1
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Guzmán-Guzmán IP, Nogueda-Torres B, Zaragoza-García O, Navarro-Zarza JE, Briceño O, Pérez-Rubio G, Falfán-Valencia R, Gutiérrez-Pérez IA, Parra-Rojas I. The Infection, Coinfection, and Abundance of Intestinal Protozoa Increase the Serum Levels of IFABP2 and TNF-α in Patients With Rheumatoid Arthritis. Front Med (Lausanne) 2022; 9:846934. [PMID: 35492365 PMCID: PMC9039364 DOI: 10.3389/fmed.2022.846934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Protozoa, nematodes, and platyhelminths are of clinical interest due to their role on the modulation of the immune responses. To determine the frequency of infection by intestinal parasites as well as the status of single or mixed infection (coinfection) and its relation with inflammation and intestinal permeability markers in patients with rheumatoid arthritis (RA), a cross-sectional study was conducted in 18 women diagnosed with RA. A fecal sample of each participant was analyzed for parasitic identification. The DAS28-erythrocyte sedimentation rate score, as well as the serum levels of TNF-α, IL-10, IL-17A, and the intestinal fatty-acid binding protein 2 (IFABP2), was determined through the ELISA technique. The T CD4+ and CD8+ lymphocytes' proportions were determined by flow cytometry. In this study, 50% (n = 9) of the total sample tested were positive to the presence of intestinal protozoa (27% by single infection and 22.2% by coinfection). Blastocystis sp. and Endolimax nana were the most frequently identified protozoa. The serum levels of IFABP2 were increased in patients with infection by protozoa, mainly in those individuals with coinfection and a larger abundance of Blastocystis sp. We found that coinfection by protozoa was related to higher levels of TNF-α and higher frequency of T CD4+ lymphocytes, mainly in patients under antirheumatic treatment. Infection by intestinal protozoa is associated with increased intestinal permeability in patients with RA; thus, infection, coinfection, and abundance of intestinal protozoa should be clinically screened because they could be an associated factor to the clinical variability of the disease.
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Affiliation(s)
| | - Benjamín Nogueda-Torres
- Department of Parasitology, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Oscar Zaragoza-García
- Faculty of Chemical-Biological Sciences, Universidad Autónoma de Guerrero, Chilpancingo, Mexico
| | | | - Olivia Briceño
- Center for Research in Infectious Diseases, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Gloria Pérez-Rubio
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | | | - Isela Parra-Rojas
- Faculty of Chemical-Biological Sciences, Universidad Autónoma de Guerrero, Chilpancingo, Mexico
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2
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Chen X, Wu Q, Gong Z, Ren T, Du Q, Yuan Y, Zuo Y, Miao Y, He J, Qiao C, Zheng Z, Zhang T, Huang L, Xie Z, Wang J, Zhu Y, Zhu C, Xu Y, Wu D, Gong F, Cheng J, Wen C, Zheng H. A Natural Plant Ingredient, Menthone, Regulates T Cell Subtypes and Lowers Pro-inflammatory Cytokines of Rheumatoid Arthritis. JOURNAL OF NATURAL PRODUCTS 2022; 85:1109-1117. [PMID: 35302365 DOI: 10.1021/acs.jnatprod.1c01231] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease with nearly 1.6 billion patients worldwide and an incidence of 0.5-1%. In recent years, basic and clinical studies have revealed that immune cell responses and corresponding secretion of inflammatory factors are important in the control of RA development. Our study found that a natural plant ingredient, menthone, could be used as a potential antirheumatism compound. In vivo observations demonstrated that menthone alleviates collagen II-induced arthritis (CIA) in mice. Furthermore, we found that menthone regulates the number of Th1 and Th17 cells in CIA mice. Importantly, menthone significantly inhibits the release of pro-inflammatory cytokines, including TNF-α, IL-1β, and IL-6, in CIA mice. Our study suggests a potential component for the development of drugs to treat rheumatoid arthritis.
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Affiliation(s)
- Xiangjie Chen
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Qiuyu Wu
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Zheng Gong
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Tengfei Ren
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Qian Du
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Yukang Yuan
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Yibo Zuo
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Ying Miao
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Jiuyi He
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Caixia Qiao
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Zhijin Zheng
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Tingting Zhang
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Lin Huang
- College of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Zhijun Xie
- College of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Jun Wang
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou 215123, China
| | - Yueping Zhu
- The Affiliated Infectious Diseases Hospital of Soochow University, Suzhou 215000, China
| | - Chuanwu Zhu
- The Affiliated Infectious Diseases Hospital of Soochow University, Suzhou 215000, China
| | - Yang Xu
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215123, China
| | - Depei Wu
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215123, China
| | - Fangyuan Gong
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
| | - Junping Cheng
- The Affiliated Infectious Diseases Hospital of Soochow University, Suzhou 215000, China
| | - Chengping Wen
- College of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Hui Zheng
- Institutes of Biology and Medical Sciences, Jiangsu Key Laboratory of Infection and Immunity, Soochow University, Suzhou 215123, China
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3
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Ohmura SI, Homma Y, Masui T, Miyamoto T. Factors Associated with Pneumocystis jirovecii Pneumonia in Patients with Rheumatoid Arthritis Receiving Methotrexate: A Single-center Retrospective Study. Intern Med 2022; 61:997-1006. [PMID: 34511571 PMCID: PMC9038457 DOI: 10.2169/internalmedicine.8205-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To investigate the risk factors for the development of Pneumocystis jirovecii pneumonia (PCP) in patients with rheumatoid arthritis (RA) undergoing methotrexate (MTX) therapy. Methods This single-center retrospective cohort study included consecutive patients with RA who received MTX for at least one year. The study population was divided into PCP and non-PCP groups, depending on the development of PCP, and their characteristics were compared. We excluded patients who received biologic disease-modifying anti-rheumatic drugs (DMARDs), Janus kinase inhibitors, and anti-PCP drugs for prophylaxis. Results Thirteen patients developed PCP, and 333 did not develop PCP. At the initiation of MTX therapy, the PCP group had lower serum albumin levels, a higher frequency of pulmonary disease and administration of DMARDs, and received a higher dosage of prednisolone (PSL) than the non-PCP group. A multivariate Cox regression analysis revealed that the concomitant use of PSL [hazard ratio (HR) 5.50, p=0.003], other DMARDs (HR 5.98, p=0.002), and serum albumin <3.5 mg/dL (HR 4.30, p=0.01) were risk factors for the development of PCP during MTX therapy. Patients with these risk factors had a significantly higher cumulative probability of developing PCP than patients who lacked these risk factors. Conclusion Clinicians should pay close attention to patients with RA who possess risk factors for the development of PCP during MTX therapy.
