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Mansilla-Polo M, Morgado-Carrasco D. Biologics Versus JAK Inhibitors. Part II: Risk of Infections. A Narrative Review. Dermatol Ther (Heidelb) 2024:10.1007/s13555-024-01203-2. [PMID: 39014279 DOI: 10.1007/s13555-024-01203-2] [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: 04/22/2024] [Accepted: 05/30/2024] [Indexed: 07/18/2024] Open
Abstract
INTRODUCTION The risk of infections associated with biological drugs (BD) and Janus kinase inhibitors (JAKi) has been extensively explored in the literature. However, there is a dearth of studies that evaluate both pharmacological groups together and, furthermore, compare them. Here, we review the risk of infections associated with BD and JAKi used in dermatology. METHODS A narrative review was performed. All relevant articles evaluating the risk of infection and opportunistic infections with BD and JAKi between January 2010 and February 2024 were selected. RESULTS Overall, the incidence of infections, serious infections, and opportunistic infections associated with BD and JAKi is low, but higher than in the general population. JAKi approved for dermatological disorders (abrocitinib, baricitinib, deucravacitinib, upadacitinib, ritlecitinib, and topical ruxolitinib) have been shown to be safe, and present a low rate of infections. We found an elevated risk, especially with anti-tumor necrosis factor (anti-TNF) agents, rituximab, and JAKi (particularly tofacitinib at high doses). Specific associations with infections include tuberculosis and tuberculosis reactivation with anti-TNF agents and tocilizumab; candidiasis with anti-interleukin (IL) 17 agents; hepatitis B virus reactivation with rituximab, anti-TNF, and JAKi; and herpes simplex and herpes zoster infections with JAKi (especially tofacitinib and upadacitinib at high doses). The incidence of infections with ustekinumab and anti-IL-23 was very low. Anti-IL-1, nemolizumab, tralokinumab, and omalizumab were not associated with an increased risk of infections. Dupilumab could decrease the incidence of cutaneous infections. CONCLUSIONS Anti-TNF agents, rituximab, and JAKi (particularly tofacitinib) can increase the risk of infections. Close monitoring of patients undergoing these therapies is recommended. Prospective studies with long-term follow-up are needed to comparatively evaluate the risks of infection deriving from treatment with BD and JAKi.
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Affiliation(s)
- Miguel Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain
- Department of Dermatology, Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Daniel Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain.
- Department of Dermatology, Hospital de Figueres, Fundació Alt Empurdà, Gerona, Spain.
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Gil A, Hoag GE, Salerno JP, Hornig M, Klimas N, Selin LK. Identification of CD8 T-cell dysfunction associated with symptoms in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and Long COVID and treatment with a nebulized antioxidant/anti-pathogen agent in a retrospective case series. Brain Behav Immun Health 2024; 36:100720. [PMID: 38327880 PMCID: PMC10847863 DOI: 10.1016/j.bbih.2023.100720] [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: 05/02/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 02/09/2024] Open
Abstract
Background Patients with post-acute sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection (PASC, i.e., Long COVID) have a symptom complex highly analogous to many features of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), suggesting they may share some aspects of pathogenesis in these similar disorders. ME/CFS is a complex disease affecting numerous organ systems and biological processes and is often preceded by an infection-like episode. It is postulated that the chronic manifestations of illness may result from an altered host response to infection or inability to resolve inflammation, as is being reported in Long COVID. The immunopathogenesis of both disorders is still poorly understood. Here, we show data that suggest Long COVID and ME/CFS may be due to an aberrant response to an immunological