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Paroli M, Becciolini A, Lo Gullo A, Parisi S, Bravi E, Andracco R, Nucera V, Ometto F, Lumetti F, Farina A, Del Medico P, Colina M, Ravagnani V, Scolieri P, Larosa M, Priora M, Visalli E, Addimanda O, Vitetta R, Volpe A, Bezzi A, Girelli F, Molica Colella AB, Caccavale R, Di Donato E, Adorni G, Santilli D, Lucchini G, Arrigoni E, Platè I, Mansueto N, Ianniello A, Fusaro E, Ditto MC, Bruzzese V, Camellino D, Bianchi G, Serale F, Foti R, Amato G, De Lucia F, Dal Bosco Y, Foti R, Reta M, Fiorenza A, Rovera G, Marchetta A, Focherini MC, Mascella F, Bernardi S, Sandri G, Giuggioli D, Salvarani C, De Andres MI, Franchina V, Molica Colella F, Ferrero G, Raffeiner B, Ariani A. Influence of Safety Warnings on the Prescribing Attitude of JAK Inhibitors for Rheumatoid Arthritis in Italy. J Clin Med 2024; 13:3929. [PMID: 38999494 PMCID: PMC11242683 DOI: 10.3390/jcm13133929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: The Janus kinase inhibitors (JAKi) tofacitinib (TOFA), baricitinib (BARI), upadacitinib (UPA), and filgotinib (FILGO) are effective drugs for the treatment of rheumatoid arthritis. However, the US Food and Drug Administration (FDA) raised concerns about the safety of TOFA after its approval. This prompted the European Medicines Agency (EMA) to issue two safety warnings for limiting TOFA use, then extended a third warning to all JAKi in patients at high risk of developing serious adverse effects (SAE). These include thrombosis, major adverse cardiac events (MACE), and cancer. The purpose of this work was to analyze how the first two safety warnings from the EMA affected the prescribing of JAKi by rheumatologists in Italy. Methods: All patients with rheumatoid arthritis who had been prescribed JAKi for the first time in a 36-month period from 1 July 2019, to 30 June 2022 were considered. Data were obtained from the medical records of 29 Italian tertiary referral rheumatology centers. Patients were divided into three groups of 4 months each, depending on whether the JAKi prescription had occurred before the EMA's first safety alert (1 July-31 October 2019, Group 1), between the first and second alerts (1 November 2019-29 February 2020, Group 2), or between the second and third alerts (1 March 2021-30 June 2021, Group 3). The percentages and absolute changes in the patients prescribed the individual JAKi were analyzed. Differences among the three groups of patients regarding demographic and clinical characteristics were also assessed. Results: A total of 864 patients were prescribed a JAKi during the entire period considered. Of these, 343 were identified in Group 1, 233 in Group 2, and 288 in Group 3. An absolute reduction of 32% was observed in the number of patients prescribed a JAKi between Group 1 and Group 2 and 16% between Group 1 and Group 3. In contrast, there was a 19% increase in the prescription of a JAKi in patients between Group 2 and Group 3. In the first group, BARI was the most prescribed drug (227 prescriptions, 66.2% of the total), followed by TOFA (115, 33.5%) and UPA (1, 0.3%). In the second group, the most prescribed JAKi was BARI (147, 63.1%), followed by TOFA (65, 27.9%) and UPA (33, 11.5%). In the third group, BARI was still the most prescribed JAKi (104 prescriptions, 36.1%), followed by UPA (89, 30.9%), FILGO (89, 21.5%), and TOFA (33, 11.5%). The number of patients prescribed TOFA decreased significantly between Group 1 and Group 2 and between Group 2 and Group 3 (p ˂ 0.01). The number of patients who were prescribed BARI decreased significantly between Group 1 and Group 2 and between Group 2 and Group 3 (p ˂ 0.01). In contrast, the number of patients prescribed UPA increased between Group 2 and Group 3 (p ˂ 0.01). Conclusions: These data suggest that the warnings issued for TOFA were followed by a reduction in total JAKi prescriptions. However, the more selective JAKi (UPA and FILGO) were perceived by prescribers as favorable in terms of the risk/benefit ratio, and their use gradually increased at the expense of the other molecules.
