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Sen R, Riofrio M, Singh JA. A narrative review of the comparative safety of disease-modifying anti-rheumatic drugs used for the treatment of rheumatoid arthritis. Expert Opin Drug Saf 2024; 23:687-714. [PMID: 38695151 DOI: 10.1080/14740338.2024.2348575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/24/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Disease-modifying anti-rheumatic drugs (DMARDs) have improved the outcomes of patients with rheumatoid arthritis (RA). DMARDs are classified into three categories: conventional synthetic DMARDs, biological DMARDs (including biosimilars), and targeted synthetic DMARDs. DMARDs, by way of their effect on the immune system, are associated with increased risk of adverse events, including infections, malignancies, cardiovascular disease, gastrointestinal perforations, and other less common events. AREAS COVERED In this narrative literature review performed with searches of the PubMed database from 1 January 2010 through 1 January 2023, we compare the risk of safety events between DMARDs using data from both randomized clinical trials and observational studies. EXPERT OPINION DMARD use in RA is associated with higher rates of serious infections, tuberculosis reactivation, opportunistic infections, and possibly malignancies. Specific biologic DMARDs and higher doses are associated with elevated risks of various adverse events (gastrointestinal perforations, thromboembolism, serious infection). Shared decision-making is paramount when choosing a treatment regimen for patients based on their own comorbidities. JAKi are the newest class of medications used for RA with robust safety data provided in clinical trials. However, more real-world evidence and phase-IV pharmacovigilance data are needed to better understand comparative safety profile of DMARDs in RA.
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Affiliation(s)
- Rouhin Sen
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
| | - Maria Riofrio
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
| | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
- Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA
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Zhou VY, Lacaille D, Lu N, Kopec JA, Qian Y, Nosyk B, Aviña-Zubieta JA, Esdaile JM, Xie H. Risk of severe infections after the introduction of biologic DMARDs in people with newly diagnosed rheumatoid arthritis: a population-based interrupted time-series analysis. Rheumatology (Oxford) 2023; 62:3858-3865. [PMID: 37014364 PMCID: PMC10691931 DOI: 10.1093/rheumatology/kead158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/16/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVES To determine the impact of the introduction of biologic DMARDs (bDMARDs) on severe infections among people newly diagnosed with RA compared with non-RA individuals. METHODS In this population-based retrospective cohort study using administrative data (from 1990-2015) for British Columbia, Canada, all incident RA patients diagnosed between 1995 and 2007 were identified. General population controls with no inflammatory arthritis were matched to RA patients based on age and gender, and were assigned the diagnosis date (i.e. index date) of the RA patients they were matched with. RA/controls were then divided into quarterly cohorts according to their index dates. The outcome of interest was all severe infections necessitating hospitalization or occurring during hospitalization after the index date. We calculated 8-year severe infection rates for each cohort and conducted interrupted time-series analyses to compare severe infection trends in RA/controls with index date during pre-bDMARDs (1995-2001) and post-bDMARDs (2003-2007) periods. RESULTS A total of 60 226 and 588 499 incident RA/controls were identified. We identified 14 245 severe infections in RA, and 79 819 severe infections in controls. The 8-year severe infection rates decreased among RA/controls with increasing calendar year of index date in the pre-bDMARDs period, but increased over time only among RA, not controls, with index date in the post-bDMARDs period. The adjusted difference between the pre- and post-bDMARDs secular trends in 8-year severe infection rates was 1.85 (P = 0.001) in RA and 0.12 (P = 0.29) in non-RA. CONCLUSION RA onset after bDMARDs introduction was associated with an elevated severe infection risk in RA patients compared with matched non-RA individuals.
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Affiliation(s)
- Vivienne Y Zhou
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Diane Lacaille
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Na Lu
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Jacek A Kopec
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Epidemiology, Biostatistics and Public Health Practice, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yi Qian
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- Center for Health Evaluation & Outcome Sciences, Vancouver, British Columbia, Canada
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John M Esdaile
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hui Xie
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
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Elsouri KN, Arboleda V, Basbous L, Heiser S, Collins DP, Ragusa P, Baxter C, Cabrera D, Akhand T, Stermer E, Sharma K, Seguro C, Hardigan P, Kesselman M, Beckler MD. Glucocorticoid use in rheumatoid arthritis patients and the onset of pneumonia: a systematic review and meta-analysis. J Osteopath Med 2023; 123:179-186. [PMID: 36691851 DOI: 10.1515/jom-2022-0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/29/2022] [Indexed: 01/25/2023]
Abstract