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Affiliation(s)
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Japan
| | - Takayuki Masui
- Department of Radiology, Seirei Hamamatsu General Hospital, Japan
| | - Toshiaki Miyamoto
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Japan
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4
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Mwanza D, Phal S, Nyokong T, Tesfalidet S, Mashazi P. Electrografting of isophthalic acid monolayer and covalent attachment of antibody onto carbon surfaces: Construction of capacitive biosensor for methotrexate detection. Electrochim Acta 2021. [DOI: 10.1016/j.electacta.2021.139360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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Talkington AM, McSweeney MD, Zhang T, Li Z, Nyborg AC, LaMoreaux B, Livingston EW, Frank JE, Yuan H, Lai SK. High MW polyethylene glycol prolongs circulation of pegloticase in mice with anti-PEG antibodies. J Control Release 2021; 338:804-812. [PMID: 34481925 DOI: 10.1016/j.jconrel.2021.08.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
Pegloticase is an enzyme used to reduce serum uric acid levels in patients with chronic, treatment-refractory gout. Clinically, about 40% of patients develop high titers of anti-PEG antibodies (APA) after initial treatment, which in turn quickly eliminate subsequent doses of pegloticase from the systemic circulation and render the treatment ineffective. We previously found that pre-infusion with high MW free PEG (40 kDa) can serve as a decoy to saturate circulating APA, preventing binding to a subsequently administered dose of PEG-liposomes and restoring their prolonged circulation in mice, without any detectible toxicity. Here, we investigated the use of 40 kDa free PEG to restore the circulation of radio-labeled pegloticase in mice using longitudinal Positron Emission Tomography (PET) imaging over 4 days. Mice injected with pegloticase developed appreciable APA titers by Day 9, which further increased through Day 14. Compared to naïve mice, mice with pegloticase-induced APA rapidly cleared 89Zr-labeled pegloticase, with ~75% lower pegloticase concentrations in the circulation at four hours after treatment. The 96-h AUC in APA+ mice was less than 30% of the AUC in naïve mice. In contrast, pre-infusion of free PEG into PEG-sensitized mice restored the AUC of pegloticase to ~80% of that seen in naïve mice, resulting in a similar biodistribution to pegloticase in naïve mice over time. These results suggest that pre-infusion of free PEG may be a promising strategy to enable the safe and efficacious use of pegloticase and other PEGylated drugs in patients that have previously failed therapy due to induced APA.
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Affiliation(s)
- Anne M Talkington
- Program in Bioinformatics and Computational Biology, University of North Carolina, Chapel Hill, NC, USA
| | - Morgan D McSweeney
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Tao Zhang
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Zibo Li
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA; Biomedical Research Imaging Center, UNC, Chapel Hill, USA
| | | | | | | | | | - Hong Yuan
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA; Biomedical Research Imaging Center, UNC, Chapel Hill, USA
| | - Samuel K Lai
- Program in Bioinformatics and Computational Biology, University of North Carolina, Chapel Hill, NC, USA; Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA; UNC/NCSU Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC, USA; Department of Microbiology and Immunology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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6
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Potera J, Kambhatla S, Gauto-Mariotti E, Manadan A. Incidence, mortality, and national costs of hospital admissions for potentially preventable infections in patients with rheumatoid arthritis. Clin Rheumatol 2021; 40:4845-4851. [PMID: 34254210 DOI: 10.1007/s10067-021-05836-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/13/2021] [Accepted: 06/20/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) patients have high infection rates. Streptococcus pneumoniae, herpes zoster (HZV), and influenza are common and potentially preventable causes of morbidity and mortality. Vaccinations have been shown to reduce the rates of these infections. In this study, we aim to determine incidence, mortality, and national costs of hospital admissions for Streptococcus pneumoniae, HZV, and influenza infections in patients with RA. METHODS We conducted a retrospective analysis of the adult RA hospitalizations in 2016 from the National Inpatient Sample database. We limited the RA cases to hospitalizations with a principal discharge diagnosis of S. pneumoniae, HZV, and influenza infections. The total number of discharges, age, length of stay, mortality, and hospital charges were recorded. RESULTS In 2016, 552,230 adult hospitalizations had either a primary or secondary diagnosis of RA. Among this group, there were 1120 hospitalizations for influenza, 590 hospitalizations for herpes zoster, and 785 hospitalizations for S. pneumoniae. These infections constituted 0.5% of RA hospitalizations and were a more common cause of hospitalizations when compared to non-RA hospitalizations. Aggregate annual national hospital charges reached $124 million and an aggregate annual LOS of 13,750 days. CONCLUSION Infections, such as influenza, HZV, and S. pneumoniae, remain a common cause of inpatient morbidity and mortality among RA patients. Additionally, the economic burden of these infections is significant. Universal vaccination programs in RA patients, as well as other interventions aiming to improve quality of care of this susceptible population, should be further studied to reduce hospitalizations, cost, morbidity, and mortality. Key Points • Streptococcus pneumoniae, herpes zoster, and influenza infections remain an important preventable cause of hospitalizations among RA patients and carry significant economic burden.
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Affiliation(s)
- Joanna Potera
- Internal Medicine Department, John H Stroger, Jr. Hospital of Cook County, 1950 West Polk Street, Chicago, IL, 60612, USA.
| | - Soumyasri Kambhatla
- Division of Rheumatology, Rush University Medical Center, 1611 W Harrison St, Suite 510, Chicago, IL, 60612, USA
| | - Estefania Gauto-Mariotti
- Internal Medicine Department, John H Stroger, Jr. Hospital of Cook County, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Augustine Manadan
- Division of Rheumatology, Rush University Medical Center, 1611 W Harrison St, Suite 510, Chicago, IL, 60612, USA
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7
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The advances of methotrexate resistance in rheumatoid arthritis. Inflammopharmacology 2020; 28:1183-1193. [DOI: 10.1007/s10787-020-00741-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022]
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8
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Khurana A, Saxena S. Immunosuppressive agents for dermatological indications in the ongoing COVID-19 pandemic: Rationalizing use and clinical applicability. Dermatol Ther 2020; 33:e13639. [PMID: 32436617 PMCID: PMC7280701 DOI: 10.1111/dth.13639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
The ongoing COVID-19 epidemic has brought to the fore many concerns related to use of immunosuppressive agents (ISAs) in dermatology. While it is unclear whether the patients on ISAs for skin conditions are more prone to develop COVID-19, and what impact the ISA may have on the clinical outcome if a patient does get infected, rationalizations based on the specific immune effects of each drug, and existing literature on incidence of various infections with each, are possible. In this review, we provide the readers with practically useful insights into these aspects, related to the conventional ISAs, and briefly mention the clinical outcome data available on related scenarios from other patient groups so far. In the end, we have attempted to provide some clinically useful points regarding practical use of each dermatologically relevant conventional ISA in the current scenario.
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Affiliation(s)
- Ananta Khurana
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
| | - Snigdha Saxena
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
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9
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Ibrahim A, Ahmed M, Conway R, Carey JJ. Risk of Infection with Methotrexate Therapy in Inflammatory Diseases: A Systematic Review and Meta-Analysis. J Clin Med 2018; 8:jcm8010015. [PMID: 30583473 PMCID: PMC6352130 DOI: 10.3390/jcm8010015] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/12/2018] [Accepted: 12/15/2018] [Indexed: 02/07/2023] Open
Abstract
The aim of this study was to determine the risk of infection in adults with inflammatory rheumatic diseases (IRDs) treated with methotrexate. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing methotrexate versus placebo in adults using MEDLINE, EMBASE, and CENTRAL databases from 1980 to August 2017. The primary outcome was the risk of infection associated with methotrexate therapy. We chose a random effect model to summarize adverse event outcomes as risk ratios (RRs) and related 95% confidence intervals (95% CI). Twelve RCTs (total patients 1146) met the inclusion criteria for our main analysis, and ten for risk of serious infection (total patients 906). Overall, methotrexate was associated with increased risk of infection in rheumatoid arthritis (RA) (RR: 1.25; 95% CI, 1.01⁻1.56; p = 0.04; I² = 0%), but not in other non-RA IRD populations. There was no increased risk of total infections (RR: 1.14; 95% CI, 0.98⁻1.34; p = 0.10; I² = 0%) or serious infections (RR: 0.76; 95% CI, 0.11⁻5.15; p = 0.78; I² = 0%) in all included IRDs. Conclusively, methotrexate use in IRDs is associated with a higher risk of all infections in RA, but not in other non-RA (IRD) populations. There is no increased risk of serious infections.