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Affiliation(s)
- Marino Paroli
- Department of Clinical, Internist, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Andrea Becciolini
- Internal Medicine and Rheumatology Unit, University Hospital of Parma, 43126 Parma, Italy
| | | | - Simone Parisi
- Rheumatology Department, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Elena Bravi
- Rheumatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Romina Andracco
- Rheumatology Unit, ASL1 Liguria, 18038 Bussana di Sanremo, Italy
| | | | | | - Federica Lumetti
- Rheumatology Unit, Azienda USL of Modena and AOU Policlinico of Modena, 41100 Modena, Italy
| | - Antonella Farina
- Internal Medicine Unit, Augusto Murri Hospital, 63900 Fermo, Italy
| | - Patrizia Del Medico
- Internal Medicine Unit, Civitanova Marche Hospital, 62012 Civitanova Marche, Italy
| | - Matteo Colina
- Rheumatology Unit, Internal Medicine Division, Department of Medicine and Oncology, Santa Maria della Scaletta Hospital, 40026 Imola, Italy
- Rheumatology Unit, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Viviana Ravagnani
- Rheumatology Unit, Santa Chiara Hospital APSS-Trento, 38122 Trento, Italy
| | - Palma Scolieri
- Rheumatology Unit, Nuovo Regina Margherita Hospital, 00154 Rome, Italy
| | - Maddalena Larosa
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, 16132 Genoa, Italy
| | | | - Elisa Visalli
- Rheumatology Unit, Policlinico San Marco Hospital, 95121 Catania, Italy
| | - Olga Addimanda
- Rheumatology Unit, AUSL of Bologna-Policlinico Sant'Orsola-AOU-IRCCS of Bologna, 40138 Bologna, Italy
| | - Rosetta Vitetta
- Rheumatology Unit, ASL VC Sant'Andrea Hospital, 13100 Vercelli, Italy
| | - Alessandro Volpe
- Rheumatology Unit, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
| | - Alessandra Bezzi
- Internal Medicine and Rheumatology Unit, AUSL della Romagna-Rimini, 47924 Rimini, Italy
| | - Francesco Girelli
- Rheumatology Unit, G.B. Morgagni-L. Pierantoni Hospital, 47121 Forlì, Italy
| | | | - Rosalba Caccavale
- Department of Clinical, Internist, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Eleonora Di Donato
- Internal Medicine and Rheumatology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Giuditta Adorni
- Internal Medicine and Rheumatology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Daniele Santilli
- Internal Medicine and Rheumatology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Gianluca Lucchini
- Internal Medicine and Rheumatology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Eugenio Arrigoni
- Rheumatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Ilaria Platè
- Rheumatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Natalia Mansueto
- Rheumatology Unit, ASL1 Liguria, 18038 Bussana di Sanremo, Italy
| | | | - Enrico Fusaro
- Rheumatology Department, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Maria Chiara Ditto
- Rheumatology Department, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Vincenzo Bruzzese
- Rheumatology Unit, Nuovo Regina Margherita Hospital, 00154 Rome, Italy
| | - Dario Camellino
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, 16132 Genoa, Italy
| | - Gerolamo Bianchi
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, 16132 Genoa, Italy
| | | | - Rosario Foti
- Rheumatology Unit, Policlinico San Marco Hospital, 95121 Catania, Italy
| | - Giorgio Amato
- Rheumatology Unit, Policlinico San Marco Hospital, 95121 Catania, Italy
| | | | - Ylenia Dal Bosco
- Rheumatology Unit, Policlinico San Marco Hospital, 95121 Catania, Italy
| | - Roberta Foti
- Rheumatology Unit, Policlinico San Marco Hospital, 95121 Catania, Italy
| | - Massimo Reta
