virus; HBVr: HBV reactivation; HBsAg+: HBsAg-positive; HBsAg-/anti-HBc+: HBsAg-negative anti-HBc antibodies-positive; HCV: hepatitis C virus; HCQ: hydroxychloroquine: IFX: infliximab; IL-6: interleukin-6; JAK: Janus kinase; LEF: leflunomide; LTBI: latent tuberculosis infection; mAb: monoclonal antibody; MTX: methotrexate; OR: odds ratio; PsA: psoriatic arthritis; PMS: post-marketing surveillance; RA: rheumatoid arthritis; TNF: tumor necrosis factor; TNFi: tumor necrosis factor inhibitor; SCK: secukinumab; SSZ: sulfasalazine; TOZ: tocilizumab; RCT: randomized controlled trial; RR: relative risk; RTX: rituximab; 3HP: 3-month once-weekly isoniazid plus rifapentine; TB: tuberculosis; tsDMARDs: targeted synthetic disease-modifying anti-rheumatic drugs; UTK: ustekinumab; WHO: World Health Organization.
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Affiliation(s)
- Ying-Ming Chiu
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Der-Yuan Chen
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan.,Translational Medicine Laboratory, Rheumatic Diseases Research Center, China Medical University Hospital, Taichung, Taiwan.,Program in Translational Medicine and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Institute of Biochemistry, Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
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5
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Chen SK, Liao KP, Liu J, Kim SC. Risk of Hospitalized Infection and Initiation of Abatacept Versus Tumor Necrosis Factor Inhibitors Among Patients With Rheumatoid Arthritis: A Propensity Score-Matched Cohort Study. Arthritis Care Res (Hoboken) 2019; 72:9-17. [PMID: 30570833 DOI: 10.1002/acr.23824] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/04/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi). METHODS Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection. RESULTS We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes. CONCLUSION In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.
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Affiliation(s)
- Sarah K Chen
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine P Liao
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jun Liu
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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6
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Galea R, Nel HJ, Talekar M, Liu X, Ooi JD, Huynh M, Hadjigol S, Robson KJ, Ting YT, Cole S, Cochlin K, Hitchcock S, Zeng B, Yekollu S, Boks M, Goh N, Roberts H, Rossjohn J, Reid HH, Boyd BJ, Malaviya R, Shealy DJ, Baker DG, Madakamutil L, Kitching AR, O’Sullivan BJ, Thomas R. PD-L1- and calcitriol-dependent liposomal antigen-specific regulation of systemic inflammatory autoimmune disease. JCI Insight 2019; 4:126025. [PMID: 31487265 PMCID: PMC6795297 DOI: 10.1172/jci.insight.126025] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 08/21/2019] [Indexed: 12/29/2022] Open
Abstract
Autoimmune diseases resulting from MHC class II-restricted autoantigen-specific T cell immunity include the systemic inflammatory autoimmune conditions rheumatoid arthritis and vasculitis. While currently treated with broad-acting immunosuppressive drugs, a preferable strategy is to regulate antigen-specific effector T cells (Teffs) to restore tolerance by exploiting DC antigen presentation. We targeted draining lymph node (dLN) phagocytic DCs using liposomes encapsulating 1α,25-dihydroxyvitamin D3 (calcitriol) and antigenic peptide to elucidate mechanisms of tolerance used by DCs and responding T cells under resting and immunized conditions. PD-L1 expression was upregulated in dLNs of immunized relative to naive mice. Subcutaneous administration of liposomes encapsulating OVA323-339 and calcitriol targeted dLN PD-L1hi DCs of immunized mice and reduced their MHC class II expression. OVA323-339/calcitriol liposomes suppressed expansion, differentiation, and function of Teffs and induced Foxp3+ and IL-10+ peripheral Tregs in an antigen-specific manner, which was dependent on PD-L1. Peptide/calcitriol liposomes modulated CD40 expression by human DCs and promoted Treg induction in vitro. Liposomes encapsulating calcitriol and disease-associated peptides suppressed the severity of rheumatoid arthritis and Goodpasture's vasculitis models with suppression of antigen-specific memory T cell differentiation and function. Accordingly, peptide/calcitriol liposomes leverage DC PD-L1 for antigen-specific T cell regulation and induce antigen-specific tolerance in inflammatory autoimmune diseases.
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Affiliation(s)
- Ryan Galea
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Hendrik J. Nel
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Meghna Talekar
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Xiao Liu
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Joshua D. Ooi
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
| | - Megan Huynh
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
| | - Sara Hadjigol
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
| | - Kate J. Robson
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
| | - Yi Tian Ting
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Suzanne Cole
- Discovery Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Karyn Cochlin
- Discovery Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Shannon Hitchcock
- Discovery Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Bijun Zeng
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Suman Yekollu
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Martine Boks
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Natalie Goh
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | | | - Jamie Rossjohn
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
- Australian Research Council Centre of Excellence in Advanced Molecular Imaging, Monash University, Clayton, Victoria, Australia
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Hugh H. Reid
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Ben J. Boyd
- Drug Delivery, Disposition and Dynamics and Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Ravi Malaviya
- Discovery Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - David J. Shealy
- Discovery Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Daniel G. Baker
- Discovery Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Loui Madakamutil
- Discovery Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - A. Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
- Departments of Nephrology and Paediatric Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Brendan J. O’Sullivan
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Ranjeny Thomas
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
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Ozen G, Pedro S, England BR, Mehta B, Wolfe F, Michaud K. Risk of Serious Infection in Patients With Rheumatoid Arthritis Treated With Biologic Versus Nonbiologic Disease-Modifying Antirheumatic Drugs. ACR Open Rheumatol 2019; 1:424-432. [PMID: 31777822 PMCID: PMC6858027 DOI: 10.1002/acr2.11064] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Objective The objective of this study is to examine the risk of serious infections (SIs) associated with biological disease‐modifying antirheumatic drugs (bDMARDs) compared with conventional synthetic disease‐modifying antirheumatic drugs (csDMARDs) in patients with rheumatoid arthritis (RA). Methods We studied patients with RA who initiated bDMARDs or csDMARDs from 2001 to 2016 in FORWARD–The National Databank for Rheumatic Diseases. Disease‐modifying antirheumatic drugs (DMARDs) were categorized into three groups: (1) csDMARDs (bDMARD‐naïve; reference), (2) tumor necrosis factor α inhibitors (TNFis), and (3) non‐TNFi biologics (abatacept, rituximab, tocilizumab, and anakinra). SIs were defined as those requiring intravenous antibiotics or hospitalization or those resulting in death. We calculated the propensity score (PS), which reflected the probability of receiving a specific DMARD group, and estimated the hazard ratio (HR) (with the 95% confidence interval [CI]) for SI from multivariable Cox models, adjusting for PS and time‐varying confounders. Results A total of 694 (5.9%) first SIs were identified in 11 623 patients with RA during 27 552 patient‐years of follow‐up. The SI incidence rate per 1000 patient‐years was 22.4 (95% CI 19.2‐26.1) for csDMARDs, 26.9 (95% CI 24.5‐29.6) for TNFis, and 23.3 (95% CI 19.0‐28.5) for non‐TNFi bDMARDs. Adjusted HRs for SIs were 1.33 (95% CI 1.05‐1.68) for TNFis and 1.48 (95% CI 1.02‐2.16) for non‐TNFi bDMARDs, compared with csDMARDs. The SI risk with non‐TNFi bDMARDs versus TNFis was not different. Other risk factors for SI were older age, higher comorbidity burden (particularly pulmonary disease), higher weighted cumulative prednisone dose, disability and disease activity, and number of prior csDMARD failures. Conclusion TNFis and non‐TNFi bDMARDs were associated with an increased SI risk compared with csDMARDs in RA, even after accounting for risk‐associated patient characteristics.