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Affiliation(s)
- Ammar Ibrahim
- Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Mohammed Ahmed
- Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Richard Conway
- Department of Rheumatic Diseases, St. James's University Hospital, Dublin, Ireland.
| | - John J Carey
- Department of Rheumatic Diseases, Galway University Hospitals, Galway, Ireland.
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10
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Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review. Eur J Med Chem 2018; 158:502-516. [PMID: 30243154 DOI: 10.1016/j.ejmech.2018.09.027] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022]
Abstract
Methotrexate (MTX) is used as an anchor disease-modifying anti-rheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA) because of its potent efficacy and tolerability. MTX benefits a large number of RA patients but partially suffered from side effects. A variety of side effects can be associated with MTX when treating RA patients, from mild to severe or discontinuation of the treatment. In this report, we reviewed the possible side effects that MTX might cause from the most common gastrointestinal toxicity effects to less frequent malignant diseases. In order to achieve regimen with less side effects, the administration of MTX with appropriate dose and a careful pretreatment inspection is necessary. Further investigations are required when combining MTX with other drugs so as to enhance the efficacy and reduce side effects at the same time. The management of MTX treatment is also discussed to provide strategies for occurred side effects. Thus, this review will provide scholars with a comprehensive understanding the side effects of MTX administration by RA patients.
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11
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Warren RB, Weatherhead SC, Smith CH, Exton LS, Mohd Mustapa MF, Kirby B, Yesudian PD. British Association of Dermatologists' guidelines for the safe and effective prescribing of methotrexate for skin disease 2016. Br J Dermatol 2017; 175:23-44. [PMID: 27484275 DOI: 10.1111/bjd.14816] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 12/25/2022]
Affiliation(s)
- R B Warren
- The Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M6 8HD, U.K
| | - S C Weatherhead
- Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - B Kirby
- St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - P D Yesudian
- Glan Clwyd Hospital, Sarn Lane, Rhyl, LL18 5UJ, U.K
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12
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Infections Associated with Biologics. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00159-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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13
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Guenther L, Langley RG, Shear NH, Bissonnette R, Ho V, Lynde C, Murray E, Papp K, Poulin Y, Zip C. Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel. J Cutan Med Surg 2016. [DOI: 10.1177/120347540400800503] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Approximately 2% of people worldwide have psoriasis, with as many as 1 million people with psoriasis in Canada alone.1,2 The severity of psoriasis ranges from mild to severe. It can lead to substantial morbidity and psychological stress and have a profound negative impact on patient quality of life.3,4 Although available therapies reduce therapies reduce the extent and severity of the disease and improve quality of life,3 reports have indicated a patient preference for more aggressive therapy and a dissatisfaction with the effectiveness of current treatment options.5 Objective: A Canadian Expert Panel, comprising Canadian dermatologists, convened in Toronto on 27 February 2004 to reach a consensus on unmet needs of patients treated with current therapies and how to include the pending biologic agents in and improve the current treatment algorithm for moderate-to-severe psoriasis. Current treatment recommendations suggest a stepwise strategy starting with topical agents followed by phototherapy and then systemic agents.3,6,7 The Panel evaluated the appropriate positioning of the biologic agents, once approved by Health Canada, for the treatment of moderate-to-severe psoriasis. Methods: The Panel reviewed available evidence and quality of these data on current therapies and from randomized, controlled clinical trials.8–14 Subsequently, consensus was achieved by small-group workshops followed by plenary discussion. Results: The Panel determined that biologic agents are an important addition to therapies currently available for moderate-to-severe psoriasis and proposed an alternative treatment algorithm to the current step wise paradigm. Conclusion: The Panel recommended a new treatment algorithm for moderate-to-severe psoriasis whereby all appropriate treatment options, including biologic agents, are considered together and patients' specific characteristics and needs are taken into account when selecting the most appropriate treatment option.
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Affiliation(s)
- Lyn Guenther
- Department of Dermatology, University of Western Ontario, London, Ontario, Canada
- The Guenther Dermatology Research Centre, 835 Richmond Street, London, Ontario, N6A 3H7, Canada
| | - Richard G Langley
- Division of Dermatogy, Department of Medicine, Dalhousie University and Queen Elizabeth II Health Science Centre, Halifax, Nova Scotia, Canada
| | - Neil H. Shear
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Science Centre, University of Toronto Medical School, Toronto, Ontario, Canada
- Ventana Clinical Research Corporation, Toronto, Ontario, Canada
| | | | - Vincent Ho
- Department of Dermatology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles Lynde
- University Health Network, University of Toronto, Toronto, Ontario, Canada
- Lynde Centre for Dermatology, Markham, Ontario, Canada
| | - Eileen Murray
- Department of Dermatology, University of Manitoba, Winnipeg, Manitoba, Canada
- Winnipeg Clinic, Winnipeg, Manitoba, Canada
| | - Kim Papp
- Probity Medical Research, Waterloo, Ontario, Canada
| | - Yves Poulin
- Department of Dermatology, Laval University, Sainte Foy, Quebec, Canada
- Centre Dermatologique, Sainte Foy, Quebec, Canada
| | - Catherine Zip
- Department of Dermatology, University of Calgary, Calgary, Alberta, Canada
- The Dermatology Centre, Calgary, Alberta, Canada
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14
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Haddad A, Li S, Thavaneswaran A, Cook RJ, Chandran V, Gladman DD. The Incidence and Predictors of Infection in Psoriasis and Psoriatic Arthritis: Results from Longitudinal Observational Cohorts. J Rheumatol 2016; 43:362-6. [DOI: 10.3899/jrheum.140067] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2015] [Indexed: 01/11/2023]
Abstract
Objective.To investigate the rate, type, characteristics, and predictors of infection in a cohort of patients with psoriatic arthritis (PsA) and a cohort of patients with psoriasis without arthritis (PsC).Methods.A cohort of patients with PsA and a cohort of patients with PsC were followed according to a standard protocol and information on the occurrence of infections was recorded. The rate of infection was estimated by fitting an exponential model. A Weibull regression model was fitted to estimate the relative risk of first infection associated with a number of covariates. Risk factors for recurrent infections were investigated using generalized estimating equations.Results.There were 498 and 74 infections reported among 695 and 509 patients with PsA and PsC, respectively, with an incidence rate of 19.6 per 100 person-years in the PsA cohort compared with 12.2 in the PsC cohort. The HR of the time to the first infection in PsA versus PsC was 1.6 (p = 0.002), and higher in patients treated with biologics versus nonbiologics at 1.56 (95% CI 1.22–2.00) in PsA and 1.50 (95% CI 0.64–3.54) in the PsC cohorts. Female sex and treatment with biologics were associated with infection in the PsA cohort, whereas a lower Psoriasis Area and Severity Index score and a higher Functional Comorbidity Index were associated with infection in the PsC cohort. Ultraviolet treatment was protective against infection in both cohorts. No difference in rates of hospitalization was found (p = 0.66). There were no infection-related deaths in either cohort.Conclusion.The incidence rate of infection was higher in the PsA than the PsC cohort and higher among patients treated with biologics. The data confirm the association between infection and biologic treatment in psoriatic disease.