- Rheumatology Unit, AUSL of Bologna-Policlinico Sant'Orsola-AOU-IRCCS of Bologna, 40138 Bologna, Italy
| | - Alessia Fiorenza
- Rheumatology Unit, ASL VC Sant'Andrea Hospital, 13100 Vercelli, Italy
| | - Guido Rovera
- Rheumatology Unit, ASL VC Sant'Andrea Hospital, 13100 Vercelli, Italy
| | - Antonio Marchetta
- Rheumatology Unit, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
| | | | - Fabio Mascella
- Internal Medicine and Rheumatology Unit, AUSL della Romagna-Rimini, 47924 Rimini, Italy
| | - Simone Bernardi
- Rheumatology Unit, G.B. Morgagni-L. Pierantoni Hospital, 47121 Forlì, Italy
| | - Gilda Sandri
- Rheumatology Unit, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Dilia Giuggioli
- Rheumatology Unit, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Carlo Salvarani
- Rheumatology Unit, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | | | - Veronica Franchina
- Medical Oncology Unit, Azienda Ospedaliera Papardo, 98158 Messina, Italy
| | | | - Giulio Ferrero
- Unit of Diagnostic and Interventional Radiology, Santa Corona Hospital, 17027 Pietra Ligure, Italy
| | - Bernd Raffeiner
- Department of Rheumatology, Bolzano Central Hospital, 39100 Bolzano, Italy
| | - Alarico Ariani
- Internal Medicine and Rheumatology Unit, University Hospital of Parma, 43126 Parma, Italy
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Sandal Uzun G, Taghiyeva A, Çakır İY, Moral K, Yardımcı GK, Bölek EÇ, Farisoğulları B, Duran E, Ayan G, Özsoy Z, Ekici M, Unaldı E, Germe ŞA, Fırlatan B, Kart-Bayram GS, Bilgin E, Kılıç L, Karadağ Ö, Akdoğan A, Bilgen ŞA, Kiraz S, Ertenli AI, Kalyoncu U. Factors that predict development of chronic kidney disease in patients with rheumatoid arthritis receiving biologic DMARDs and mortality rates. Int J Rheum Dis 2024; 27:e14967. [PMID: 38057290 DOI: 10.1111/1756-185x.14967] [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: 07/22/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVES We aimed to determine the choice of biologic/targeted synthetic disease-modifying anti-rheumatic drugs (b/ts-DMARDs), factors associated with the development of chronic kidney disease (CKD), and mortality in RA patients with CKD receiving b/ts-DMARDs. METHODS Two thousand one hundred forty-one RA (79.4% female) patients were included in the analysis from the HUR-BIO prospective registry. Patients were divided into the CKD group and the non-CKD group. Age and gender-matched patients were selected from the non-CKD group, and then three main groups were determined. CKD was staged according to the glomerular filtration rate criteria. The clinical characteristics of the patients, disease activities, treatment choices, drug retention rate, and mortality rates were compared between the groups. RESULTS CKD was detected in 90/2141 (4.2%) RA patients on b/ts-DMARDs. Forty patients (2.3%) developed CKD during follow-up after the initiation of b/ts-DMARDs. In the CKD group, anti-TNF agents were chosen as the first-line b/ts-DMARDs therapy in 64.4% of patients, with etanercept leading in 31 (34.4%) patients. In multivariate analysis, age at the start of treatment, DAS-28-ESR at last visit, amyloidosis, hypertension, and history of smoking were the factors associated with the development of CKD in RA patients receiving b/ts-DMARDs. The mortality rate in RA-CKD patients until the onset of the pandemic was 15.41 per 1000 patient years, whereas it was 85.9 per 1000 patient years after the pandemic. CONCLUSION Comorbidities and control of disease activity are critical in the development of CKD in RA patients receiving b/ts-DMARDs. While there was no significant difference in mortality rate between CKD and non-CKD patients, the overall mortality rate increased after the COVID-19 pandemic duration in both groups.