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Affiliation(s)
| | - Sofia Pedro
- FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
| | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System Omaha
| | - Bella Mehta
- Hospital for Special Surgery New York New York
| | - Frederick Wolfe
- FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
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Ozen G, Pedro S, Schumacher R, Simon TA, Michaud K. Safety of abatacept compared with other biologic and conventional synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: data from an observational study. Arthritis Res Ther 2019; 21:141. [PMID: 31174592 PMCID: PMC6555014 DOI: 10.1186/s13075-019-1921-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/17/2019] [Indexed: 02/06/2023] Open
Abstract
Background To assess the risks of malignancies, infections and autoimmune diseases in patients with rheumatoid arthritis (RA) treated with abatacept compared with other biologic (b) disease-modifying antirheumatic drugs (DMARDs) or conventional synthetic (cs)DMARDs, in a US-wide observational RA cohort Methods Data were reviewed from patients (≥ 18 years) with RA who were registered with FORWARD, the National Databank for Rheumatic Diseases, and who initiated abatacept, other bDMARDs or csDMARDs between 2005 and 2015. Patients who switched treatment during the study could be allocated to more than one group. The incidence rates (IRs) by treatment were calculated for malignancies, hospitalized infections and autoimmune diseases identified by six monthly questionnaires and medical records. The hazard ratios (HRs) (95% confidence intervals [CIs]) for all outcomes with abatacept compared with other bDMARDs or csDMARDs were determined using marginal structural models adjusted for clinical confounders. Results In the study sample, 1496 initiated abatacept, 3490 initiated another bDMARD and 1520 initiated a csDMARD. The risk of malignancies with abatacept was not statistically significant versus other bDMARDs (HR [95% CI)] 1.89 [0.93, 3.84]) or versus csDMARDs (HR [95% CI] 0.93 [0.20, 4.27]). Patients receiving abatacept versus other bDMARDs were at a lower risk of hospitalized infections (HR [95% CI] 0.37 [0.18, 0.75]); the risk versus csDMARDs was lower with wide CIs (HR [95% CI] 0.31 [0.09, 1.05]). The relative risks for psoriasis were similar between treatment groups (HR [95% CI] 1.46 [0.76, 2.81] and HR [95% CI] 2.05 [0.59, 7.16] for abatacept versus other bDMARDs and versus csDMARDS, respectively). The IR (95% CI) of severe infusion/injection reactions was lower with abatacept compared with other bDMARDs (1.57 [1.11, 2.17] vs 2.31 [1.87, 2.82] per 100 patient-years, respectively). Conclusions In this analysis, abatacept was well tolerated and did not result in an overall increased risk of malignancies, infections or autoimmune diseases compared with other bDMARDs or csDMARDs. Electronic supplementary material The online version of this article (10.1186/s13075-019-1921-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gulsen Ozen
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Sofia Pedro
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA
| | | | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA. .,FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA.
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Abatacept initiation in rheumatoid arthritis and the risk of serious infection: A population-based cohort study. Semin Arthritis Rheum 2019; 48:1053-1058. [DOI: 10.1016/j.semarthrit.2019.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 11/19/2022]
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Grøn KL, Arkema EV, Glintborg B, Mehnert F, Østergaard M, Dreyer L, Nørgaard M, Krogh NS, Askling J, Hetland ML. Risk of serious infections in patients with rheumatoid arthritis treated in routine care with abatacept, rituximab and tocilizumab in Denmark and Sweden. Ann Rheum Dis 2019; 78:320-327. [PMID: 30612115 DOI: 10.1136/annrheumdis-2018-214326] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/08/2018] [Accepted: 11/26/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To estimate (1) crude and age-and gender-adjusted incidence rates (IRs) of serious infections (SI) and (2) relative risks (RR) of SI in patients with rheumatoid arthritis (RA) initiating treatment with abatacept, rituximab or tocilizumab in routine care. METHODS This is an observational cohort study conducted in parallel in Denmark and Sweden including patients with RA in Denmark (DANBIO) and Sweden (Anti-Rheumatic Treatment in Sweden Register/Swedish Rheumatology Quality Register) who started abatacept/rituximab/tocilizumab in 2010-2015. Patients could contribute to more than one treatment course. Incident SI (hospitalisations listing infection) and potential confounders were identified through linkage to national registries. Age- and gender-adjusted IRs of SI per 100 person years and additionally adjusted RRs of SI during 0-12 and 0-24 months since start of treatment were assessed (Poisson regression). Country-specific RRs were pooled using inverse variance weighting. RESULTS We identified 8987 treatment courses (abatacept: 2725; rituximab: 3363; tocilizumab: 2899). At treatment start, rituximab-treated patients were older, had longer disease duration and more previous malignancies; tocilizumab-treated patients had higher C reactive protein. During 0-12 and 0-24 months of follow-up, 456 and 639 SI events were identified, respectively. The following were the age- and gender-adjusted 12-month IRs for abatacept/rituximab/tocilizumab: 7.1/8.1/6.1 for Denmark and 6.0/6.4/4.7 for Sweden. The 24-month IRs were 6.1/7.5/5.2 for Denmark and 5.6/5.8/4.3 for Sweden. Adjusted 12-month RRs for tocilizumab versus rituximab were 0.82 (0.50 to 1.36) for Denmark and 0.76 (0.57 to 1.02) for Sweden, pooled 0.78 (0.61 to 1.01); for abatacept versus rituximab 0.94 (0.55 to 1.60) for Denmark and 0.86 (0.66 to 1.13) for Sweden, pooled 0.88 (0.69 to 1.12); and for abatacept versus tocilizumab 1.15 (0.69 to 1.90) for Denmark and 1.14 (0.83 to 1.55) for Sweden, pooled 1.13 (0.91 to 1.42). The adjusted RRs for 0-24 months were similar. CONCLUSION For patients starting abatacept, rituximab or tocilizumab, differences in baseline characteristics were seen. Numerical differences in IR of SI between drugs were observed. RRs seemed to vary with drug (tocilizumab < abatacept < rituximab) but should be interpreted with caution due to few events and risk of residual confounding.