CONTEXT Rheumatoid arthritis (RA) is a systemic autoimmune disease that commonly affects joints. Although many treatment options exist, the most common, disease-modifying antirheumatic drugs (DMARDs), have been associated with pulmonary infections. These types of infections (specifically pneumonia) can be detrimental to RA patients. This leads providers to utilize other treatment modalities such as glucocorticoids (GCs). GCs are commonly utilized to treat RA; however, the role of GCs in the onset of pneumonia in RA patients is not fully understood. OBJECTIVES The goal of this study was to systematically review and statistically analyze pooled data documenting pneumonia as an adverse event in RA patients on DMARDs as a monotherapy vs RA patients on DMARDs and GCs as combination therapy utilizing the Population, Intervention, Comparison, and Outcomes (PICO) framework. METHODS On August 1, 2021, a search was conducted and completed on six databases: Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, International Pharmaceutical Abstracts (IPA), and ClinicalTrials.gov. A total of 12 researchers were involved with the search and screening of articles (K.E., P.R.; V.A., D.P.C.; C.B., D.C.; T.A., E.S.; S.H., L.B.; K.S., C.S.). Search terms were identified utilizing Medical Subject Headings (MeSH) and Emtree and included "glucocorticoids," "rheumatoid arthritis," "pneumonia," and "respiratory tract infections," Inclusion criteria included human subjects over the age of 18 with seropositive RA, on a combination of GC (prednisone, methylprednisolone, or prednisolone) with DMARD (methotrexate [MTX], hydroxychloroquine [HCQ], or sulfasalazine [SSZ]) and developed pneumonia of bacterial, viral, or fungal origin. The control groups were on a DMARD monotherapy regimen. Articles were excluded if they were not in English, had less than 20 participants, were case reports or literature reviews, included animal subjects, and did not adhere to the established PICO framework. Five teams of two researchers individually sorted through abstracts of articles based on the inclusion and exclusion criteria. The same teams individually sorted through full-text articles of selected abstracts based on the same criteria. Conflicts between each team were resolved by a separate researcher. Odds ratios were utilized to quantify the effect sizes of combined studies from a random effects model. Chi-square tests and I2 statistics were utilized to analyze heterogeneity. RESULTS A total of 3360 articles were identified from all databases, and 416 duplicate articles were removed. Thus, a total of 2944 articles abstracts were screened, of which 2819 articles either did not meet the inclusion criteria or did meet the exclusion criteria. A total of 125 articles were retrieved and assessed for full-text eligibility, of which only three observational articles were included for meta-analysis. Statistical results revealed that patients treated with DMARDs monotherapy are 95% (95% CI: 0.65-0.99) less likely to develop pneumonia compared to patients treated with a DMARD and GCs (p=0.002). CONCLUSIONS Our data suggest that RA patients have a higher probability of developing pneumonia on combination therapy with GCs, compared to monotherapy with DMARDs. To our knowledge, our findings are the first to systematically review and statistically evaluate the relationship between the use of GCs and show an increased chance of developing pneumonia.
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Affiliation(s)
- Kawther N Elsouri
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Vania Arboleda
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | | | - Samantha Heiser
- William Carey University College of Osteopathic Medicine, Hattiesburg, MS, USA
| | - Dylon P Collins
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Philip Ragusa
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Courney Baxter
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Dominick Cabrera
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Tanisha Akhand
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Evan Stermer
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Kiran Sharma
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Charmaine Seguro
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Patrick Hardigan
- Nova Southeastern University Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Marc Kesselman
- Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Michelle Demory Beckler
- Nova Southeastern University Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
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Impact of Concomitant Corticosteroids on Tofacitinib Induction Efficacy and Infection Rates in Ulcerative Colitis. Dig Dis Sci 2023; 68:2624-2634. [PMID: 36739367 PMCID: PMC9899108 DOI: 10.1007/s10620-022-07794-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 12/05/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tofacitinib is an oral small molecule Janus kinase inhibitor for the treatment of ulcerative colitis. AIM To report efficacy and infection rates in patients receiving tofacitinib induction treatment, by baseline corticosteroid status. METHODS We evaluated efficacy and safety data from OCTAVE Induction 1&2 in patients with moderately-to-severely active ulcerative colitis who received tofacitinib 10 mg twice daily or placebo for 8 weeks, based on induction baseline oral corticosteroid use (Corticosteroid-Yes/No) and dose (< 20/ ≥ 20 mg/day). Infections of interest included serious infections, herpes zoster (HZ), and adjudicated opportunistic infections (OIs). RESULTS At OCTAVE Induction 1&2 baseline, 478/1092 (43.8%) patients were receiving corticosteroids. Tofacitinib demonstrated significant induction efficacy versus placebo for both Corticosteroid-Yes and Corticosteroid-No. With adjustment for prior tumor necrosis factor inhibitor and immunosuppressant failure, there were no statistically significant differences in remission and clinical response rates for Corticosteroid-Yes versus Corticosteroid-No. Among tofacitinib-treated patients, HZ and OIs occurred more frequently in Corticosteroid-Yes versus Corticosteroid-No, regardless of dose (< 20 mg vs. ≥ 20 mg). Infection incidence rates (regardless of severity/seriousness) during tofacitinib induction were generally similar regardless of baseline corticosteroid use. The proportion of tofacitinib-treated patients with HZ was 0.2% for Corticosteroid-No versus 1.1% for Corticosteroid-Yes < 20 mg and 1.0% for Corticosteroid-Yes ≥ 20 mg. Two out of three patients had HZ OIs. CONCLUSIONS Tofacitinib induction efficacy (clinical response and remission) was similar in baseline corticosteroid subgroups. Infections of interest were rare; HZ and OIs occurred more frequently among those receiving tofacitinib and corticosteroids versus those receiving tofacitinib without corticosteroids. TRIAL REGISTRATION http://www. CLINICALTRIALS gov (NCT01465763[21/10/2011]; NCT01458951[21/10/2011]).