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Takayanagi N. Biological agents and respiratory infections: Causative mechanisms and practice management. Respir Investig 2015; 53:185-200. [PMID: 26344608 DOI: 10.1016/j.resinv.2015.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/26/2015] [Indexed: 06/05/2023]
Abstract
Biological agents are increasingly being used to treat patients with immune-mediated inflammatory disease. In Japan, currently approved biological agents for patients with rheumatoid arthritis (RA) include tumor necrosis factor inhibitors, interleukin-6 receptor-blocking monoclonal antibody, and T-cell costimulation inhibitor. Rheumatologists have recognized that safety issues are critical aspects of treatment decisions in RA. Therefore, a wealth of safety data has been gathered from a number of sources, including randomized clinical trials and postmarketing data from large national registries. These data revealed that the most serious adverse events from these drugs are respiratory infections, especially pneumonia, tuberculosis, nontuberculous mycobacteriosis, and Pneumocystis jirovecii pneumonia, and that the most common risk factors associated with these respiratory infections are older age, concomitant corticosteroid use, and underlying respiratory comorbidities. Because of this background, in 2014, the Japanese Respiratory Society published their consensus statement of biological agents and respiratory disorders. This review summarizes this statement and adds recent evidence, especially concerning respiratory infections in RA patients, biological agents and respiratory infections, and practice management of respiratory infections in patients treated with biological agents. To decrease the incidence of infections and reduce mortality, we should know the epidemiology, risk factors, management, and methods of prevention of respiratory infections in patients receiving biological agents.
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Affiliation(s)
- Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya, Saitama 360-0105, Japan.
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Ranjan P, Chakrawarty A, Kumari A, Kumar J. Immunization in Patients with Rheumatic Diseases: A Practical Guide for General Practitioners. J Clin Diagn Res 2015; 9:OE01-4. [PMID: 26155514 DOI: 10.7860/jcdr/2015/14147.5972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/23/2015] [Indexed: 11/24/2022]
Abstract
Patients with rheumatic diseases are susceptible to various infections throughout the course of the disease. The increased risk of infections can be attributed partly to the aberrant immune system and partly to the effect of immunosuppressive drugs used in the treatment of the disease. Immunization appears to be an excellent strategy to prevent infections in such patients. However, the effect of vaccines in these patients is modified due to disease per se and/or immunosuppressive drugs. Biological agents, that frequently increase the susceptibility to infections, are now being initiated earlier in the course of the disease and also for new indications. Thus, concerns regarding safety, efficacy and potential adverse effects of vaccines in these patients are more complex than in any other immunosuppressive conditions. Different patients show different amount of immunosuppression in response to disease modifying drugs. Besides, there is lack of adequately powered randomised controlled trials investigating the efficacy of a vaccine in terms of actual prevention of the disease. Pneumococcal and influenza vaccines are the most studied vaccines and they are strongly recommended in rheumatic patients. In general, live vaccines should be avoided among patients receiving high doses of immunosuppressive drugs. However, they may be given to patients receiving low dose steroids and methotrexate. Non-live vaccines may be administered as per the recommendations of national guidelines. There is necessity to increase awareness among patients and doctors towards promoting the appropriate and judicious use of vaccines in the patients with rheumatic diseases.
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Affiliation(s)
- Piyush Ranjan
- Assistant Professor, Department of Medicine, All India Institute of Medical Sciences , New Delhi, India
| | - Avinash Chakrawarty
- Assistant Professor, Department of Geriatric Medicine, All India Institute of Medical Sciences , New Delhi, India
| | - Archana Kumari
- Assistant Professor, Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences and Research , New Delhi, India
| | - Jitendra Kumar
- Senior Resident, Department of Paediatrics, All India Institute of Medical Sciences , New Delhi, India
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Klotsche J, Niewerth M, Haas JP, Huppertz HI, Zink A, Horneff G, Minden K. Long-term safety of etanercept and adalimumab compared to methotrexate in patients with juvenile idiopathic arthritis (JIA). Ann Rheum Dis 2015; 75:855-61. [DOI: 10.1136/annrheumdis-annrheumdis-2014-206747] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 04/05/2015] [Indexed: 12/20/2022]
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Jamilloux Y, Valeyre D, Lortholary O, Bernard C, Kerever S, Lelievre L, Neel A, Broussolle C, Seve P. The spectrum of opportunistic diseases complicating sarcoidosis. Autoimmun Rev 2015; 14:64-74. [PMID: 25305373 DOI: 10.1016/j.autrev.2014.10.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/23/2014] [Indexed: 12/21/2022]
Abstract
Sarcoidosis is an inflammatory disease marked by a paradoxical immune status. The anergic state, which results from various immune defects, contrasts with the inflammatory formation of granulomas. Sarcoidosis patients may be at risk for opportunistic infections (OIs) and a substantial number of cases have been reported, even in untreated sarcoidosis. It is not clear how OIs in patients with sarcoidosis are different from other groups at risk. In this review, we discuss the most common OIs: mycobacterial infection (including tuberculosis), cryptococcosis, progressive multifocal leukoencephalopathy, and aspergillosis. Unlike peripheral lymphocytopenia, corticosteroids are a major risk factor for OIs but the occurrence of Ols in untreated patients suggests more complex predisposing mechanisms. Opportunistic infections presenting with extrapulmonary features are often misdiagnosed as new localizations of sarcoidosis. Aspergillomas mostly develop on fibrocystic lungs. Overall, physicians should be aware of the possible occurrence of OIs during sarcoidosis, even in untreated patients.
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Desalermos AP, Frank S, Farraye FA. Recurrent Bell's palsy in a patient with Crohn's disease on methotrexate. J Clin Gastroenterol 2014; 48:651-2. [PMID: 24492402 DOI: 10.1097/mcg.0000000000000079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Athanasios P Desalermos
- *Section of Gastroenterology †Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA
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Caza T, Oaks Z, Perl A. Interplay of Infections, Autoimmunity, and Immunosuppression in Systemic Lupus Erythematosus. Int Rev Immunol 2014; 33:330-63. [DOI: 10.3109/08830185.2013.863305] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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From the Medical Board of the National Psoriasis Foundation: Vaccination in adult patients on systemic therapy for psoriasis. J Am Acad Dermatol 2013; 69:1003-13. [DOI: 10.1016/j.jaad.2013.06.046] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 06/21/2013] [Accepted: 06/29/2013] [Indexed: 12/29/2022]
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Taylor A, Sheng KC, Herrero LJ, Chen W, Rulli NE, Mahalingam S. Methotrexate treatment causes early onset of disease in a mouse model of Ross River virus-induced inflammatory disease through increased monocyte production. PLoS One 2013; 8:e71146. [PMID: 23951095 PMCID: PMC3741301 DOI: 10.1371/journal.pone.0071146] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/02/2013] [Indexed: 12/26/2022] Open
Abstract
Part of the Togaviridae family, alphaviruses, including chikungunya virus (CHIKV), Sindbis virus (SINV) and Ross River virus (RRV), are able to cause significant inflammatory pathologies ranging from arthritis to encephalitis. Following symptomatic infection with arthritis-associated alphaviruses, patients often experience severe joint pain, affecting distal and small joints, which can last six months or longer. Recently, methotrexate (MTX), a disease modifying anti-rheumatic drug (DMARD), was used to treat patients experiencing chronic rheumatic symptoms following infection with CHIKV. Here, the effect of MTX on Ross River virus disease (RRVD) in mice was examined to better understand its therapeutic potential for alphaviral-induced musculoskeletal disease and to further our knowledge of the development of alphaviral pathologies. Using a mouse model, we analyzed the effect of MTX on RRVD. RRV disease pathogenesis in response to MTX treatment was determined by measuring levels of proinflammatory factors, cellular infiltrates, viral titer and histological analysis of infected tissues. RRV-infected mice receiving MTX treatment rapidly developed musculoskeletal disease, which correlated with a significant influx of inflammatory cell infiltrates into the skeletal muscle tissue. Although no difference was observed in the level of proinflammatory cytokines and chemokines, the viral load increased at early time points post infection in the serum and quadriceps of MTX treated mice, possibly contributing to disease pathogenesis. Results suggest that MTX treatment of acute RRVD in mice provides no therapeutic benefit and underline the importance of inflammatory monocytes in alphaviral induced arthritides.