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Affiliation(s)
- Kathrine Lederballe Grøn
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark .,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Østergaard
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Dreyer
- Departments of Clinical Medicine and Rheumatology, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Predictors of hypogammaglobulinemia during rituximab maintenance therapy in rheumatoid arthritis: A 12-year longitudinal multi-center study. Semin Arthritis Rheum 2018; 48:149-154. [DOI: 10.1016/j.semarthrit.2018.02.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/19/2018] [Accepted: 02/16/2018] [Indexed: 12/24/2022]
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12
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Singh JA. Infections With Biologics in Rheumatoid Arthritis and Related Conditions: a Scoping Review of Serious or Hospitalized Infections in Observational Studies. Curr Rheumatol Rep 2017; 18:61. [PMID: 27613285 DOI: 10.1007/s11926-016-0609-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biologic use is a major advance in the treatment of several autoimmune conditions, including rheumatoid arthritis. In this review, we summarize key studies of serious/hospitalized infections in rheumatoid arthritis (RA). RA is a risk factor for infections. High RA disease activity is associated with higher risk of serious infection. The risk of serious infections with tumor necrosis factor inhibitor (TNFi) biologics is increased in the first 6 months of initiating therapy, and this risk was higher compared to the use of traditional disease-modifying anti-rheumatic drugs (DMARDs). Emerging data also suggest that biologics may differ from each other regarding the risk of serious or hospitalized infections. Past history of serious infections, glucocorticoid dose, and older age were other important predictors of risk of serious infections in patients treated with biologics.
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Affiliation(s)
- Jasvinder A Singh
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA. .,Division of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA. .,Medicine Service, Birmingham VA Medical Center, Birmingham, AL, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
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13
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Harrold LR, Reed GW, Karki C, Magner R, Shewade A, John A, Kremer JM, Greenberg JD. Risk of Infection Associated With Subsequent Biologic Agent Use After Rituximab: Results From a National Rheumatoid Arthritis Patient Registry. Arthritis Care Res (Hoboken) 2017; 68:1888-1893. [PMID: 27111064 PMCID: PMC5132134 DOI: 10.1002/acr.22912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 03/20/2016] [Accepted: 04/05/2016] [Indexed: 12/12/2022]
Abstract
Objective To assess whether the time between the last rituximab infusion and initiation of a different biologic agent influenced infection risk in patients with rheumatoid arthritis (RA). Methods Patients with RA who newly initiated rituximab within the Consortium of Rheumatology Researchers of North America registry were included if they switched to a nonrituximab biologic agent and had ≥1 followup visit within 12 months of switching. Patients were categorized by duration of time between their last rituximab infusion and initiation of a subsequent biologic agent (≤5 months, 6–11 months, and ≥12 months). The primary outcome was time to first infectious event. Adjusted Cox regression models estimated the association between time to starting a subsequent biologic agent and infection. Results A total of 44 overall infections (7 serious, 37 nonserious) were reported during the 12‐month followup in the 215 patients included in this analysis (104 switched at ≤5 months, 67 at 6–11 months, and 44 at ≥12 months). Median (interquartile range) time to infection was 4 (2–5) months. Infection rates per patient‐year in the ≤5‐month, 6–11‐month, and ≥12‐month groups were 0.34 (95% confidence interval [95% CI] 0.22–0.52), 0.30 (95% CI 0.17–0.52), and 0.41 (95% CI 0.22–0.77), respectively. After adjustment, time to switch to a subsequent biologic agent was not associated with infection, which remained unchanged when number and rate of rituximab retreatments were included in the models. Conclusion In this real‐world cohort of patients with RA, infection rates ranged from 0.30 to 0.41 per patient‐year, with no significant difference in the rate between patients who initiated a subsequent biologic agent earlier versus later after rituximab treatment.