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Affiliation(s)
- Güllü Sandal Uzun
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Arzu Taghiyeva
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - İbrahim Y Çakır
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kenan Moral
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gözde Kübra Yardımcı
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ertuğrul Ç Bölek
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Bayram Farisoğulları
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Emine Duran
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gizem Ayan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Zehra Özsoy
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mustafa Ekici
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Erdinç Unaldı
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Şerife A Germe
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Büşra Fırlatan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gözde S Kart-Bayram
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Emre Bilgin
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Levent Kılıç
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ömer Karadağ
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Akdoğan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Şule A Bilgen
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sedat Kiraz
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Ihsan Ertenli
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Kilić P, Ikić L, Mayer M, Artuković M, Maštrović Radončić K, Ikić Matijašević M. Safe and Efficient Use of Tocilizumab in Rheumatoid Arthritis Patient on Maintenance Hemodialysis: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1517. [PMID: 37763636 PMCID: PMC10533146 DOI: 10.3390/medicina59091517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023]
Abstract
Background: Rheumatoid arthritis (RA) is a chronic systemic autoimmune and inflammatory disease. Conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs), Janus kinase inhibitors, and rituximab are used to treat the disease. There are no recommendations or guidelines for the treatment of patients with both inflammatory arthritis and end-stage renal disease (ESRD), despite the safety and efficacy of the mentioned drugs. The anti-interleukin-6 receptor antibody tocilizumab (TCZ) has not been used as a long-term therapy for hemodialysis (HD) patients with RA, except in a few case reports. Case Description: We present the case of a 41-year-old patient with RA and ESRD on maintenance HD due to type 1 diabetes-related complications. Due to high RA disease activity, the patient was not a suitable candidate for a kidney transplant. Because TCZ is used to treat both RA and kidney transplant rejection, therapy with a full dose of TCZ was administered. The patient has achieved sustained clinical remission (for the past four years) with no adverse events reported. Conclusions: Herein, we present the safe and effective use of TCZ in an RA patient on HD who is also a candidate for kidney transplant. Consequently, TCZ could be the treatment of choice for RA patients with ESRD who have not achieved disease control (low activity or remission) with conventional synthetic DMARDs. Clinical studies are required to evaluate the efficacy and safety of biologic DMARDs and Janus kinase inhibitors in patients with both inflammatory arthritis and ESRD.
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Affiliation(s)
- Paula Kilić
- Department of Clinical Immunology, Rheumatology, and Pulmonology, University Hospital Sveti Duh, 10000 Zagreb, Croatia;
| | - Lucija Ikić
- Department of Anatomy and Physiology, University of Applied Health Sciences, 10000 Zagreb, Croatia;
| | - Miroslav Mayer
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
- Division of Clinical Immunology and Rheumatology, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Marinko Artuković
- Department of Clinical Immunology, Rheumatology, and Pulmonology, University Hospital Sveti Duh, 10000 Zagreb, Croatia;
| | - Ksenija Maštrović Radončić
- Department of Physical Medicine and Rehabilitation, University Hospital Sveti Duh, 10000 Zagreb, Croatia;
| | - Marina Ikić Matijašević
- Department of Clinical Immunology, Rheumatology, and Pulmonology, University Hospital Sveti Duh, 10000 Zagreb, Croatia;
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
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[Nephrological management and drug dosing in patients with rheumatic diseases and renal insufficiency]. Z Rheumatol 2022; 81:811-828. [PMID: 36350405 DOI: 10.1007/s00393-022-01283-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND In patients with inflammatory rheumatic diseases and renal insufficiency there are two challenges for physicians: to adapt the antirheumatic medication to the renal function and to carry out a nephroprotective treatment that prevents long-term deterioration of renal function and reduces the elevated cardiovascular risk. METHODS A literature search (in PubMed) was carried out and the current state of knowledge on nephroprotective treatment strategies and the treatment of rheumatic diseases in the presence of renal insufficiency was collated, evaluated and summarized. RESULTS Lifestyle interventions, especially the cessation of smoking and drug treatment strategies form the basis of nephroprotection including the control of diabetes mellitus with metformin, sodium glucose transporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP1) analogues and control of hypertension with blockade of the renin-angiotensin-aldosterone system (RAAS), hyperlipidemia, hyperphosphatemia and metabolic acidosis. The SGLT2 inhibitors are also effective for nondiabetic nephropathy. The elevated cardiovascular risk is further reduced by effective control of inflammatory rheumatic activity. Numerous conventional disease modifying antirheumatic drugs, especially methotrexate and the Janus kinase (JAK) inhibitors baricitinib and filgotinib, must mostly be adapted to the renal function. In contrast, biologics can be given in standard doses with the exception of anakinra. The increased cardiovascular risk currently limits the use of tofacitinib in patients with renal insufficiency. CONCLUSION The antirheumatic medication should be modified and a complex nephroprotective treatment concept is mandatory in the management of patients with rheumatic disease and renal insufficiency, that in the best-case scenario can be guaranteed by a close interdisciplinary cooperation of rheumatologists and nephrologists.