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Yue S, Bo L. Formulation and Development of Prednisolone Loaded Nanoparticulate Injection for the Treatment of Arthritis. INT J PHARMACOL 2022. [DOI: 10.3923/ijp.2022.611.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Current Take on Systemic Sclerosis Patients' Vaccination Recommendations. Vaccines (Basel) 2021; 9:vaccines9121426. [PMID: 34960174 PMCID: PMC8708328 DOI: 10.3390/vaccines9121426] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune inflammatory rheumatic disease. The prevalence of SSc ranges from 7 to 700 cases per million worldwide. Due to multiple organ involvement and constant inflammatory state, this group of patients presents an increased risk of infectious diseases. This paper aimed to gather the up-to-date evidence on vaccination strategies for patients with SSc and to be a useful tool for the prevention and management of infectious diseases. The authors conducted a scoping review in which each paragraph presents data on a specific vaccine’s safety, immunogenicity, and efficacy. The work deals with the following topics: SARS-CoV-2, seasonal influenza, S. pneumoniae, HAV, HBV, HZV, N. meningitidis, H. influenzae, HPV, and diphtheria-tetanus-pertussis.
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Suzuki M, Kojima T, Takahashi N, Asai S, Terabe K, Kaneko A, Hirano Y, Hanabayashi M, Oguchi T, Takagi H, Kanayama Y, Yabe Y, Funahashi K, Fujibayashi T, Tsuboi S, Ito T, Yoshioka Y, Ishikawa H, Sobue Y, Nishiume T, Yokota Y, Ishiguro N. Higher doses of methotrexate associated with discontinuation of oral glucocorticoids after initiation of biological DMARDs: A retrospective observational study based on data from a Japanese multicenter registry study. Mod Rheumatol 2021; 31:796-802. [PMID: 33492191 DOI: 10.1080/14397595.2021.1879428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Glucocorticoids are important drugs used to treat rheumatoid arthritis. We recommend glucocorticoid discontinuation as soon as possible given the associated side-effects, but many patients continue to take oral glucocorticoids long-term. The present study aimed to explore factors associated with glucocorticoid discontinuation at 52 weeks after initiating biological disease-modifying antirheumatic drugs (bDMARDs). METHODS Subjects were 564 patients from a Japanese multicenter registry who were administered glucocorticoids and methotrexate (MTX) followed by initiation of the first bDMARD. We examined the status of oral glucocorticoid use at 52 weeks after initiating the first bDMARD. RESULTS By 52 weeks after bDMARD initiation, 164 patients (29.1%) discontinued glucocorticoids. Multivariable analysis identified age, MTX dose, and glucocorticoid dose as factors independently associated with glucocorticoid discontinuation. After adjusting for baseline characteristics using propensity score matching, among patient groups administered MTX ≤ 8 mg/week and MTX > 8 mg/week, 105 pairs remained. A significantly higher rate of glucocorticoid discontinuation (41.0%) was noted for patients administered MTX > 8 mg/week. CONCLUSION Our findings suggest that glucocorticoids may be discontinued after initiating bDMARDs. Moreover, higher MTX doses (>8 mg/week) at the time of bDMARD initiation were associated with glucocorticoid discontinuation among patients treated with bDMARDs.
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Affiliation(s)
- Mochihito Suzuki
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Nobunori Takahashi
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Shuji Asai
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kenya Terabe
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Atsushi Kaneko
- Department of Orthopedic Surgery and Rheumatology, Nagoya Medical Center, Aichi, Japan
| | - Yuji Hirano
- Department of Rheumatology, Toyohashi Municipal Hospital, Aichi, Japan
| | | | - Takeshi Oguchi
- Department of Orthopedic Surgery and Rheumatology, Anjo Kosei Hospital, Aichi, Japan
| | - Hideki Takagi
- Department of Orthopedic Surgery, Nagoya Central Hospital, Aichi, Japan
| | | | - Yuichiro Yabe
- Department of Rheumatology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Koji Funahashi
- Department of Orthopedic Surgery, Kariya-Toyota General Hospital, Aichi, Japan
| | - Takayoshi Fujibayashi
- Department of Orthopedic Surgery and Rheumatology, Konan Kosei Hospital, Aichi, Japan
| | - Seiji Tsuboi
- Department of Orthopedic Surgery, Shizuoka Kosei Hospital, Shizuoka, Japan
| | | | - Yutaka Yoshioka
- Department of Orthopedic Surgery, Handa Municipal Hospital, Aichi, Japan
| | - Hisato Ishikawa
- Department of Rheumatology, Japanese Red Cross, Nagoya Daiichi Hospital, Aichi, Japan
| | - Yasumori Sobue
- Department of Rheumatology, Japanese Red Cross, Nagoya Daiichi Hospital, Aichi, Japan
| | - Tsuyoshi Nishiume
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yutaka Yokota
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Kilian A, Chock YP, Huang IJ, Graef ER, Upton LA, Khilnani A, Krupnikova SDS, Almaghlouth I, Cappelli LC, Fernandez-Ruiz R, Frankel BA, Frankovich J, Harrison C, Kumar B, Monga K, Vega JAR, Singh N, Sparks JA, Sullo E, Young KJ, Duarte-Garcia A, Putman M, Johnson S, Grainger R, Wallace ZS, Liew JW, Jayatilleke A. Acute respiratory viral adverse events during use of antirheumatic disease therapies: A scoping review. Semin Arthritis Rheum 2020; 50:1191-1201. [PMID: 32931985 PMCID: PMC7832282 DOI: 10.1016/j.semarthrit.2020.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION COVID-19 is an acute respiratory viral infection that threatens people worldwide, including people with rheumatic disease, although it remains unclear to what extent various antirheumatic disease therapies increase susceptibility to complications of viral respiratory infections. OBJECTIVE The present study undertakes a scoping review of available evidence regarding the frequency and severity of acute respiratory viral adverse events related to antirheumatic disease therapies. METHODS Online databases were used to identify, since database inception, studies reporting primary data on acute respiratory viral infections in patients utilizing antirheumatic disease therapies. Independent reviewer pairs charted data from eligible studies using a standardized data abstraction tool. RESULTS A total of 180 studies were eligible for qualitative analysis. While acknowledging that the extant literature has a lack of specificity in reporting of acute viral infections or complications thereof, the data suggest that use of glucocorticoids, JAK inhibitors (especially high-dose), TNF inhibitors, and anti-IL-17 agents may be associated with an increased frequency of respiratory viral events. Available data suggest no increased frequency or risk of respiratory viral events with NSAIDs, hydroxychloroquine, sulfasalazine, methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide, or apremilast. One large cohort study demonstrated an association with leflunomide use and increased risk of acute viral respiratory events compared to non-use. CONCLUSION This scoping review identified that some medication classes may confer increased risk of acute respiratory viral infections. However, definitive data are lacking and future studies should address this knowledge gap.