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Affiliation(s)
- Leslie R Harrold
- University of Massachusetts Medical School, Worcester, and Corrona, Southborough, Massachusetts
| | - George W Reed
- University of Massachusetts Medical School, Worcester, and Corrona, Southborough, Massachusetts
| | | | - Robert Magner
- University of Massachusetts Medical School, Worcester
| | | | - Ani John
- Genentech, South San Francisco, California
| | - Joel M Kremer
- Albany Medical College and the Center for Rheumatology, Albany, New York
| | - Jeffrey D Greenberg
- Corrona, Southborough, Massachusetts, and New York University School of Medicine, New York
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14
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Mori S, Yoshitama T, Hidaka T, Sakai F, Hasegawa M, Hashiba Y, Suematsu E, Tatsukawa H, Mizokami A, Yoshizawa S, Hirakata N, Ueki Y. Comparative risk of hospitalized infection between biological agents in rheumatoid arthritis patients: A multicenter retrospective cohort study in Japan. PLoS One 2017; 12:e0179179. [PMID: 28594905 PMCID: PMC5464634 DOI: 10.1371/journal.pone.0179179] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/24/2017] [Indexed: 12/20/2022] Open
Abstract
Objective Knowing the risk of hospitalized infection associated with individual biological agents is an important factor in selecting the best treatment option for patients with rheumatoid arthritis (RA). This study examined the comparative risk of hospitalized infection between biological agents in a routine care setting. Methods We used data for all RA patients who had first begun biological therapy at rheumatology divisions of participating community hospitals in Japan between January 2009 and December 2014. New treatment episodes with etanercept, infliximab, adalimumab, abatacept, or tocilizumab were included. Patients were allowed to contribute multiple treatment episodes with different biological agents. Incidence rates (IRs) of hospitalized infection during the first year of follow-up were examined. Cox regression analysis was used to calculate hazard ratios (HRs) for overall hospitalized infection and for pulmonary hospitalized infection, adjusting for possible confounders. Results A total of 1596 new treatment episodes were identified. The incidence of overall hospitalized infection during the first year was 86 with 1239 person-years (PYs), yielding a crude IR of 6.9 per 100 PYs (95% confidence interval [CI], 5.6–8.6). After correction for confounders, no significant difference in risk of hospitalized infection was observed between treatment groups: adjusted HRs (95% CI) were 1.54 (0.78–3.04) for infliximab, 1.72 (0.88–3.34) for adalimumab, 1.11 (0.55–2.21) for abatacept, and 1.02 (0.55–1.87) for tocilizumab compared with etanercept. Patient-specific factors such as age, RA functional class, body mass index (BMI), prednisolone use, and chronic lung disease contributed more to the risk of hospitalized infection than specific biological agents. The incidence of pulmonary hospitalized infection was 50 and a crude IR of 4.0 per 100 PYs (95% CI, 3.1–5.3). After adjustment for confounders, adalimumab had a significantly higher HR for pulmonary hospitalized infection compared with tocilizumab: an adjusted HR (95% CI) was 4.43 (1.72–11.37) for adalimumab. BMI, prednisolone use, diabetes mellitus, and chronic lung disease were also significant factors associated with the risk of pulmonary hospitalized infection. Conclusions The magnitude of the risk of overall hospitalized infection was not determined by the type of biological agents, and patient-specific risk factors had more impact on the risk of hospitalized infection. For pulmonary hospitalized infections, the use of adalimumab was significantly associated with a greater risk of this complication than tocilizumab use.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization (NHO) Kumamoto Saishunsou National Hospital, Kohshi, Kumamoto, Japan
- * E-mail:
| | - Tamami Yoshitama
- Yoshitama Clinic for Rheumatic Diseases, Kirishima, Kagoshima, Japan
| | - Toshihiko Hidaka
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Mizue Hasegawa
- Department of Respiratory Medicine, Tokyo Women’s Medical University Yachiyo Medical Center, Yachiyo, Chiba
| | - Yayoi Hashiba
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - Eiichi Suematsu
- Department of Internal Medicine and Rheumatology, Clinical Research Institute, NHO Kyushu Medical Center, Fukuoka, Japan
| | | | - Akinari Mizokami
- Department of Rheumatology, Japan Community Healthcare Organization (JCHO) Isahaya General Hospital, Isahaya, Nagasaki, Japan
| | - Shigeru Yoshizawa
- Department of Rheumatology, NHO Fukuoka National Hospital, Fukuoka, Japan
| | - Naoyuki Hirakata
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
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15
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Cantini F, Niccoli L, Nannini C, Cassarà E, Kaloudi O, Giulio Favalli E, Becciolini A, Benucci M, Gobbi FL, Guiducci S, Foti R, Mosca M, Goletti D. Second-line biologic therapy optimization in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Semin Arthritis Rheum 2017; 47:183-192. [PMID: 28413099 DOI: 10.1016/j.semarthrit.2017.03.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/05/2017] [Accepted: 03/15/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The Italian board for the TAilored BIOlogic therapy (ITABIO) reviewed the most consistent literature to indicate the best strategy for the second-line biologic choice in patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA). METHODS Systematic review of the literature to identify English-language articles on efficacy of second-line biologic choice in RA, PsA, and ankylosing spondylitis (AS). Data were extracted from available randomized, controlled trials, national biologic registries, national healthcare databases, post-marketing surveys, and open-label observational studies. RESULTS Some previously stated variables, including the patients׳ preference, the indication for anti-tumor necrosis factor (TNF) monotherapy in potential childbearing women, and the intravenous route with dose titration in obese subjects resulted valid for all the three rheumatic conditions. In RA, golimumab as second-line biologic has the highest level of evidence in anti-TNF failure. The switching strategy is preferable for responder patients who experience an adverse event, whereas serious or class-specific side effects should be managed by the choice of a differently targeted drug. Secondary inadequate response to etanercept (ETN) should be treated with a biologic agent other than anti-TNF. After two or more anti-TNF failures, the swapping to a different mode of action is recommended. Among non-anti-TNF targeted biologics, to date rituximab (RTX) and tocilizumab (TCZ) have the strongest evidence of efficacy in the treatment of anti-TNF failures. In PsA and AS patients failing the first anti-TNF, the switch strategy to a second is advisable, taking in account the evidence of adalimumab efficacy in patients with uveitis. The severity of psoriasis, of articular involvement, and the predominance of enthesitis and/or dactylitis may drive the choice toward ustekinumab or secukinumab in PsA, and the latter in AS. CONCLUSION Taking in account the paucity of controlled trials, second-line biologic therapy may be reasonably optimized in patients with RA, SpA, and PsA.