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Higuchi T, Tanaka E, Inoue E, Abe M, Saka K, Sugano E, Sugitani N, Higuchi Y, Ochiai M, Yamaguchi R, Sugimoto N, Ikari K, Yamanaka H, Harigai M. Impact of Concomitant Chronic Kidney Disease on Hospitalized Infections and Remission in Patients with Rheumatoid Arthritis: Results from the IORRA Cohort. Mod Rheumatol 2021; 32:875-884. [PMID: 34751783 DOI: 10.1093/mr/roab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate the impact of concomitant chronic kidney disease (CKD) on unfavourable clinical events and remission in Japanese patients with rheumatoid arthritis (RA). METHODS We included 5,103 patients with RA with CKD from the Institute of Rheumatology Rheumatoid Arthritis (IORRA) cohort in 2012. CKD stages were classified into four groups: CKD with normal eGFR ≥60 ml/min/1.73 m2 and proteinuria; mild CKD, eGFR ≥45-<60; moderate CKD, eGFR ≥30-<45; and severe CKD, eGFR <30. We assessed the association between concomitant CKD and the occurrence of unfavourable clinical events or achieving remission during a 5-year observational period. RESULTS Of the 5,103 patients with RA, 686 (86.6%) had CKD. Concomitant CKD was associated with hospitalized infections (adjusted hazard ratio [aHR] 1.52, 95% confidence interval [CI] 1.07-2.13, p=0.02), especially in the moderate to severe CKD group (aHR 1.93, 95% CI 1.12-3.13, p=0.02). Of all subjects, 2,407 (47.2%) had active RA at baseline and 401 (16.7%) had CKD. Concomitant CKD was also associated with failure of achieving remission (aHR 0.82, 95% CI 0.68-0.99, p=0.04). CONCLUSION Concomitant CKD was a risk factor for hospitalized infections in Japanese patients with RA and failure of achieving remission in patients with active RA.
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Affiliation(s)
- Tomoaki Higuchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eiichi Tanaka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eisuke Inoue
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Showa University Research Administration Center, Showa University, Tokyo, Japan
| | - Mai Abe
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kumiko Saka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eri Sugano
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naohiro Sugitani
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoko Higuchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Moeko Ochiai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Rei Yamaguchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naoki Sugimoto
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Katsunori Ikari
- Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Department of Orthopedic Surgery, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Hisashi Yamanaka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Sanno Medical Center, Tokyo, Japan.,Department of Rheumatology, International University of Health and Welfare, Tokyo, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Pu T, Ni Y, Li PH, Yu D, Yu Q, Yu LM. Pancytopenia After Low-Dose Methotrexate Therapy in Two Hemodialysis Patients with Rheumatoid Arthritis. Am J Med Sci 2021; 363:185-190. [PMID: 34562416 DOI: 10.1016/j.amjms.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/24/2021] [Accepted: 08/09/2021] [Indexed: 11/01/2022]
Abstract
Methotrexate (MTX) is an effective medication in the treatment of rheumatoid arthritis (RA), other rheumatic diseases and various solid tumors. However, its side effects, including gastrointestinal discomfort, oral ulcers, and especially bone marrow suppression, could be fatal and require special attention, particularly in patients with renal failure. We present two hemodialysis patients with RA who presented with a complication of severe pancytopenia after treatment with MTX. After receiving various supportive and blood purification treatments, both patients recovered. We reviewed twenty-four pancytopenia patients on dialysis associated with methotrexate. Among these patients, high morbidity and mortality were observed, indicating that MTX should be used cautiously in the absence of alternatives in such a population. Compared with the patients who recovered, the deceased patients showed a lower level of leukocytes. Which dialysis method might be the best choice is unclear. The mode of renal replacement therapy can be chosen according to the actual situation.