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Affiliation(s)
- Adam Taylor
- Institute for Glycomics, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Kuo-Ching Sheng
- Institute for Glycomics, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Lara J. Herrero
- Institute for Glycomics, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Weiqiang Chen
- Institute for Glycomics, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Nestor E. Rulli
- Institute for Glycomics, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Suresh Mahalingam
- Institute for Glycomics, Griffith University, Gold Coast Campus, Queensland, Australia
- * E-mail:
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Rozental T, Mascarenhas LF, Rozenbaum R, Gomes R, Mattos GS, Magno CC, Almeida DN, Rossi MID, Favacho ARM, de Lemos ERS. Coxiella burnetii, the agent of Q fever in Brazil: its hidden role in seronegative arthritis and the importance of molecular diagnosis based on the repetitive element IS1111 associated with the transposase gene. Mem Inst Oswaldo Cruz 2013; 107:695-7. [PMID: 22850965 DOI: 10.1590/s0074-02762012000500021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 04/12/2012] [Indexed: 11/22/2022] Open
Abstract
Coxiella burnetii is the agent of Q fever , an emergent worldwide zoonosis of wide clinical spectrum. Although C. burnetii infection is typically associated with acute infection, atypical pneumonia and flu-like symptoms, endocarditis, osteoarticular manifestations and severe disease are possible, especially when the patient has a suppressed immune system; however, these severe complications are typically neglected. This study reports the sequencing of the repetitive element IS1111 of the transposase gene of C. burnetii from blood and bronchoalveolar lavage (BAL) samples from a patient with severe pneumonia following methotrexate therapy, resulting in the molecular diagnosis of Q fever in a patient who had been diagnosed with active seronegative polyarthritis two years earlier. To the best of our knowledge, this represents the first documented case of the isolation of C. burnetii DNA from a BAL sample.
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Affiliation(s)
- Tatiana Rozental
- Laboratório de Hantaviroses e Rickettsioses, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil.
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Yoo HG, Yu HM, Jun JB, Jeon HS, Yoo WH. Risk factors of severe infections in patients with rheumatoid arthritis treated with leflunomide. Mod Rheumatol 2012; 23:709-15. [PMID: 22791271 DOI: 10.1007/s10165-012-0716-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 06/25/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the risk of severe infection requiring or complicating hospitalization associated with leflunomide therapy in patients with rheumatoid arthritis (RA). METHODS We performed a retrospective study of RA patients who were prescribed leflunomide between 2004 and 2011. Background clinical and laboratory features were compared between patients who suffered severe leflunomide-associated infections and those who did not. RESULTS Since January 2005, 401 RA patients have started on leflunomide. Among those, 33 (8.2%) developed severe infections: pneumonia, oral candidiasis, pyelonephritis, pulmonary tuberculosis, cellulitis, disseminated herpes zoster, tonsillitis, and pulmonary cryptococcosis. Logistic regression showed that age at entry, the presence of DM, and daily dosage of corticosteroid were associated with development of severe infections. CONCLUSIONS These results showed that some patients with RA who were taking leflunomide developed severe infections requiring hospitalization, and that older age, DM, and a higher daily dosage of corticosteroid were risk factors associated with leflunomide-associated severe infections.
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Affiliation(s)
- Han-Gyul Yoo
- Department of Pharmacy Practice, University of Rhode Island, Kingston, RI 02881, USA
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Antin-Ozerkis D, Evans J, Rubinowitz A, Homer RJ, Matthay RA. Pulmonary manifestations of rheumatoid arthritis. Clin Chest Med 2011; 31:451-78. [PMID: 20692539 DOI: 10.1016/j.ccm.2010.04.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pulmonary disease is a major source of morbidity and mortality in rheumatoid arthritis, manifesting most commonly as interstitial lung disease, airways disease, rheumatoid nodules, and pleural effusions. The diagnostic assessment of respiratory abnormalities is complicated by underlying risk for infection, the use of drugs with known pulmonary toxicity, and the frequency of lung disease related to rheumatoid arthritis itself. Evaluation and management of rheumatoid arthritis-associated pulmonary disease frequently necessitates a multidisciplinary approach.
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Jang HI, Shin HM. Wild Panax ginseng (Panax ginseng C.A. Meyer) protects against methotrexate-induced cell regression by enhancing the immune response in RAW 264.7 macrophages. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2011; 38:949-60. [PMID: 20821825 DOI: 10.1142/s0192415x10008378] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Many traditional herbal medicines have been re-evaluated to determine whether they enhance immune responses. In this study, the possible use of wild Panax ginseng (WPG) for enhancement of host immunity in chemotherapy was investigated. In the cell proliferation assay, WPG significantly enhanced the proliferation of RAW 264.7 macrophages and protected against cell regression in macrophages treated with methotrexate (MTX). WPG induced the production of nitric oxide and the expression of inducible nitric oxide synthase and cyclooxygense-2 mRNA. Furthermore, WPG enhanced the production of cytokines including interleukin (IL)-1alpha, IL-1beta, IL-6, tumor necrosis factor-alpha and granulocyte-macrophage colony-stimulating factor, and chemokines such as macrophage chemotactic protein-1 and regulated upon activation, normal T-cell expressed and secreted (RANTES), regardless of MTX co-administration. Taken together, these results provide the first evidence that WPG triggers immune responses through the prevention of macrophage cell regression caused by MTX and functional activation of macrophages.
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Affiliation(s)
- Hyo Il Jang
- College of Oriental Medicine, Dongguk University, Gyeongju 780-714, South Korea
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Watanabe H, Suzuki R, Asano T, Shio K, Iwadate H, Kobayashi H, Matsuoka T, Aikawa K, Ohira H. A case of emphysematous pyelonephritis in a patient with rheumatoid arthritis taking corticosteroid and low-dose methotrexate. Int J Rheum Dis 2010; 13:180-3. [PMID: 20536605 DOI: 10.1111/j.1756-185x.2010.01460.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease that is characterized by chronic synovial inflammation. Patients with RA have increased risk of infection; this is related to RA itself or the adverse effects of medication. In this report, we describe a case of emphysematous pyelonephritis in a patient with RA associated with AA amyloidosis and steroid-induced diabetes mellitus who was taking corticosteroid and low-dose methotrexate.
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Affiliation(s)
- Hiroshi Watanabe
- Department of Gastroenterology and Rheumatology, School of Medicine, Fukushima Medical University, Fukushima, Japan.
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Ruyssen-Witrand A, Fautrel B, Saraux A, Le-Loët X, Pham T. Infections induced by low-dose corticosteroids in rheumatoid arthritis: A systematic literature review. Joint Bone Spine 2010; 77:246-51. [DOI: 10.1016/j.jbspin.2010.02.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Accepted: 02/03/2010] [Indexed: 11/30/2022]
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Simard JF, Stoll ML, Shadick NA, Karlson EW, Solomon DH. Validity of self-report of infections in a longitudinal cohort of patients with rheumatoid arthritis differs by source of report and infection severity. J Clin Epidemiol 2010; 63:1358-62. [PMID: 20430581 DOI: 10.1016/j.jclinepi.2010.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 12/22/2009] [Accepted: 01/06/2010] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We evaluated and compared the validity of patients' and rheumatologists' reports of infection with those confirmed by medical record review. STUDY DESIGN AND SETTING Reports of infections in 961 patients with rheumatoid arthritis from the Brigham and Women's Rheumatoid Arthritis Sequential Study (BRASS) were included over a 2-year period. BRASS is a longitudinal prospective cohort that collects detailed questionnaire data from patients semiannually and their treating rheumatologists every year. RESULTS Rheumatologist report of infection was more likely to be confirmed by medical record review than patient self-report (57.1% vs. 34.3% for definite or possible infections). Confirmation rates varied based on whether the participant received her primary care from the same network of health care providers. For participants with primary care "out of network," between 7.0% and 23.1% of patient or rheumatologist reports were confirmed by medical record review vs. between 16.1% and 41.7% for those with primary care "in network." CONCLUSION The present study shows that relying strictly on patient or rheumatologist report of infection for a confirmed endpoint is not ideal but useful in case finding. The confirmation rate is affected by a number of factors including severity and definition of the infection and limited by data availability.