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Affiliation(s)
- Fabrizio Cantini
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy.
| | - Laura Niccoli
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | - Carlotta Nannini
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | - Emanuele Cassarà
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | - Olga Kaloudi
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | | | | | | | | | - Serena Guiducci
- Department of Biomedicine, Section of Rheumatology, University of Florence, Florence, Italy
| | - Rosario Foti
- Rheumatology Unit, Vittorio-Emanuele University Hospital of Catania, Catania, Italy
| | - Marta Mosca
- UO di Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
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16
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Ramiro S, Sepriano A, Chatzidionysiou K, Nam JL, Smolen JS, van der Heijde D, Dougados M, van Vollenhoven R, Bijlsma JW, Burmester GR, Scholte-Voshaar M, Falzon L, Landewé RBM. Safety of synthetic and biological DMARDs: a systematic literature review informing the 2016 update of the EULAR recommendations for management of rheumatoid arthritis. Ann Rheum Dis 2017; 76:1101-1136. [DOI: 10.1136/annrheumdis-2016-210708] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/28/2016] [Accepted: 02/19/2017] [Indexed: 12/25/2022]
Abstract
ObjectivesTo assess the safety of synthetic (s) and biological (b) disease-modifying antirheumatic drugs (DMARDs) for the management of rheumatoid arthritis (RA) to inform the European League Against Rheumatism recommendations for the management of RA.MethodsSystematic literature review (SLR) of observational studies comparing any DMARD with another intervention for the management of patients with RA. All safety outcomes were included. A comparator group was required for the study to be included. Risk of bias was assessed with the Hayden's tool.ResultsTwenty-six observational studies addressing diverse safety outcomes of therapy with bDMARDs met eligibility criteria (15 on serious infections, 4 on malignancies). Substantial heterogeneity precluded meta-analysis. Together with the evidence from the 2013 SLR, based on 15 studies, 7 at low risk of bias, patients on bDMARDs compared with patients on conventional sDMARDs had a higher risk of serious infections (adjusted HR (aHR) 1.1 to 1.8)—without differences across bDMARDs—a higher risk of tuberculosis (aHR 2.7 to 12.5), but no increased risk of infection by herpes zoster. Patients on bDMARDs did not have an increased risk of malignancies in general, lymphoma or non-melanoma skin cancer, but the risk of melanoma may be slightly increased (aHR 1.5).ConclusionsThese findings confirm the known safety pattern of bDMARDs, including both tumour necrosis factor-α inhibitor (TNFi) and non-TNFi, for the treatment of RA.
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Krack G, Zeidler H, Zeidler J. Claims Data Analysis of Tumor Necrosis Factor Inhibitor Treatment Dosing Among Patients with Rheumatoid Arthritis: A Systematic Review of Methods. Drugs Real World Outcomes 2016; 3:265-278. [PMID: 27747836 PMCID: PMC5042945 DOI: 10.1007/s40801-016-0089-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background With tumor necrosis factor inhibitors, changes of dosing, switching between drugs, insufficient adherence, and persistence are frequent in rheumatoid arthritis. Because this is often associated with decreased efficiency and increased costs, dosage analyses based on claims data are of increasing interest for healthcare providers and payers. Nevertheless, no standardized methods exist to ensure high-quality research. Objective In this review, we compare and discuss applied methods in claims data-based dosage analyses of tumor necrosis factor inhibitor prescriptions in patients with rheumatoid arthritis. Methods A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The dosage analysis methods performed within the selected studies were classified into switching, persistence, adherence, and dosage-change analyses, and were then compared and finally discussed. Results A total of 45 studies were found to be relevant. In most studies, a change in dose or persistence was evaluated, followed by switching and adherence analyses. Analyses of changed dose exhibit the most extensive variation of methods. We divided them into three principal methods, where a specified reference dose is compared with (1) the last dose, (2) any dose, or (3) all doses. Conclusion The systematic review identified a high variation of methods. Our results may be helpful for choosing appropriate methods in future studies. The results also demonstrate the need for evidence-based recommendations of methods used in claims data research.
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Affiliation(s)
- Gundula Krack
- Munich Center of Health Sciences (MC-Health), Ludwig Maximilian University of Munich, Ludwigstraße 28, 80539, Munich, Germany. .,German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany.
| | - Henning Zeidler
- Division of Immunology and Rheumatology, Medical School Hannover, Hannover, Germany
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover, Germany
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Yun H, Xie F, Delzell E, Levitan EB, Chen L, Lewis JD, Saag KG, Beukelman T, Winthrop KL, Baddley JW, Curtis JR. Comparative Risk of Hospitalized Infection Associated With Biologic Agents in Rheumatoid Arthritis Patients Enrolled in Medicare. Arthritis Rheumatol 2016; 68:56-66. [PMID: 26315675 DOI: 10.1002/art.39399] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/18/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The risks of hospitalized infection associated with biologic agents used to treat rheumatoid arthritis (RA) are unclear. The aim of this study was to determine whether the associated risk of hospitalized infections differed between specific biologic agents used to treat RA. METHODS In a retrospective cohort study using Medicare data from 2006-2011 for all enrolled patients with RA, new episodes of treatment with etanercept, adalimumab, certolizumab, golimumab, infliximab, abatacept, rituximab, and tocilizumab were identified. Patients were required to have received another biologic agent previously and to have been continuously enrolled in Medicare medical and pharmacy plans during the baseline period and throughout followup. Followup started on the date of initiation of treatment with the new biologic agent (after previous treatment with a different biologic agent) and ended on the date of the earliest hospitalized infection, at 12 months, after an exposure gap of >30 days, or at the time of death or loss of Medicare coverage. Cox regression analysis was used to calculate the adjusted hazard ratio (HR) for hospitalized infection, adjusting for an infection risk score and other confounders. RESULTS Of 31,801 new biologic treatment episodes in patients who had previously received another biologic agent, 12.0% were with etanercept, 15.2% with adalimumab, 5.9% with certolizumab, 4.4% with golimumab, 12.4% with infliximab, 28.9% with abatacept, 14.8% with rituximab, and 6.3% with tocilizumab. During followup, we identified 2,530 hospitalized infections; incidence rates ranged from 13.1 per 100 person-years (abatacept) to 18.7 per 100 person-years (rituximab). After adjustment, etanercept (HR 1.24, 95% confidence interval [95% CI] 1.07-1.45), infliximab (HR 1.39, 95% CI 1.21-1.60), and rituximab (HR 1.36, 95% CI 1.21-1.53) had significantly higher HRs for hospitalized infection compared with abatacept. CONCLUSION In RA patients with prior exposure to a biologic agent, exposure to etanercept, infliximab, or rituximab was associated with a greater 1-year risk of hospitalized infection compared with the risk associated with exposure to abatacept.