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Affiliation(s)
- Tao Pu
- Department of Nephrology and Rheumatology, The Affiliated Hospital of Zunyi Medical University, Guizhou, PR China.
| | - Yu Ni
- Department of Nephrology and Rheumatology, The Affiliated Hospital of Zunyi Medical University, Guizhou, PR China.
| | - Pan-Hong Li
- Key Laboratory of Cell Engineering in Guizhou Province, The Affiliated Hospital of Zunyi Medical University, Guizhou, PR China.
| | - Dan Yu
- Key Laboratory of Cell Engineering in Guizhou Province, The Affiliated Hospital of Zunyi Medical University, Guizhou, PR China.
| | - Qiong Yu
- Key Laboratory of Cell Engineering in Guizhou Province, The Affiliated Hospital of Zunyi Medical University, Guizhou, PR China.
| | - Li-Mei Yu
- Key Laboratory of Cell Engineering in Guizhou Province, The Affiliated Hospital of Zunyi Medical University; The Team of Scientific and Technological Innovation Talents on The Basic and Clinical Research of Amniotic Membrane and Bone Marrow Stem Cells in Guizhou Province, Zunyi, Guizhou Province, PR China.
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7
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Fractures in patients with rheumatoid arthritis and end-stage renal disease. Arch Osteoporos 2020; 15:146. [PMID: 32948922 DOI: 10.1007/s11657-020-00815-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/01/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Having rheumatoid arthritis (RA) or end-stage renal disease (ESRD) can lead to fractures. RA independently increases the risk of hip or other femur fracture in dialysis patients. Use of corticosteroids is a potentially modifiable risk factor for fractures among persons with RA and ESRD on dialysis. PURPOSE Rheumatoid arthritis (RA) and end-stage renal disease (ESRD) both independently increase fracture risk; however, how RA and ESRD interplay to affect fracture risk is unknown. We aim to determine the association of RA with fracture in ESRD and identify risk factors for fracture in patients with RA and ESRD. METHODS A retrospective cohort study was conducted using the United States Renal Data System (USRDS) to identify ESRD adults with and without a history of RA who initiated dialysis in 2005-2008. International Classification of Diseases, 9th Revision (ICD-9) codes were used to identify fractures following start of dialysis. Risk for incident fracture was compared between those with and without RA. Potential risk factors for fracture among persons with RA and ESRD were analyzed. RESULTS There were 754 persons with ESRD and RA, of whom 126 (17%) had any incident fracture. In multivariable adjusted final models, among ESRD patients, RA was an independent risk factor for hip/femur fracture (RR 1.28, 95% CI 1.01-1.64). Among persons with RA and ESRD, in final models, only corticosteroid use was a significant risk factor for both any incident (RR 2.00, 95% CI 1.40-2.87) and hip/femur (RR 1.97, 95% CI 1.24-3.11) fracture. Those with higher body mass index had a lower relative risk of hip/femur fracture (RR 0.95, 95% CI 0.91-0.99). CONCLUSION Among ESRD patients, those with RA have a 28% increased risk for hip or other femur fracture. Use of corticosteroids is a potentially modifiable risk factor for fractures among persons with RA and ESRD.
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Paudyal S, Waller JL, Oliver A, Le B, Zleik N, Nahman NS, Carbone L. Rheumatoid Arthritis and Mortality in End Stage Renal Disease. J Clin Rheumatol 2020; 26:48-53. [PMID: 32073514 DOI: 10.1097/rhu.0000000000000916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether rheumatoid arthritis (RA) is a risk factor for cardiovascular disease (CVD) events, all-cause mortality and cardiovascular mortality in End Stage Renal Disease (ESRD). METHODS Cohort study of adult patients with ESRD in the United States Renal Data System (USRDS) with RA and a 5% random sample of those without RA. CVD events, all-cause mortality and cardiovascular mortality were determined in those with RA compared to those without RA using Cox Proportional Hazards modeling. RESULTS 2,824 subjects, 407 with RA and 2,417 without RA, were included in the analyses. The duration of the study was up to 5 years, depending on mortality and initiation of dialysis. There were no significant differences in CVD events by RA status (n = 311 [76.4% RA] vs. n = 1936 [80.1% without RA], p = 0.09). Subjects with RA had a significantly shorter mean time in months from start of dialysis to an incident CVD event (20.1 ± 12.2 vs. 21.2 ± 14.1, p < 0.01) than those without RA. In multivariable adjusted models, RA was not associated with an increased risk for all-cause mortality (aHR = 1.09, 95%CI 0.94-1.27) or cardiovascular mortality (aHR = 0.95, 95% CI 0.74-1.22) within 5 years. Risk factors for all-cause mortality and cardiovascular mortality in RA included older age and a higher Charlson comorbidity index (CCI). CONCLUSIONS Clinicians should be aware that persons with RA who develop ESRD incur cardiac events sooner than the general population. However, RA is not an independent risk factor for all-cause or cardiovascular mortality in ESRD.