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Affiliation(s)
- Julia F Simard
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
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Harle P, Straub RH, Fleck M. Elective surgery in rheumatic disease and immunosuppression: to pause or not. Rheumatology (Oxford) 2010; 49:1799-800. [DOI: 10.1093/rheumatology/keq049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Grewal P, Brassard A. Fact or fiction: does the non-HIV/AIDS immunosuppressed patient need Pneumocystis jiroveci pneumonia prophylaxis? An updated literature review. J Cutan Med Surg 2010; 13:308-12. [PMID: 19919808 DOI: 10.2310/7750.2009.09010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) is a potentially fatal fungal infection occurring in immunocompromised patients. OBJECTIVE To determine whether PJP prophylaxis is required in the non-human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) immunocompromised patient and, if so, the optimal prophylactic therapy. METHODS A thorough literature review, with the appropriate MeSH terms, was conducted using PubMed, Medline, and The Cochrane Database. A number of cases describing PJP in patients with various systemic diseases and immunosuppressive medications, along with a Cochrane review, were highlighted. RESULTS Although there are a number of case reports in the literature, the only collagen vascular disease with an increased incidence of PJP is Wegener granulomatosis. Oral trimethoprim-sulfamethoxazole continues to be the prophylaxis of choice for PJP. CONCLUSION There is currently no evidence to recommend PJP prophylaxis in the non-HIV/AIDS immunocompromised population. If physicians do decide to use prophylaxis, they should always weigh the benefits with the potential risks. Further studies are needed to better quantify the risks of PJP with immunosuppressive medications.
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Affiliation(s)
- Parbeer Grewal
- Division of Dermatology, University of Alberta, Edmonton, AB, Canada
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Ledwich LJ, Harrington TM, Ayoub WT, Sartorius JA, Newman ED. Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert. ACTA ACUST UNITED AC 2010; 61:1505-10. [PMID: 19877088 DOI: 10.1002/art.24873] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications. METHODS A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fisher's exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites. RESULTS PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001). CONCLUSION The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.
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Härle P, Straub RH, Fleck M. Perioperative management of immunosuppression in rheumatic diseases—what to do? Rheumatol Int 2009; 30:999-1004. [DOI: 10.1007/s00296-009-1323-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 11/29/2009] [Indexed: 12/21/2022]
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MORI SHUNSUKE, CHO ISAMU, SUGIMOTO MINEHARU. A Followup Study of Asymptomatic Carriers ofPneumocystis jiroveciDuring Immunosuppressive Therapy for Rheumatoid Arthritis. J Rheumatol 2009; 36:1600-5. [DOI: 10.3899/jrheum.081270] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To examine the preventive effects of prophylaxis againstPneumocystis jiroveci-induced pneumonia (PCP) in patients receiving immunosuppressive therapy for rheumatoid arthritis (RA) who are colonized by this organism.Methods.We performed molecular testing by polymerase chain reaction (PCR) forP. jirovecion induced sputum or bronchoalveolar lavage fluids of 82 patients with RA. During primary prophylaxis, asymptomatic carriers of this organism were examined by high-resolution computed tomography and PCR every 2 weeks. RA patients who had developed PCP received PCR tests every week. Once negative results were obtained, PCR testing was scheduled at Months 1, 3, and 6, followed by reexaminations every 6 months.Results.We found 9 cases of asymptomatic carriage ofP. jiroveci.All the carriers had received low doses of methotrexate. Upon introduction of PCP prophylaxis, 5 cases tested negative for PCR within 1 month. Three carriers developed PCP before starting prophylaxis, but these tested negative for PCR after short periods (1–2 weeks) of PCP treatment. OnceP. jiroveciwas eradicated, all cases maintained negative PCR results during followup without prophylactic intervention, even after resuming immunosuppressive therapy. One patient refused PCP prophylaxis, but no PCP developed.Conclusion.RA patients with asymptomatic carriage ofP. jirovecibenefited from short-term prophylaxis against PCP. Positive PCR results appeared to be predictive of future development of PCP in RA patients. Identification ofP. jirovecicarriers will encourage prompt introduction of PCP prophylaxis when rheumatologists consider immunosuppressive therapy for RA.
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McLean-Tooke A, Aldridge C, Waugh S, Spickett GP, Kay L. Methotrexate, rheumatoid arthritis and infection risk--what is the evidence? Rheumatology (Oxford) 2009; 48:867-71. [DOI: 10.1093/rheumatology/kep101] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Lebeaux D, Lanternier F, Lefort A, Lecuit M, Lortholary O. Risque infectieux fongique au cours des maladies systémiques. Presse Med 2009; 38:260-73. [DOI: 10.1016/j.lpm.2008.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 11/19/2008] [Accepted: 11/19/2008] [Indexed: 11/24/2022] Open
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Caporali R, Caprioli M, Bobbio-Pallavicini F, Montecucco C. DMARDS and infections in rheumatoid arthritis. Autoimmun Rev 2008; 8:139-43. [DOI: 10.1016/j.autrev.2008.05.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lacaille D, Guh DP, Abrahamowicz M, Anis AH, Esdaile JM. Use of nonbiologic disease-modifying antirheumatic drugs and risk of infection in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2008; 59:1074-81. [PMID: 18668604 DOI: 10.1002/art.23913] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with increased frequency of and mortality from infections, which may be related to host factors, RA itself, inflammation, or medication side effects. This study was undertaken to determine the effect of nonbiologic disease-modifying antirheumatic drugs (DMARDs) on infection risk in RA. METHODS We performed a retrospective, longitudinal study of a population-based RA cohort in British Columbia, Canada, followed from January 1996 to March 2003 using administrative data. We evaluated mild infections (requiring a physician visit or antibiotics) and serious infections (requiring or complicating hospitalization). Adjusted risk of mild and serious infections associated with DMARD exposure was estimated using generalized estimating equation extension of multivariate Poisson regression models, after adjusting for baseline covariates (age, sex, RA duration, socioeconomic status) and time-dependent covariates (corticosteroids, comorbidity, prior infections). RESULTS A total of 27,710 individuals with RA provided 162,710 person-years of followup. Of these, 25,608 (92%) had at least 1 mild infection and 4,941 (18%) had at least 1 serious infection. Use of DMARDs without corticosteroids was associated with a small decrease in mild infection risk of statistical significance but unclear clinical significance (adjusted rate ratio [RR] 0.90, 95% confidence interval [95% CI] 0.88-0.93 relative to no corticosteroid or DMARD use). Use of DMARDs without corticosteroids was not associated with increased serious infection risk (adjusted RR 0.92, 95% CI 0.85-1.0). Use of corticosteroids increased the risk of mild and serious infections. CONCLUSION Our results indicate that use of nonbiologic DMARDs, including methotrexate, does not increase the risk of infection in RA, whereas use of corticosteroids does. This has important implications for counseling individuals with RA concerning risks and benefits of DMARDs.