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Papiris SA, Manali ED, Kolilekas L, Kagouridis K, Maniati M, Filippatos G, Bouros D. Acute Respiratory Events in Connective Tissue Disorders. Respiration 2016; 91:181-201. [PMID: 26938462 DOI: 10.1159/000444535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Subacute-acute, hyperacute, or even catastrophic and fulminant respiratory events occur in almost all classic connective tissue disorders (CTDs); they may share systemic life-threatening manifestations, may precipitously lead to respiratory failure requiring ventilatory support as well as a combination of specific therapeutic measures, and in most affected patients constitute the devastating end-of-life event. In CTDs, acute respiratory events may be related to any respiratory compartment including the airways, lung parenchyma, alveolar capillaries, lung vessels, pleura, and ventilatory muscles. Acute respiratory events may also precipitate disease-specific extrapulmonary organ involvement such as aspiration pneumonia and lead to digestive tract involvement and heart-related respiratory events. Finally, antirheumatic drug-related acute respiratory toxicity as well as lung infections related to the rheumatic disease and/or to immunosuppression complete the spectrum of acute respiratory events. Overall, in CTDs the lungs significantly contribute to morbidity and mortality, since they constitute a common site of disease involvement; a major site of infections related to the 'mater' disease; a major site of drug-related toxicity, and a common site of treatment-related infectious complications. The extreme spectrum of the abovementioned events, as well as the 'vicious' coexistence of most of the aforementioned manifestations, requires skills, specific diagnostic and therapeutic means, and most of all a multidisciplinary approach of adequately prepared and expert scientists. Avoiding lung disease might represent a major concern for future advancements in the treatment of autoimmune disorders.
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Affiliation(s)
- Spyros A Papiris
- 2nd Department of Pneumonology, x2018;Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Brocq O, Acquacalda E, Berthier F, Albert C, Bolla G, Millasseau E, Destombe C, Azulay J, Asquier C, Florent A, Le Seaux S, Euller-Ziegler L. Influenza and pneumococcal vaccine coverage in 584 patients taking biological therapy for chronic inflammatory joint: A retrospective study. Joint Bone Spine 2015; 83:155-9. [PMID: 26725745 DOI: 10.1016/j.jbspin.2015.11.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate influenza and pneumococcal vaccine coverage in patients taking biological therapy for chronic inflammatory joint disease and to identify factors associated with the decision to administer these two vaccines. METHODS Retrospective cross-sectional questionnaire study of a cohort of 584 patients taking biological therapy for chronic inflammatory joint disease (rheumatoid arthritis or spondyloarthritis). We studied the influenza and pneumococcal vaccine coverage rates, information about these vaccines given to patients by the primary-care physician and rheumatologist, and reasons for not administering the vaccines. RESULTS Overall vaccine coverage rates were 44% for influenza and 62% for pneumococcus. Factors associated with being vaccinated were patient age, previous influenza vaccination, and patient information. Concern about adverse effects and absence of patient information by the primary-care physician and rheumatologist were associated with very low coverage rates. CONCLUSION This study showed insufficient vaccine coverage rates, particularly against influenza, in a population at high risk because of exposure to biological therapy. Patient information by healthcare professionals about influenza and pneumococcal vaccination has a major impact and should be renewed as often as possible.
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Affiliation(s)
- Olivier Brocq
- Rhumatologie, centre hospitalier Princesse Grâce, boulevard Pasteur, 98000 Monaco, Monaco.
| | - Emilie Acquacalda
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
| | | | - Christine Albert
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
| | - Gilles Bolla
- Service de rhumatologie, centre hospitalier de Cannes, 06400 Cannes, France
| | - Elodie Millasseau
- Service de rhumatologie, centre hospitalier Fréjus-Saint-Raphaël, 83800 Saint-Raphaël, France
| | - Claire Destombe
- Service de rhumatologie, centre hospitalier Fréjus-Saint-Raphaël, 83800 Saint-Raphaël, France
| | - Johanna Azulay
- Service de rhumatologie, centre hospitalier de Cannes, 06400 Cannes, France
| | - Caroline Asquier
- Service de rhumatologie, centre hospitalier de Cannes, 06400 Cannes, France
| | - Amélie Florent
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
| | - Sylvie Le Seaux
- Service de rhumatologie, centre hospitalier Fréjus-Saint-Raphaël, 83800 Saint-Raphaël, France
| | - Liana Euller-Ziegler
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
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Singh JA, Saag KG, Bridges SL, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O'Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2015; 68:1-26. [PMID: 26545940 DOI: 10.1002/art.39480] [Citation(s) in RCA: 1307] [Impact Index Per Article: 145.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/14/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To develop a new evidence-based, pharmacologic treatment guideline for rheumatoid arthritis (RA). METHODS We conducted systematic reviews to synthesize the evidence for the benefits and harms of various treatment options. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence. We employed a group consensus process to grade the strength of recommendations (either strong or conditional). A strong recommendation indicates that clinicians are certain that the benefits of an intervention far outweigh the harms (or vice versa). A conditional recommendation denotes uncertainty over the balance of benefits and harms and/or more significant variability in patient values and preferences. RESULTS The guideline covers the use of traditional disease-modifying antirheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids in early (<6 months) and established (≥6 months) RA. In addition, it provides recommendations on using a treat-to-target approach, tapering and discontinuing medications, and the use of biologic agents and DMARDs in patients with hepatitis, congestive heart failure, malignancy, and serious infections. The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. CONCLUSION This RA guideline should serve as a tool for clinicians and patients (our two target audiences) for pharmacologic treatment decisions in commonly encountered clinical situations. These recommendations are not prescriptive, and the treatment decisions should be made by physicians and patients through a shared decision-making process taking into account patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | | | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon, and McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | | | | | - Deborah Parks
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | - Amye Leong
- Healthy Motivation, Santa Barbara, California
| | | | - John T Schousboe
- University of Minnesota and Park Nicollet Clinic, St. Louis Park
| | | | - Seth Ginsberg
- Global Healthy Living Foundation, New York, New York
| | - James Grober
- NorthShore University Health System, Evanston, Illinois
| | | | | | - Amy S Miller
- American College of Rheumatology, Atlanta, Georgia
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22
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Singh JA, Saag KG, Bridges SL, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O'Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St.Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2015; 68:1-25. [DOI: 10.1002/acr.22783] [Citation(s) in RCA: 794] [Impact Index Per Article: 88.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/14/2015] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Elie A. Akl
- American University of Beirut, Beirut, Lebanon, and McMaster University; Hamilton Ontario Canada
| | | | | | | | | | | | | | | | | | - Deborah Parks
- Washington University School of Medicine; St. Louis Missouri
| | | | | | | | - Amye Leong
- Healthy Motivation; Santa Barbara California
| | | | | | | | | | - James Grober
- NorthShore University Health System; Evanston Illinois
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Pereira R, Lago P, Faria R, Torres T. Safety of Anti-TNF Therapies in Immune-Mediated Inflammatory Diseases: Focus on Infections and Malignancy. Drug Dev Res 2015; 76:419-27. [DOI: 10.1002/ddr.21285] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/02/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Rui Pereira
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
| | - Paula Lago
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
- Department of Gastroenterology; Centro Hospitalar do Porto; Portugal
| | - Raquel Faria
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
- Clinical Immunology Unit; Centro Hospitalar do Porto; Portugal
| | - Tiago Torres
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
- Department of Dermatology; Centro Hospitalar do Porto; Portugal
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Abstract
PURPOSE OF REVIEW The management of inflammatory arthritis has been revolutionized by the use of biologic therapy. However, an important safety issue has been identified with regard to the risk of serious and opportunistic infections with biologic therapy. This review aims to summarize the most recent data available in the field. RECENT FINDINGS The risk of infection in inflammatory arthritis is partly determined by the nature of the underlying disease, comorbidities and other immunosuppressive treatments, in particular glucocorticoids. Data are conflicting with regard to the absolute risk of infection with biologic agents, as a result of differing study methodologies, classification of outcomes and patient populations. There appear to be some differences in risk of infection between biologic agents, which relate to their varying modes of action. SUMMARY Long-term observational data about the risk of infection and biologic therapy continue to emerge, although there are inherent limitations with this type of data. The process of determining the risk of infection for an individual patient should incorporate a range of factors, which may contribute to the infection risk.