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Affiliation(s)
- Sunita Paudyal
- From the Division of Rheumatology, University of South Carolina School of Medicine, Columbia, SC
| | - Jennifer L Waller
- Department of Population Health Sciences, Division of Biostatistics and Data Science, Medical College of Georgia at Augusta University, Augusta, GA
| | - Alyce Oliver
- Department of Medicine, Division of Rheumatology and Adult Allergy, Medical College of Georgia at Augusta University, Augusta, GA
| | - Brian Le
- Department of Medicine, Division of Rheumatology and Adult Allergy, Medical College of Georgia at Augusta University, Augusta, GA
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA
| | - Nour Zleik
- Department of Medicine, Division of Rheumatology and Adult Allergy, Medical College of Georgia at Augusta University, Augusta, GA
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA
| | - N Stanley Nahman
- Department of Medicine, Division of Nephrology, Medical College of Georgia at Augusta University, Augusta, GA
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA
| | - Laura Carbone
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta GA
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Honda S, Katsumata Y, Karasawa K, Yamanaka H, Harigai M. Management of End-stage Renal Disease Associated with Systemic Rheumatic Diseases. JMA J 2020; 3:20-28. [PMID: 33324772 PMCID: PMC7733740 DOI: 10.31662/jmaj.2019-0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/22/2019] [Indexed: 11/15/2022] Open
Abstract
The outcomes of rheumatic diseases (RDs) have improved over the past decades. However, a significant proportion of the patients still suffer from end-stage renal disease (ESRD) and have to bear the burden of hemodialysis. It is crucial to prevent patients with RDs from developing ESRD from viewpoints of medicine and medical economics. For those who already have ESRD, it is important to improve vial prognosis and quality of life through appropriate management of disease activity and comorbidities related to ESRD. Thus, rheumatologists and nephrologists need to recognize risk factors associated with progression to ESRD along with their appropriate management. Although the activity of most RDs tends to decrease after initiation of hemodialysis, disease activity may still increase, and recognizing how to appropriately use immunosuppressive agents even after the development of ESRD is crucial. The treatment of RDs needs extra attention as hydroxychloroquine requires more frequent monitoring for adverse drug reactions; therapeutic drug monitoring is necessary for mycophenolate mofetil, cyclosporine A, and tacrolimus; cyclophosphamide and azathioprine need dose adjustments; methotrexate and bucillamine are contraindicated in patients with ESRD; leflunomide and sulfasalazine do not require significant dose reduction and iguratimod should be carefully administered. The pharmacokinetics of biological agents such as rituximab or belimumab are not affected by ESRD, and dose adjustments are not necessary. Collaboration between rheumatologists and nephrologists is needed more than ever and is expected to produce a complementary effect and achieve better outcomes in clinical settings, although this cooperation has not always been conducted appropriately.
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Affiliation(s)
- Suguru Honda
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasuhiro Katsumata
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunori Karasawa
- Department of Nephrology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisashi Yamanaka
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
- Division of Epidemiology and Pharmacoepidemiology, Department of Rheumatology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
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Chan MM, Yang X, Wang H, Saaoud F, Sun Y, Fong D. The Microbial Metabolite Trimethylamine N-Oxide Links Vascular Dysfunctions and the Autoimmune Disease Rheumatoid Arthritis. Nutrients 2019; 11:E1821. [PMID: 31394758 PMCID: PMC6723051 DOI: 10.3390/nu11081821] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/21/2019] [Accepted: 08/05/2019] [Indexed: 12/13/2022] Open
Abstract
Diet and microbiota each have a direct impact on many chronic, inflammatory, and metabolic diseases. As the field develops, a new perspective is emerging. The effects of diet may depend on the microbiota composition of the intestine. A diet that is rich in choline, red meat, dairy, or egg may promote the growth, or change the composition, of microbial species. The microbiota, in turn, may produce metabolites that increase the risk of cardiovascular disease. This article reviews our current understanding of the effects of the molecule trimethylamine-N-oxide (TMAO) obtained from food or produced by the microbiota. We review the mechanisms of actions of TMAO, and studies that associate it with cardiovascular and chronic kidney diseases. We introduce a novel concept: TMAO is one among a group of selective uremic toxins that may rise to high levels in the circulation or accumulate in various organs. Based on this information, we evaluate how TMAO may harm, by exacerbating inflammation, or may protect, by attenuating amyloid formation, in autoimmune diseases such as rheumatoid arthritis.