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Affiliation(s)
- Diane Lacaille
- University of British Columbia and Arthritis Research Centre of Canada, 895 West 10th Avenue, Vancouver, BC, Canada.
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Mori S, Cho I, Ichiyasu H, Sugimoto M. Asymptomatic carriage of Pneumocystis jiroveci in elderly patients with rheumatoid arthritis in Japan: a possible association between colonization and development of Pneumocystis jiroveci pneumonia during low-dose MTX therapy. Mod Rheumatol 2008; 18:240-6. [PMID: 18306977 DOI: 10.1007/s10165-008-0037-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 11/26/2007] [Indexed: 12/01/2022]
Abstract
Low-dose methotrexate (MTX) has been used effectively for rheumatoid arthritis (RA) because of its favorable risk-benefit ratio. One of the recent concerns arising from this therapy is a possible increase in the rate of opportunistic infections, particularly Pneumocystis jiroveci pneumonia (PCP). In this study, we report two cases of PCP occurring during low-dose methotrexate therapy for RA and review 13 additional cases from the literature on Japanese patients with RA. The average age of these patients was 67.7 years, and most were over the age of 60. MTX-associated PCP appears to occur more frequently in elderly individuals in Japan. To identify individuals with a high risk of PCP, we performed a polymerase chain reaction on specimens from induced sputum or bronchoalveolar lavage fluids from 55 patients with RA. At that point in time, they showed no evidence of PCP development. We found six patients (10.9%) having asymptomatic carriage of P. jiroveci. The mean age of the P. jiroveci-positive patients was 74.7 years, which was significantly older than the P. jiroveci-negative patients (mean age 63.6 years). Of the RA patients over the age of 65, 18.8% (6 cases out of 32) were carriers of P. jiroveci. There were no significant differences in RA duration or counts of white blood cells or lymphocytes between the positive and negative groups. Notably, we encountered a case of PCP occurring in an asymptomatic carrier of P. jiroveci during low-dose MTX therapy for RA. This case appeared to be a reactivation of latent infection. By careful follow-up on the carriers of P. jiroveci, we succeeded in promptly diagnosing PCP, and we employed the appropriate therapeutic strategies for this possibly life-threatening complication.
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Affiliation(s)
- Shunsuke Mori
- Clinical Research Center for Rheumatic Disease and Department of Rheumatology, Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto, Japan.
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Strangfeld A, Listing J. Bacterial and opportunistic infections during anti-TNF therapy. Best Pract Res Clin Rheumatol 2006; 20:1181-95. [PMID: 17127203 DOI: 10.1016/j.berh.2006.08.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Tumour necrosis factor alpha (TNF-alpha) plays a crucial role in host defence against bacterial infections. Summarizing the results, the findings of immunological and clinical research suggest a higher infection risk in rheumatoid arthritis and ankylosing spondylitis patients receiving anti-TNF treatment. This is especially true for granulomatous infections in patients treated with the monoclonal TNF-alpha antibodies infliximab or adalimumab. Furthermore, patients treated with TNF inhibitors have a higher susceptibility to infections because of their higher active and more severe disease. Therefore, patients receiving anti-TNF treatment should be closely monitored for serious infections. A rapid and sufficient treatment of infections that are not mild and transient is recommended. There are atypical signs and symptoms as well as atypical pathogen that should be considered. Patients should be educated about how to avoid infectious complications.
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Affiliation(s)
- Anja Strangfeld
- German Rheumatism Research Centre, Epidemiology Unit, Charitéplatz 1, D-10117 Berlin, Germany
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Grover R, Dhir V, Aneja R, Arya V, Galle A, Marwaha V, Kumar A. Severe infections following leflunomide therapy for Rheumatoid Arthritis. Rheumatology (Oxford) 2006; 45:918-20. [PMID: 16717066 DOI: 10.1093/rheumatology/kel130] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kalantzis A, Marshman Z, Falconer DT, Morgan PR, Odell EW. Oral effects of low-dose methotrexate treatment. ACTA ACUST UNITED AC 2006; 100:52-62. [PMID: 15953917 DOI: 10.1016/j.tripleo.2004.08.020] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Methotrexate is used increasingly in low-dose regimes for a variety of conditions, particularly rheumatoid arthritis. While certain adverse effects of low-dose methotrexate have been described in detail, oral complications have received little attention. This article includes a summary of the uses and pharmacology of low-dose methotrexate and the mechanisms that lead to general and oral toxicity. The literature relevant to potential oral adverse effects is discussed and 7 illustrative cases are presented. The oral effects noted range from nonhealing ulcers to lymphoma-like lesions. Dental practitioners should be aware of the possible oral effects of low-dose methotrexate that have so far been largely unrecognized.
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Affiliation(s)
- Athanasios Kalantzis
- Department of Oral Pathology, GKT Dental Institute, Guy's Tower, King's College London, Guy's Hospital, London, UK.
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Wolfe F, Caplan L, Michaud K. Treatment for rheumatoid arthritis and the risk of hospitalization for pneumonia: Associations with prednisone, disease-modifying antirheumatic drugs, and anti–tumor necrosis factor therapy. ACTA ACUST UNITED AC 2006; 54:628-34. [PMID: 16447241 DOI: 10.1002/art.21568] [Citation(s) in RCA: 311] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Pneumonia is a major cause of mortality and morbidity in rheumatoid arthritis (RA). This study was undertaken to determine the rate and predictors of hospitalization for pneumonia and the extent to which specific RA treatments increase pneumonia risk. METHODS RA patients (n = 16,788) were assessed semiannually for 3.5 years. Pneumonia was confirmed by medical records or detailed patient interview. Covariates included RA severity measures, diabetes, pulmonary disease, and myocardial infarction. Cox proportional hazards regression was used to determine the multivariable risk associated with RA treatments. RESULTS After adjustment for covariates, prednisone use increased the risk of pneumonia hospitalization (hazard ratio [HR] 1.7 [95% confidence interval 1.5-2.0]), including a dose-related increase in risk (< or = 5 mg/day HR 1.4 [95% confidence interval 1.1-1.6], > 5-10 mg/day HR 2.1 [95% confidence interval 1.7-2.7], > 10 mg/day HR 2.3 [95% confidence interval 1.6-3.2]). Leflunomide also increased the risk (HR 1.2 [95% confidence interval 1.0-1.5]). HRs for etanercept (0.8 [95% confidence interval 0.6-110]) and sulfasalazine (0.7 [95% confidence interval 0.5-1.0]) did not reflect an increased risk of pneumonia. HRs for infliximab, adalimumab, and methotrexate were not significantly different from zero. CONCLUSION There is a dose-related relationship between prednisone use and pneumonia risk in RA. No increase in risk was found for anti-tumor necrosis factor therapy or methotrexate. These data call into question the belief that low-dose prednisone is safe. Because corticosteroid use is common in RA, the results of this study suggest that prednisone exposure may have important public health consequences.
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Affiliation(s)
- Frederick Wolfe
- National Data Bank for Rheumatic Diseases and University of Kansas School of Medicine, Wichita, Kansas 67214, USA.