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Risk of infection with biologic antirheumatic therapies in patients with rheumatoid arthritis. Best Pract Res Clin Rheumatol 2015; 29:290-305. [PMID: 26362745 DOI: 10.1016/j.berh.2015.05.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 05/08/2015] [Indexed: 12/11/2022]
Abstract
There are currently 10 licensed biologic therapies for the treatment of rheumatoid arthritis in 2014. In this article, we review the risk of serious infection (SI) for biologic therapies. This risk has been closely studied over the last 15 years within randomised controlled trials, long-term extension studies and observational drug registers, especially for the first three antitumour necrosis factor (TNF) drugs, namely infliximab, etanercept and adalimumab. The risk of SI with the newer biologics rituximab, tocilizumab, abatacept and tofacitinib is also reviewed, although further data from long-term observational studies are awaited. Beyond all-site SI, we review the risk of tuberculosis, other opportunistic infections and herpes zoster, and the effect of screening on TB rates. Lastly, we review emerging opportunities for stratifying the risk. Patients can be risk-stratified based on both modifiable and non-modifiable patient characteristics such as age, co-morbidity, glucocorticoid use, functional status and recent previous SI.
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Desai RJ, Solomon DH, Weinblatt ME, Shadick N, Kim SC. An external validation study reporting poor correlation between the claims-based index for rheumatoid arthritis severity and the disease activity score. Arthritis Res Ther 2015; 17:83. [PMID: 25880932 PMCID: PMC4394559 DOI: 10.1186/s13075-015-0599-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 03/16/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION We conducted an external validation study to examine the correlation of a previously published claims-based index for rheumatoid arthritis severity (CIRAS) with disease activity score in 28 joints calculated by using C-reactive protein (DAS28-CRP) and the multi-dimensional health assessment questionnaire (MD-HAQ) physical function score. METHODS Patients enrolled in the Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS) and Medicare were identified and their data from these two sources were linked. For each patient, DAS28-CRP measurement and MD-HAQ physical function scores were extracted from BRASS, and CIRAS was calculated from Medicare claims for the period of 365 days prior to the DAS28-CRP measurement. Pearson correlation coefficient between CIRAS and DAS28-CRP as well as MD-HAQ physical function scores were calculated. Furthermore, we considered several additional pharmacy and medical claims-derived variables as predictors for DAS28-CRP in a multivariable linear regression model in order to assess improvement in the performance of the original CIRAS algorithm. RESULTS In total, 315 patients with enrollment in both BRASS and Medicare were included in this study. The majority (81%) of the cohort was female, and the mean age was 70 years. The correlation between CIRAS and DAS28-CRP was low (Pearson correlation coefficient = 0.07, P = 0.24). The correlation between the calculated CIRAS and MD-HAQ physical function scores was also found to be low (Pearson correlation coefficient = 0.08, P = 0.17). The linear regression model containing additional claims-derived variables yielded model R(2) of 0.23, suggesting limited ability of this model to explain variation in DAS28-CRP. CONCLUSIONS In a cohort of Medicare-enrolled patients with established RA, CIRAS showed low correlation with DAS28-CRP as well as MD-HAQ physical function scores. Claims-based algorithms for disease activity should be rigorously tested in distinct populations in order to establish their generalizability before widespread adoption.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, 1620 Tremont Street, Boston, 02120, MA, USA.
| | - Daniel H Solomon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, 1620 Tremont Street, Boston, 02120, MA, USA. .,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, 02125, MA, USA.
| | - Michael E Weinblatt
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, 02125, MA, USA.
| | - Nancy Shadick
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, 02125, MA, USA.
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, 1620 Tremont Street, Boston, 02120, MA, USA. .,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, 02125, MA, USA.