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Affiliation(s)
- Adam Kilian
- Division of Rheumatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Yu Pei Chock
- Division of Rheumatology, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Irvin J Huang
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Elizabeth R Graef
- Division of Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Laura A Upton
- Georgetown University School of Medicine, Washington, DC
| | - Aneka Khilnani
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Sonia D Silinsky Krupnikova
- Division of Rheumatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Laura C Cappelli
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ruth Fernandez-Ruiz
- Division of Rheumatology, Department of Medicine, New York University Langone Health, New York, NY
| | - Brittany A Frankel
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Jourdan Frankovich
- Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | | | - Bharat Kumar
- Division of Rheumatology, Department of Medicine, University of Iowa, Iowa City, IA
| | - Kanika Monga
- Division of Rheumatology, Department of Medicine, University of Texas Houston, Houston, TX
| | - Jorge A Rosario Vega
- Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Jeffrey A Sparks
- Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Elaine Sullo
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Kristen J Young
- Division of Rheumatology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ali Duarte-Garcia
- Division of Rheumatology and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Michael Putman
- Division of Rheumatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Sindhu Johnson
- Division of Rheumatology, Toronto Western Hospital, Mount Sinai Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachuse General Hospital and Harvard Medical School, Boston, MA
| | - Jean W Liew
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Aruni Jayatilleke
- Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA.
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Ben Nessib D, Fazaa A, Miladi S, Sellami M, Ouenniche K, Souabni L, Kassab S, Chekili S, Ben Abdelghani K, Laatar A. Do immunosuppressive agents hamper the vaccination response in patients with rheumatic diseases? A review of the literature. Therapie 2020; 76:215-219. [PMID: 32951867 DOI: 10.1016/j.therap.2020.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/03/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
Abstract
Patients with auto-immune disease are more susceptible to infection than similar populations without auto-immune disease. Vaccination seems to be one of the most effective methods to prevent patients from possible infections, but may be impaired by concomitant immunomodulators. The aim of this review was to evaluate the effect of immunosuppressive drugs on vaccination efficiency. We found that the majority of studies confirms that neither the use of corticosteroids and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) nor the use of biological agents, except rituximab, reduce the efficacy of inactivated vaccines such as pneumococcal and influenza vaccines. Even if rituximab has been shown to reduce humoral responses following influenza and pneumococcal vaccination, this response can be modestly restored 6-10 months after rituximab administration. To sum up, treatment guidelines recommending routine use of pneumococcal and influenza vaccines for immune compromised patients should be followed in order to avoid severe infections.
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Affiliation(s)
- Dorra Ben Nessib
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia.
| | - Alia Fazaa
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Sawsen Miladi
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Meriem Sellami
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Kmar Ouenniche
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Leila Souabni
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Salma Kassab
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Salma Chekili
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Kawther Ben Abdelghani
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
| | - Ahmed Laatar
- Rheumatology department, Monji Slim hospital, 2046 Marsa, Tunisia; Faculty of medicine of Tunis, University Tunis el Manar, 1068 Tunis, Tunisia
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Lenti MV, Mengoli C, Vernero M, Aronico N, Conti L, Borrelli de Andreis F, Cococcia S, Di Sabatino A. Preventing Infections by Encapsulated Bacteria Through Vaccine Prophylaxis in Inflammatory Bowel Disease. Front Immunol 2020; 11:485. [PMID: 32269571 PMCID: PMC7109446 DOI: 10.3389/fimmu.2020.00485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/03/2020] [Indexed: 12/23/2022] Open
Abstract
Inflammatory bowel disease (IBD), which comprises ulcerative colitis and Crohn's disease, is an immune-mediated, chronic-relapsing, disabling disorder which is associated with increased mortality and poor patients' quality of life. Patients with IBD are at increased risk of infections for many reasons. In fact, IBD often requires a lifelong immunosuppressive and/or biologic therapy, both commonly associated with respiratory and opportunistic infections, but also gastrointestinal, urinary tract infections, and sepsis. Moreover, impaired spleen function has been found in a considerable proportion of IBD patients, further increasing the risk of developing infections sustained by encapsulated bacteria, such as S. pneumoniae, H. influenzae, and N. meningitidis. Finally, comorbidities and surgery represent additional risk factors for these patients. Despite the availability of vaccinations against the most common serotypes of encapsulated bacteria, uncertainties still exist regarding a proper vaccination strategy and the actual effectiveness of vaccinations in this particular setting. Aim of this narrative review is to focus on the broad topic of vaccinations against encapsulated bacteria in IBD patients, discussing the clinical impact of infections, predisposing factors, vaccinations strategies, and unmet research and clinical needs.