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Affiliation(s)
- Marion M Chan
- Department of Microbiology and Immunology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA.
| | - Xiaofeng Yang
- Center for Inflammation, Translational and Clinical Lung Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
| | - Hong Wang
- Department of Microbiology and Immunology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
- Center for Metabolic Disease Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
| | - Fatma Saaoud
- Center for Metabolic Disease Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
| | - Yu Sun
- Center for Metabolic Disease Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
| | - Dunne Fong
- Department of Cell Biology and Neuroscience, Rutgers, the State University of New Jersey, Piscataway, NJ 08854, USA
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Rodrigues JC, Bargman JM. Antimalarial Drugs for the Prevention of Chronic Kidney Disease in Patients with Rheumatoid Arthritis: The Importance of Controlling Chronic Inflammation? Clin J Am Soc Nephrol 2018; 13:679-680. [PMID: 29661771 PMCID: PMC5969469 DOI: 10.2215/cjn.03300318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jennifer C Rodrigues
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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Ciszek M, Kisiel B, Czerwinski J, Hryniewiecka E, Lewandowska D, Borczon S, Tlustochowicz W, Paczek L. Kidney Transplant Recipients With Rheumatic Diseases: Epidemiological Data From the Polish Transplant Registries 1998-2015. Transplant Proc 2018; 50:1654-1657. [PMID: 30056876 DOI: 10.1016/j.transproceed.2018.03.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/15/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
Abstract
Chronic kidney disease (CKD) is a common complication of rheumatic disorders. We analyzed the incidence of different rheumatic conditions as a primary diagnosis of end-stage renal disease (ESRD) in kidney transplant recipients in Poland. Data were received from the national waiting list for organ transplantation (Poltransplant) registries. Primary diagnosis leading to ESRD were analyzed in 15,984 patients who received kidney transplants between 1998 and 2015. There was no information about primary diagnosis in 4981 cases (31%) and in 1482 cases (9%) the diagnosis was described as unknown. Rheumatic diseases were specified in 566 (5.14%) kidney transplant recipients: lupus erythematosus, (systemic lupus erythematous nephritis) in 211 (1.92%), vasculitis in 176 (1.60%), amyloidosis AA in 82 (0.75%), hemolytic uremic syndrome in 59 (0.54%), secondary glomerulonephritis in 24 (0.22%), scleroderma in 9 (0.08%), rheumatoid arthritis in 4 (0.04%) and Sjögren syndrome in 1 (0.01%). Graft survival at 1 and 5 years were significantly better in the nonrheumatic versus rheumatic group (90 vs 87% and 76 vs 72% respectively, P = .04). Recipient survival at 5 years was significantly better in the nonrheumatic versus the rheumatic group (88 vs 84%, P = .02). Our study showed that systemic lupus erythematosus and systemic vasculitides are the major rheumatic causes of ESRD in the Polish population. Long-term graft and recipient survival were significantly better in the nonrheumatic versus the rheumatic group in the Poltransplant cohort.
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Affiliation(s)
- M Ciszek
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | - B Kisiel
- Department of Internal Diseases and Rheumatology, Military Institute of Medicine, Warsaw, Poland
| | - J Czerwinski
- Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland; Polish Transplant Coordinating Centre, Poltransplant, Warsaw, Poland
| | - E Hryniewiecka
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland; Department of Clinical Nursing, Medical University of Warsaw, Warsaw, Poland
| | - D Lewandowska
- Polish Transplant Coordinating Centre, Poltransplant, Warsaw, Poland; Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - S Borczon
- Polish Transplant Coordinating Centre, Poltransplant, Warsaw, Poland
| | - W Tlustochowicz
- Department of Internal Diseases and Rheumatology, Military Institute of Medicine, Warsaw, Poland
| | - L Paczek
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland; Department of Bioinformatics, Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Warsaw, Poland
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