trigger-like infection, resulting in a dysregulated immune system with CD8 T-cell dysfunction reminiscent of some aspects of T-cell clonal exhaustion, a phenomenon associated with oxidative stress. As there is an urgent need for diagnostic tools and treatment strategies for these two related disabling disorders, here, in a retrospective case series, we have also identified a potential nebulized antioxidant/anti-pathogen treatment that has evidence of a good safety profile. This nebulized agent is comprised of five ingredients previously reported individually to relieve oxidative stress, attenuate NF-κB signaling, and/or to act directly to inhibit pathogens, including viruses. Administration of this treatment by nebulizer results in rapid access of small doses of well-studied antioxidants and agents with anti-pathogen potential to the lungs; components of this nebulized agent are also likely to be distributed systemically, with potential to enter the central nervous system. Methods and Findings: We conducted an analysis of CD8 T-cell function and severity of symptoms by self-report questionnaires in ME/CFS, Long COVID and healthy controls. We developed a CD8 T-cell functional assay, assessing CD8 T-cell dysfunction by intracellular cytokine staining (ICS) in a group of ME/CFS (n = 12) and Long COVID patients (n = 8), comparing to healthy controls (HC) with similar age and sex (n = 10). Magnet-enriched fresh CD8 T-cells in both patient groups had a significantly diminished capacity to produce both cytokines, IFNγ or TNFα, after PMA stimulation when compared to HC. The symptom severity questionnaire showed similar symptom profiles for the two disorders. Fortuitously, through a retrospective case series, we were able to examine the ICS and questionnaire data of 4 ME/CFS and 4 Long COVID patients in conjunction with their treatment (3-15 months). In parallel with the treatment pursued electively by participants in this retrospective case series, there was an increase in CD8 T-cell IFNγ and TNFα production and a decrease in overall self-reported symptom severity score by 54%. No serious treatment-associated side effects or laboratory anomalies were noted in these patients. Conclusions Here, in this small study, we present two observations that appear potentially fundamental to the pathogenesis and treatment of Long COVID and ME/CFS. The first is that both disorders appear to be characterized by dysfunctional CD8 T-cells with severe deficiencies in their abilities to produce IFNγ and TNFα. The second is that in a small retrospective Long COVID and ME/CFS case series, this immune dysfunction and patient health improved in parallel with treatment with an immunomodulatory, antioxidant pharmacological treatment with anticipated anti-pathogen activity. This work provides evidence of the potential utility of a biomarker, CD8 T-cell dysfunction, and suggests the potential for benefit from a new nebulized antioxidant/anti-pathogen treatment. These immune biomarker data may help build capacity for improved diagnosis and tracking of treatment outcomes during clinical trials for both Long COVID and ME/CFS while providing clues to new treatment avenues that suggest potential efficacy for both conditions.
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Affiliation(s)
- Anna Gil
- University of Massachusetts Chan Medical School, Department of Pathology, Worcester, MA, USA
| | | | - John P. Salerno
- Inspiritol, Inc., Fairfield, CT, USA
- The Salerno Center for Complementary Medicine, New York, USA
| | - Mady Hornig
- Columbia University Mailman School of Public Health, New York, USA
| | - Nancy Klimas
- Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Liisa K. Selin
- University of Massachusetts Chan Medical School, Department of Pathology, Worcester, MA, USA
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Singer D, Thompson-Leduc P, Gupta D, Poston S, Cheng WY, Ma S, Pawlowski JE, Duh MS, Devine F, Banatwala A, Bernstein E, Farraye FA. Economic and Clinical Burden of Herpes Zoster Among Patients With Inflammatory Bowel Disease in the United States. CROHN'S & COLITIS 360 2023; 5:otad033. [PMID: 37497018 PMCID: PMC10368335 DOI: 10.1093/crocol/otad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Indexed: 07/28/2023] Open