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Affiliation(s)
- Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Caterina Mengoli
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Marta Vernero
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Nicola Aronico
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Laura Conti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Sara Cococcia
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
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Spivey CA, Winthrop KL, Griffith J, Kaplan CM, Qiao Y, Postlethwaite AE, Wang J. Retrospective Analysis of the Impact of Adalimumab Initiation on Corticosteroid Utilization and Medical Costs Among Biologic-Naïve Patients with Rheumatoid Arthritis. Rheumatol Ther 2020; 7:133-147. [PMID: 31741182 PMCID: PMC7021911 DOI: 10.1007/s40744-019-00184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Treatment guidelines recommend low-dose corticosteroids as short-term therapy among rheumatoid arthritis (RA) patients. However, it may be difficult to wean/eliminate steroids once initiated. Initiation of more effective therapies such as biologics may help to taper corticosteroid use. The objective was to examine the impact of adalimumab (ADA) initiation on steroid utilization and non-drug medical costs among patients with RA. METHODS A retrospective analysis was conducted among adult RA patients initiating ADA as the initial biologic in the MarketScan Database (2012-2016). Study outcomes included whether oral/injectable steroids were used, daily dose, dosage categories (< 5 and ≥ 5 mg/day), number of steroid injections, and non-drug medical costs. Outcomes were compared 6 months pre- and post-ADA initiation. Mixed effects logistic, classical linear, multinomial logistic models, and linear model with a log link and gamma distribution were used to adjust for patient demographic and health characteristics. RESULTS The sample included 7404 ADA initiators. Compared to pre-ADA initiation, in the post-initiation period there was a reduction in proportions of patients using oral steroids (from 71.80 to 62.56%) and injectable steroids (from 34.91 to 29.88%), average daily dose of oral steroids (from 3.30 to 2.62 mg/day), patients with dose ≥ 5 mg/day (from 21.76 to 16.34%), number of injections (from 0.64 to 0.53), and non-drug medical costs (from $5356.30 to $5146.84) (P < 0.01). The multivariate analysis produced similar patterns. For example, post-ADA initiation, patients were less likely to use oral steroids [odds ratio (OR) 0.51; 95% confidence interval (CI) 0.47-0.56]; coefficient estimate for daily dose reduction was - 0.68 (95% CI - 0.81 to - 0.56); ratio estimate for medical costs was 0.91 (95% CI 0.86-0.97). CONCLUSIONS Among patients with RA, following ADA initiation, there is a reduction in steroid utilization and dosage, and non-drug medical costs. Prospective studies should be conducted to confirm this relationship in the future.
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Affiliation(s)
- Christina A Spivey
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - Kevin L Winthrop
- Oregon Health & Science University School of Public Health, Portland, OR, USA
| | - Jenny Griffith
- AbbVie, Health Economics and Outcomes Research, North Chicago, IL, USA
| | - Cameron M Kaplan
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Yanru Qiao
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | | | - Junling Wang
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA.
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Chiu YM, Chen DY. Infection risk in patients undergoing treatment for inflammatory arthritis: non-biologics versus biologics. Expert Rev Clin Immunol 2020; 16:207-228. [PMID: 31852268 DOI: 10.1080/1744666x.2019.1705785] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Despite the therapeutic effectiveness of biologics targeting immune cells or cytokines in patients with inflammatory arthritis, which reflects their pathogenic roles, an increased infection risk is observed in those undergoing biological treatment. However, there are limited data regarding the comparison of infection risks in inflammatory arthritis patients treated with non-biologics (csDMARDs), biologics (bDMARDs), including tumor necrosis factor (TNF) inhibitors and non-TNF inhibitors, or targeted synthetic (ts)DMARDs.Areas covered: Through a review of English-language literature as of 30 June 2019, we focus on the existing evidence on the risk of infections caused by bacteria, Mycobacterium tuberculosis, and hepatitis virus in inflammatory arthritis patients undergoing treatment with csDMARDs, bDMARDs, or tsDMARDs.Expert opinion: While the risks of bacterial and mycobacterial infection are increased in arthritis patients treated with csDMARDs, the risks are further higher in those receiving bDMARDs therapy, particularly TNF inhibitors. Regarding HBV infection, antiviral therapy may effectively prevent HBV reactivation in patients receiving bDMARDs, especially rituximab. However, more data are needed to establish effective preventive strategies for HBsAg-negative/HBcAb-positive patients. It seems safe to use cyclosporine and TNF inhibitors in patients with HCV infection, while those undergoing rituximab therapies should be frequently monitored for HCV activity.Abbreviations: ABT: abatacept; ADA: adalimumab; AS: ankylosing spondylitis; bDMARDs: biologic disease-modifying anti-rheumatic drugs; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; CS: corticosteroids; CsA: cyclosporine A; csDMARDs: conventional synthetic disease-modifying anti-rheumatic drugs; CZP: certolizumab; DAAs: direct-acting antiviral agents; DM: diabetes mellitus; DOT: directly observed therapy; EIN: Emerging Infections Network; ETN: etanercept; GOL: golimumab; GPRD: General Practice Research Database; HBV: hepatitis B virus; HBVr: HBV reactivation; HBsAg+: HBsAg-positive; HBsAg-/anti-HBc+: HBsAg-negative anti-HBc antibodies-positive; HCV: hepatitis C virus; HCQ: hydroxychloroquine: IFX: infliximab; IL-6: interleukin-6; JAK: Janus kinase; LEF: leflunomide; LTBI: latent tuberculosis infection; mAb: monoclonal antibody; MTX: methotrexate; OR: odds ratio; PsA: psoriatic arthritis; PMS: post-marketing surveillance; RA: rheumatoid arthritis; TNF: tumor necrosis factor; TNFi: tumor necrosis factor inhibitor; SCK: secukinumab; SSZ: sulfasalazine; TOZ: tocilizumab; RCT: randomized controlled trial; RR: relative risk; RTX: rituximab; 3HP: 3-month once-weekly isoniazid plus rifapentine; TB: tuberculosis; tsDMARDs: targeted synthetic disease-modifying anti-rheumatic drugs; UTK: ustekinumab; WHO: World Health Organization.