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Curtis JR, Yang S, Patkar NM, Chen L, Singh JA, Cannon GW, Mikuls TR, Delzell E, Saag KG, Safford MM, DuVall S, Alexander K, Napalkov P, Winthrop KL, Burton MJ, Kamauu A, Baddley JW. Risk of hospitalized bacterial infections associated with biologic treatment among US veterans with rheumatoid arthritis. Arthritis Care Res (Hoboken) 2014; 66:990-7. [PMID: 24470378 DOI: 10.1002/acr.22281] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 01/07/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The comparative risk of infection associated with non-anti-tumor necrosis factor (anti-TNF) biologic agents is not well established. Our objective was to compare risk for hospitalized infections between anti-TNF and non-anti-TNF biologic agents in US veterans with rheumatoid arthritis (RA). METHODS Using 1998-2011 data from the US Veterans Health Administration, we studied RA patients initiating rituximab, abatacept, or anti-TNF therapy. Exposure was based upon days supplied (injections) or usual dosing intervals (infusions). Treatment episodes were defined as new biologic agent use. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for hospitalization for a bacterial infection were estimated from Cox proportional hazards models, adjusting for potential confounders. RESULTS Among 3,152 unique RA patients contributing 4,158 biologic treatment episodes to rituximab (n = 596), abatacept (n = 451), and anti-TNF agents (n = 3,111), the patient mean age was 60 years and 87% were male. The most common infections were pneumonia (37%), skin/soft tissue (22%), urinary tract (9%), and bacteremia/sepsis (7%). Hospitalized infection rates per 100 person-years were 4.4 (95% CI 3.1-6.4) for rituximab, 2.8 (95% CI 1.7-4.7) for abatacept, and 3.0 (95% CI 2.5-3.5) for anti-TNF. Compared to etanercept, the adjusted rate of hospitalized infection was not different for adalimumab (HR 1.4, 95% CI 0.9-2.2), abatacept (HR 1.1, 95% CI 0.6-2.1), or rituximab (HR 1.4, 0.8-2.6), although it was increased for infliximab (HR 2.3, 95% CI 1.3-4.0). Infection risk was greater for those taking prednisone >7.5 mg/day (HR 1.8, 95% CI 1.3-2.7) and in the highest quartile of C-reactive protein (HR 2.3, 95% CI 1.4-3.8) and erythrocyte sedimentation rate (HR 4.1, 95% CI 2.3-7.2) compared to the lowest quartile. CONCLUSION In older, predominantly male US veterans with RA, the risk of hospitalized bacterial infections associated with rituximab or abatacept was similar to etanercept.
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Alawneh KM, Ayesh MH, Khassawneh BY, Saadeh SS, Smadi M, Bashaireh K. Anti-TNF therapy in Jordan: a focus on severe infections and tuberculosis. Biologics 2014; 8:193-8. [PMID: 24790412 PMCID: PMC4003144 DOI: 10.2147/btt.s59574] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background A high rate of infection has been reported in patients receiving treatment with anti-tumor necrosis factor (anti-TNF). This study describes the rate of and risk factors for serious infections in patients receiving anti-TNF agents in Jordan. Methods This retrospective observational study was conducted at a large tertiary referral center in the north of Jordan. Between January 2006 and January 2012, 199 patients who received an anti-TNF agent (infliximab, adalimumab, or etanercept) were included. Patients received the anti-TNF treatment for rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, or other conditions. A serious infection was defined as any bacterial, viral, or fungal infection that required hospitalization, administration of appropriate intravenous antimicrobial therapy, and temporary withholding of anti-TNF treatment. Results The mean duration of anti-TNF treatment was 26.2 months. Steroids were used in 29.1% of patients, while 54.8% were given additional immunosuppressant therapy (methotrexate or azathioprine). Only one anti-TNF agent was given in 70.4% of patients, while 29.6% received different anti-TNF agents for the duration of treatment. Serious infections were documented in 39 patients (19.6%), including respiratory tract infections (41%), urinary tract infections (30.8%), and skin infections (20.5%), and extrapulmonary tuberculosis in three patients (7.7%). Exposure to more than one anti-TNF agent was the only factor associated with a significant increase in the rate of infection (relative risk 1.9, 95% confidence interval 1.06–4.0, P=0.03). Conclusion Serious infections, including tuberculosis, were a common problem in patients receiving anti-TNF agents, and exposure to more than one anti-TNF agent increased the risk of serious infection.
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Affiliation(s)
- Khaldoon M Alawneh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Mahmoud H Ayesh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Basheer Y Khassawneh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Salwa Shihadeh Saadeh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Mahmoud Smadi
- College of Science, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaldoun Bashaireh
- Department of Special Surgery, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
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Yun H, Xie F, Delzell E, Chen L, Levitan EB, Lewis JD, Saag KG, Beukelman T, Winthrop K, Baddley JW, Curtis JR. Risk of hospitalised infection in rheumatoid arthritis patients receiving biologics following a previous infection while on treatment with anti-TNF therapy. Ann Rheum Dis 2014; 74:1065-71. [PMID: 24608404 DOI: 10.1136/annrheumdis-2013-204011] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 02/05/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The risk of subsequent infections in rheumatoid arthritis (RA) patients who receive biologic therapy after a serious infection is unclear. OBJECTIVE To compare the subsequent risk of hospitalised infections associated with specific biologic agents among RA patients previously hospitalised for infection while receiving anti-tumour necrosis factor (anti-TNF) therapy. METHODS Using 2006-2010 Medicare data for 100% of beneficiaries with RA enrolled in Medicare, we identified patients hospitalised with an infection while on anti-TNF agents. Follow-up began 61 days after hospital discharge and ended at the earliest of: next infection, loss of Medicare coverage or 18 months after start of follow-up. We calculated the incidence rate of subsequent hospitalised infection for each biologic and used Cox regression to control for potential confounders. RESULTS 10 794 eligible hospitalised infections among 10183 unique RA patients who contributed at least 1 day of biologic exposure during follow-up. We identified 7807 person-years of exposure to selected biologics--333 abatacept, 133 rituximab and 7341 anti-TNFs (1797 etanercept, 1405 adalimumab, 4139 infliximab)--and 2666 associated infections. Mean age across biologic exposure cohorts was 64-69 years. The crude incidence rate of subsequent hospitalised infection ranged from 27.1 to 34.6 per 100 person-years. After multivariable adjustment, abatacept (HR: 0.80, 95% CI 0.64 to 0.99) and etanercept (HR: 0.83, 95% CI 0.72 to 0.96) users had significantly lower risks of subsequent infection compared to infliximab users. CONCLUSIONS Among RA patients who experienced a hospitalised infection while on anti-TNF therapy, abatacept and etanercept were associated with the lowest risk of subsequent infection compared to other biologic therapies.
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Affiliation(s)
- Huifeng Yun
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth Delzell
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lang Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James D Lewis
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Timothy Beukelman
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kevin Winthrop
- Divisions of Infectious Diseases, Public Health, and Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - John W Baddley
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Ernst D, Schmidt R, Witte T. Sekundäre Immundefizienz bei rheumatologischen Erkrankungen. Z Rheumatol 2013; 72:634-40, 642. [DOI: 10.1007/s00393-013-1160-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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