Abstract
Background Patients with ulcerative colitis (UC) or Crohn's disease (CD) are at increased risk of herpes zoster (HZ); however, relevant cost and healthcare resource utilization (HCRU) data are limited. Methods We estimated HCRU (hospitalization, emergency department [ED], and outpatient visits) and costs in patients with UC or CD, with and without HZ, using administrative claims data (October 2015-February 2020). HCRU and costs (2020 US dollars) were compared at 1 month, 1 quarter, and 1 year after the index date, using propensity score adjustment and generalized linear models. Results In total, 20 948 patients were included: UC+/HZ+ (n = 431), UC+/HZ- (n = 10 285), CD+/HZ+ (n = 435), and CD+/HZ- (n = 9797). Patients with HZ had higher all-cause HCRU rates and all-cause total healthcare costs relative to those without HZ. In the first month, adjusted incidence rate ratios (aIRRs) for hospitalizations and ED visits for patients with UC and HZ compared with UC alone were 2.87 (95% confidence interval [CI], 1.93-4.27) and 2.66 (95% CI,1.74-4.05), respectively; for those with CD and HZ, aIRRs were 3.34 (95% CI, 2.38-4.70) and 3.31 (95% CI, 2.32-4.71), respectively, compared with CD alone (all P < .001). Adjusted cost differences in UC and CD cohorts with HZ over the first month were $2189 and $3774, respectively, chiefly driven by higher inpatient costs. The incremental impact on HCRU and costs in cohorts with HZ predominantly occurred during the first quarter following diagnosis. Conclusions HZ is associated with increased HCRU and costs in patients with UC and CD, especially shortly after diagnosis.
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Affiliation(s)
- David Singer
- Address correspondence to: David Singer, PharmD, MS, GSK, US Health Outcomes and Epidemiology—Vaccines, FMC Tower Suite 1700, 2929 Walnut Street, Philadelphia, PA 19104, USA. Phone: +16465995595 ()
| | - Philippe Thompson-Leduc
- Analysis Group, Inc., Health Economics and Outcomes Research, 1190 Avenue des Canadiens-de-Montréal, Suite 1500, Montréal, QC H3B 0G7, Canada
| | - Deepshekhar Gupta
- Analysis Group, Inc., Health Economics and Outcomes Research, 1010 El Camino Real, Suite 310, Menlo Park, CA 94025, USA
| | - Sara Poston
- GSK, US Health Outcomes and Epidemiology—Vaccines, FMC Tower Suite 1700, 2929 Walnut Street, Philadelphia, PA 19104, USA
| | - Wendy Y Cheng
- Analysis Group, Inc., Health Economics and Outcomes Research, 111 Huntington Avenue, 14 Floor, Boston, MA 02199, USA
| | - Siyu Ma
- GSK, US Health Outcomes and Epidemiology—Vaccines, FMC Tower Suite 1700, 2929 Walnut Street, Philadelphia, PA 19104, USA
- Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - John E Pawlowski
- GSK, Medical Affairs, FMC Tower Suite 1700, 2929 Walnut Street, Philadelphia, PA 19104, USA
| | - Mei Sheng Duh
- Analysis Group, Inc., Health Economics and Outcomes Research, 111 Huntington Avenue, 14 Floor, Boston, MA 02199, USA
| | - Francesca Devine
- Analysis Group, Inc., Health Economics and Outcomes Research, 151 West 42 Street, 23rd Floor, New York, NY 10036, USA
| | - Azeem Banatwala
- Analysis Group, Inc., Health Economics and Outcomes Research, 333 South Hope Street, 27 Floor, Los Angeles, CA 90071, USA
| | - Emma Bernstein
- Analysis Group, Inc., Health Economics and Outcomes Research, 111 Huntington Avenue, 14 Floor, Boston, MA 02199, USA
- Baylor University, Department of Political Science, One Bear Place #97276, Waco, TX 76798-7276, USA
| | - Francis A Farraye
- Mayo Clinic, Division of Gastroenterology and Hepatology, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Dai C, Jiang M, Huang YH. Anti-TNF Therapy and the Risk of Herpes Zoster Among Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:e156. [PMID: 34259845 DOI: 10.1093/ibd/izab178] [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: 12/09/2022]
Affiliation(s)
- Cong Dai
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, China
| | - Min Jiang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, China
| | - Yu-Hong Huang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, China
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