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Affiliation(s)
- Ying-Ming Chiu
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Der-Yuan Chen
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan.,Translational Medicine Laboratory, Rheumatic Diseases Research Center, China Medical University Hospital, Taichung, Taiwan.,Program in Translational Medicine and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Institute of Biochemistry, Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
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Ozen G, Pedro S, England BR, Mehta B, Wolfe F, Michaud K. Risk of Serious Infection in Patients With Rheumatoid Arthritis Treated With Biologic Versus Nonbiologic Disease-Modifying Antirheumatic Drugs. ACR Open Rheumatol 2019; 1:424-432. [PMID: 31777822 PMCID: PMC6858027 DOI: 10.1002/acr2.11064] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Objective The objective of this study is to examine the risk of serious infections (SIs) associated with biological disease‐modifying antirheumatic drugs (bDMARDs) compared with conventional synthetic disease‐modifying antirheumatic drugs (csDMARDs) in patients with rheumatoid arthritis (RA). Methods We studied patients with RA who initiated bDMARDs or csDMARDs from 2001 to 2016 in FORWARD–The National Databank for Rheumatic Diseases. Disease‐modifying antirheumatic drugs (DMARDs) were categorized into three groups: (1) csDMARDs (bDMARD‐naïve; reference), (2) tumor necrosis factor α inhibitors (TNFis), and (3) non‐TNFi biologics (abatacept, rituximab, tocilizumab, and anakinra). SIs were defined as those requiring intravenous antibiotics or hospitalization or those resulting in death. We calculated the propensity score (PS), which reflected the probability of receiving a specific DMARD group, and estimated the hazard ratio (HR) (with the 95% confidence interval [CI]) for SI from multivariable Cox models, adjusting for PS and time‐varying confounders. Results A total of 694 (5.9%) first SIs were identified in 11 623 patients with RA during 27 552 patient‐years of follow‐up. The SI incidence rate per 1000 patient‐years was 22.4 (95% CI 19.2‐26.1) for csDMARDs, 26.9 (95% CI 24.5‐29.6) for TNFis, and 23.3 (95% CI 19.0‐28.5) for non‐TNFi bDMARDs. Adjusted HRs for SIs were 1.33 (95% CI 1.05‐1.68) for TNFis and 1.48 (95% CI 1.02‐2.16) for non‐TNFi bDMARDs, compared with csDMARDs. The SI risk with non‐TNFi bDMARDs versus TNFis was not different. Other risk factors for SI were older age, higher comorbidity burden (particularly pulmonary disease), higher weighted cumulative prednisone dose, disability and disease activity, and number of prior csDMARD failures. Conclusion TNFis and non‐TNFi bDMARDs were associated with an increased SI risk compared with csDMARDs in RA, even after accounting for risk‐associated patient characteristics.