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Listing J, Strangfeld A, Kary S, Rau R, von Hinueber U, Stoyanova-Scholz M, Gromnica-Ihle E, Antoni C, Herzer P, Kekow J, Schneider M, Zink A. Infections in patients with rheumatoid arthritis treated with biologic agents. ACTA ACUST UNITED AC 2005; 52:3403-12. [PMID: 16255017 DOI: 10.1002/art.21386] [Citation(s) in RCA: 461] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To estimate the incidence rates of serious and nonserious infections in patients with rheumatoid arthritis (RA) who start treatment with a biologic agent, and to compare these rates with those in patients with RA who receive conventional treatment. METHODS Patients enrolled in the German biologics register between May 2001 and September 2003 were included. Treating rheumatologists assessed adverse events and serious adverse events. All adverse events and serious adverse events experienced within 12 months after study entry were analyzed. Propensity score methods were applied to estimate which part of a rate increase was likely to be attributable to differences in patient characteristics. RESULTS Data were available for 512 patients receiving etanercept, 346 patients receiving infliximab, 70 patients receiving anakinra, and 601 control patients treated with disease-modifying antirheumatic drugs. The total number of adverse events per 100 patient-years was 22.6 (95% confidence interval [95% CI] 18.7-27.2) among patients receiving etanercept, 28.3 (95% CI 23.1-34.7) among patients receiving infliximab, and 6.8 (95% CI 5.0-9.4) among controls (P < 0.0001). Significant differences in the rate of serious adverse events were also observed. For patients receiving etanercept, those receiving infliximab, and controls, the total numbers of serious adverse events per 100 patient-years were 6.4 (95% CI 4.5-9.1), 6.2 (95% CI 4.0-9.5), and 2.3 (95% CI 1.3-3.9), respectively (P = 0.0016). After adjusting for differences in the case patient mix, the relative risks of serious adverse events were 2.2 (95% CI 0.9-5.4) for patients receiving etanercept and 2.1 (95% CI 0.8-5.5) for patients receiving infliximab, compared with controls. CONCLUSION Patients treated with biologic agents have a higher a priori risk of infection. However, our data suggest that this risk is increased by treatment with tumor necrosis factor inhibitors.
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Affiliation(s)
- Joachim Listing
- German Rheumatism Research Centre, Schumannstrasse 21/22, D-10117 Berlin, Germany.
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Guenther L, Langley RG, Shear NH, Bissonnette R, Ho V, Lynde C, Murray E, Papp K, Poulin Y, Zip C. Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel. J Cutan Med Surg 2005; 8:321-37. [PMID: 15868311 DOI: 10.1007/s10227-005-0035-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 2% of people worldwide have psoriasis, with as many as 1 million people with psoriasis in Canada alone.1,2 The severity of psoriasis ranges from mild to severe. It can lead to substantial morbidity and psychological stress and have a profound negative impact on patient quality of life.3,4 Although available therapies reduce therapies reduce the extent and severity of the disease and improve quality of life,3 reports have indicated a patient preference for more aggressive therapy and a dissatisfaction with the effectiveness of current treatment options.5 OBJECTIVE A Canadian Expert Panel, comprising Canadian dermatologists, convened in Toronto on 27 February 2004 to reach a consensus on unmet needs of patients treated with current therapies and how to include the pending biologic agents in and improve the current treatment algorithm for moderate-to-severe psoriasis. Current treatment recommendations suggest a stepwise strategy starting with topical agents followed by phototherapy and then systemic agents.3,6,7 The Panel evaluated the appropriate positioning of the biologic agents, once approved by Health Canada, for the treatment of moderate-to-severe psoriasis. METHODS The Panel reviewed available evidence and quality of these data on current therapies and from randomized, controlled clinical trials.8-14 Subsequently, consensus was achieved by small-group workshops followed by plenary discussion. RESULTS The Panel determined that biologic agents are an important addition to therapies currently available for moderate-to-severe psoriasis and proposed an alternative treatment algorithm to the current step wise paradigm. CONCLUSION The Panel recommended a new treatment algorithm for moderate-to-severe psoriasis whereby all appropriate treatment options, including biologic agents, are considered together and patients' specific characteristics and needs are taken into account when selecting the most appropriate treatment option.
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Affiliation(s)
- Lyn Guenther
- Department of Dermatology, University of Western Ontario, London, Ontario, Canada.
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Abstract
The immunotoxic effects of drugs are divided into immunosuppression, immunostimulation, hypersensitivity and autoimmunity. The major adverse consequences of immunosuppression are infectious complications and virus-induced malignancies. Flu-like reactions, more frequent autoimmune diseases and hypersensitivity reactions to unrelated allergens, and inhibition of drug-metabolising enzymes are the adverse effects related to immunostimulation. Hypersensitivity reactions are the most frequent immunotoxic effects of drugs. They include immune-mediated ('allergic') and non immune-mediated ('pseudoallergic') reactions. Drug-induced autoimmune reactions, either systemic or organ-specific, are seemingly rare. A review of drug-induced immunotoxic effects demonstrates that immunotoxicity is a significant cause of morbidity and even mortality. As immunotoxicologists have long focused on immunosuppression, the nonclinical immunotoxicity safety assessment of unexpected immunosuppression is based on a number of relatively well standardised and validated animal models and assays. However, there is no general consensus regarding the minimal requirement for this assessment. Many different assays can be used to extend the assessment case by case. Few animal models and assays have been validated for use in the nonclinical safety assessment of unexpected immunostimulation. The situation is worse regarding the prediction of hypersensitivity and autoimmune reactions. Our limited understanding of the molecular and cellular mechanisms of immunotoxicity accounts, at least partly, for this situation. Recent guidelines for the immunotoxicity safety assessment of drugs, even though conflicting on several points, will serve as an impetus not only to refine current animal models and assays, but also to search for better alternatives. The new data generated will have to be interpreted and extended to animal species other than just rodents. Likewise, animal results will have to be compared with findings in humans. The search for immunological endpoints that can be used in several animal species and in humans will therefore become essential. Specific endpoints and clinical criteria that can be included in clinical trials to further investigate the potential for immunotoxicity of new drugs will have to be defined. Because immunotoxicity plays a key role in drug-induced adverse effects, the role of immunotoxicology in drug safety assessment is indisputable and the systematic nonclinical as well as clinical immunotoxicity assessment of every new drug is deemed essential.
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Kazlow Stern D, Tripp JM, Ho VC, Lebwohl M. The Use of Systemic Immune Moderators in Dermatology: An Update. Dermatol Clin 2005; 23:259-300. [PMID: 15837155 DOI: 10.1016/j.det.2004.09.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In addition to corticosteroids, dermatologists have access to an array of immunomodulatory therapies. Azathioprine, cyclophosphamide, methotrexate, cyclosporine, and mycophenolate mofetil are the systemic immunosuppressive agents most commonly used by dermatologists. In addition, new developments in biotechnology have spurred the development of immunobiologic agents that are able to target the immunologic process of many inflammatory disorders at specific points along the inflammatory cascade. Alefacept, efalizumab, etanercept, and infliximab are the immunobiologic agents that are currently the most well known and most commonly used by dermatologists. This article reviews the pharmacology, mechanism of action, side effects, and clinical applications of these therapies.
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Affiliation(s)
- Dana Kazlow Stern
- Department of Dermatology, Mount Sinai School of Medicine, New York, NY 10029-6574, USA
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Gea-Banacloche JC, Opal SM, Jorgensen J, Carcillo JA, Sepkowitz KA, Cordonnier C. Sepsis associated with immunosuppressive medications: an evidence-based review. Crit Care Med 2005; 32:S578-90. [PMID: 15542967 DOI: 10.1097/01.ccm.0000143020.27340.ff] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for sepsis associated with immunosuppressive medications that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION Immunosuppressed patients, by definition, are susceptible to a wider spectrum of infectious agents than immunologically normal patients and, thus, require a broader spectrum antimicrobial regimen when they present with sepsis or septic shock. Special expertise managing immunosuppressed patient populations is needed to predict and establish the correct diagnosis and to choose appropriate empiric and specific agents and maximize the likelihood that patients will survive these microbial challenges.
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