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Affiliation(s)
| | - Sofia Pedro
- FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
| | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System Omaha
| | - Bella Mehta
- Hospital for Special Surgery New York New York
| | - Frederick Wolfe
- FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD-The National Databank for Rheumatic Diseases Wichita Kansas
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Abatacept initiation in rheumatoid arthritis and the risk of serious infection: A population-based cohort study. Semin Arthritis Rheum 2019; 48:1053-1058. [DOI: 10.1016/j.semarthrit.2019.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 11/19/2022]
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15
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Lee EB, Yamanaka H, Liu Y, Tsai W, Chen C, Kwok K, Yoo H, Llamado LJ, Wang L, Luo Y, Sugiyama N, Tanaka Y. Efficacy and safety of tofacitinib for the treatment of rheumatoid arthritis in patients from the Asia-Pacific region: Post-hoc analyses of pooled clinical study data. Int J Rheum Dis 2019; 22:1094-1106. [PMID: 30900375 PMCID: PMC6617812 DOI: 10.1111/1756-185x.13516] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 01/08/2019] [Accepted: 01/27/2019] [Indexed: 02/05/2023]
Abstract
AIM We report tofacitinib efficacy and safety in Asia-Pacific patients who participated in the rheumatoid arthritis (RA) clinical development program. METHOD This post-hoc analysis included pooled data from patients with RA in the Asia-Pacific region treated with tofacitinib with/without conventional synthetic disease-modifying antirheumatic drugs in Phase (P)1, 2, 3, and long-term extension (LTE) studies (one LTE ongoing; January 2016 data-cut). Efficacy was assessed over 24 months in patients who received tofacitinib 5 (N = 397) or 10 (N = 382) mg twice daily or placebo (N = 243) in three P2 and five P3 studies. Endpoints included American College of Rheumatology (ACR)20/50/70 responses, Disease Activity Score in 28 joints, erythrocyte sedimentation rate (DAS28-4[ESR]) and Clinical Disease Activity Index (CDAI) remission rates, and change from baseline in Health Assessment Questionnaire-Disability Index (∆HAQ-DI). Safety data pooled over 92 months from one P1, four P2, six P3, and two LTE studies for all tofacitinib doses (N = 1464) included incidence rates (IRs) (patients with events/100 patient-years) for adverse events (AEs) of special interest. RESULTS At month 3, patients receiving tofacitinib 5/10 mg twice daily improved vs placebo in ACR20 (69.2%/77.9% vs 27.5%), ACR50 (36.9%/44.4% vs 9.5%), and ACR70 (15.1%/22.4% vs 2.7%) responses, remission rates for DAS28-4(ESR) (8.5%/18.5% vs 2.6%) and CDAI (6.1%/12.3% vs 0.5%), and ∆HAQ-DI (-0.5/-0.6 vs -0.1); improvements were sustained through 24 months. IRs (95% CI) were 9.4 (8.5, 10.3) for serious AEs, 9.1 (8.3, 10.1) for discontinuations due to AEs, 3.7 (3.2, 4.3) for serious infections, 5.9 (5.2, 6.7) for herpes zoster, and 0.8 (0.6, 1.1) for malignancies (excluding non-melanoma skin cancer). CONCLUSION In Asia-Pacific patients, tofacitinib improved signs/symptoms over 24 months. Safety over 92 months was generally consistent with global tofacitinib studies; however, infection IRs were higher in Asia-Pacific patients.
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Affiliation(s)
- Eun Bong Lee
- Seoul National University College of MedicineSeoulKorea
| | | | - Yi Liu
- West China Hospital of Sichuan UniversitySichuanChina
| | | | | | | | | | | | | | | | | | - Yoshiya Tanaka
- University of Occupational and Environmental Health JapanKitakyushuJapan
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16
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Wiese AD, Griffin MR, Schaffner W, Stein CM, Greevy RA, Mitchel EF, Grijalva CG. Long-acting Opioid Use and the Risk of Serious Infections: A Retrospective Cohort Study. Clin Infect Dis 2019; 68:1862-1869. [PMID: 30239630 PMCID: PMC6522680 DOI: 10.1093/cid/ciy809] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/13/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Although evidence from animal and human studies indicates opioid analgesics increase susceptibility to infections, it is unclear whether the risk varies by specific opioid. We compared the risk of serious infection among patients initiating long-acting opioid analgesics with and without previously reported immunosuppressive properties. METHODS We conducted a retrospective cohort study of Tennessee Medicaid enrollees age ≥18 years initiating long-acting opioids (1995-2015). Hospitalizations for serious infection were identified using validated coding algorithms. We used multivariable Poisson regression models to calculate adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) to compare the infection risk among patients using long-acting opioids with known immunosuppressive properties (morphine, fentanyl, methadone) to the infection risk among patients using long-acting opioids without known immunosuppressive properties (oxycodone, oxymorphone, tramadol) accounting for demographics, opioid dose, comorbidities and pain conditions, medication use, frailty indicators, and healthcare encounter history using exposure propensity scores. We further compared users of individual long-acting opioids to long-acting morphine users (considered the prototypical immunosuppressive opioid). RESULTS Among the 61 240 patients initiating opioids with immunosuppressive properties and 22 811 patients initiating opioids without immunosuppressive properties, we identified 1906 serious infections. Nonimmunosuppressive opioid users had a lower rate of infections than immunosuppressive opioid users (aIRR:0.78 [CI: 0.66-0.91]). Among individual opioids, oxycodone users had a lower rate of infection than morphine users (aIRR:0.73 [CI: 0.60-0.89]). There were no significant differences in the infection risk between other opioids and morphine. CONCLUSION The risk of serious infections among long-acting opioid users varies by opioid type. Providers should carefully consider the risk of serious infections when making pain management decisions.
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Affiliation(s)
- Andrew D Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie R Griffin
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee
| | - William Schaffner
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert A Greevy
- Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward F Mitchel
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee
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Luís M, Freitas J, Costa F, Buttgereit F, Boers M, Jap DS, Santiago T. An updated review of glucocorticoid-related adverse events in patients with rheumatoid arthritis. Expert Opin Drug Saf 2019; 18:581-590. [PMID: 31056959 DOI: 10.1080/14740338.2019.1615052] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Glucocorticoids represent a cornerstone in the treatment of rheumatoid arthritis. Their effect as a disease-modifying treatment in rheumatoid arthritis is well established. Despite this, the risk of adverse events of glucocorticoids, especially in high doses and over a long time, is constantly highlighted. Data on the prevalence and impact of glucocorticoid-related adverse effects in rheumatoid arthritis is needed, therefore, to be regularly revisited. AREAS COVERED In this review, our primary aim was to provide an update of evidence from randomized controlled trials and observational cohort studies on the safety of glucocorticoid treatment in rheumatoid arthritis. Our secondary aim was to provide a critical overview of the concerns raised with both study designs - randomized clinical trials versus nonrandomized observational studies - regarding the assessment of the safety of glucocorticoids in rheumatoid arthritis. EXPERT OPINION In the meantime, adherence to recommendations and consensus on standardized methodologies for monitoring and reporting adverse events is essential to improve our knowledge and competence in the best management of glucocorticoids.
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Affiliation(s)
- Mariana Luís
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - João Freitas
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Flávio Costa
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Frank Buttgereit
- b Department of Rheumatology and Clinical Immunology , Charité University Medicine , Berlin , Germany
| | - Maarten Boers
- c Department of Epidemiology and Biostatistics, Amsterdam Rheumatology and Immunology Center , Amsterdam University Medical Centers, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Da Silva Jap
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal.,e Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Tânia Santiago
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal
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Kim H, Cho S, Lee J, Bae S, Sung Y. Increased risk of opportunistic infection in early rheumatoid arthritis. Int J Rheum Dis 2019; 22:1239-1246. [DOI: 10.1111/1756-185x.13585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 02/13/2019] [Accepted: 03/18/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Hyoungyoung Kim
- Department of Rheumatology Hanyang University Hospital for Rheumatic Diseases Seoul Korea
| | - Soo‐Kyung Cho
- Department of Rheumatology Hanyang University Hospital for Rheumatic Diseases Seoul Korea
- Clinical Research Center for Rheumatoid Arthritis (CRCRA) Hanyang University Seoul Korea
| | - Jiyoung Lee
- Clinical Research Center for Rheumatoid Arthritis (CRCRA) Hanyang University Seoul Korea
| | - Sang‐Cheol Bae
- Department of Rheumatology Hanyang University Hospital for Rheumatic Diseases Seoul Korea
- Clinical Research Center for Rheumatoid Arthritis (CRCRA) Hanyang University Seoul Korea
| | - Yoon‐Kyoung Sung
- Department of Rheumatology Hanyang University Hospital for Rheumatic Diseases Seoul Korea
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Wiese AD, Griffin MR, Stein CM, Schaffner W, Greevy RA, Mitchel EF, Grijalva CG. Validation of discharge diagnosis codes to identify serious infections among middle age and older adults. BMJ Open 2018; 8:e020857. [PMID: 29921683 PMCID: PMC6009457 DOI: 10.1136/bmjopen-2017-020857] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Hospitalisations for serious infections are common among middle age and older adults and frequently used as study outcomes. Yet, few studies have evaluated the performance of diagnosis codes to identify serious infections in this population. We sought to determine the positive predictive value (PPV) of diagnosis codes for identifying hospitalisations due to serious infections among middle age and older adults. SETTING AND PARTICIPANTS We identified hospitalisations for possible infection among adults >=50 years enrolled in the Tennessee Medicaid healthcare programme (2008-2012) using International Classifications of Diseases, Ninth Revision diagnosis codes for pneumonia, meningitis/encephalitis, bacteraemia/sepsis, cellulitis/soft-tissue infections, endocarditis, pyelonephritis and septic arthritis/osteomyelitis. DESIGN Medical records were systematically obtained from hospitals randomly selected from a stratified sampling framework based on geographical region and hospital discharge volume. MEASURES Two trained clinical reviewers used a standardised extraction form to abstract information from medical records. Predefined algorithms served as reference to adjudicate confirmed infection-specific hospitalisations. We calculated the PPV of diagnosis codes using confirmed hospitalisations as reference. Sensitivity analyses determined the robustness of the PPV to definitions that required radiological or microbiological confirmation. We also determined inter-rater reliability between reviewers. RESULTS The PPV of diagnosis codes for hospitalisations for infection (n=716) was 90.2% (95% CI 87.8% to 92.2%). The PPV was highest for pneumonia (96.5% (95% CI 93.9% to 98.0%)) and cellulitis (91.1% (95% CI 84.7% to 94.9%)), and lowest for meningitis/encephalitis (50.0% (95% CI 23.7% to 76.3%)). The adjudication reliability was excellent (92.7% agreement; first agreement coefficient: 0.91). The overall PPV was lower when requiring microbiological confirmation (45%) and when requiring radiological confirmation for pneumonia (79%). CONCLUSIONS Discharge diagnosis codes have a high PPV for identifying hospitalisations for common, serious infections among middle age and older adults. PPV estimates for rare infections were imprecise.
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Affiliation(s)
- Andrew D Wiese
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Marie R Griffin
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee, USA
| | - C Michael Stein
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - William Schaffner
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Edward F Mitchel
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee, USA
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Accortt NA, Lesperance T, Liu M, Rebello S, Trivedi M, Li Y, Curtis JR. Impact of Sustained Remission on the Risk of Serious Infection in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2018; 70:679-684. [PMID: 28960869 PMCID: PMC5947836 DOI: 10.1002/acr.23426] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 09/19/2017] [Indexed: 12/31/2022]
Abstract
Objective This retrospective analysis examined how sustained remission impacted risk of serious infections in patients with rheumatoid arthritis (RA) enrolled in a clinical registry. Methods Inclusion criteria included RA diagnosis, age ≥18 years, and ≥2 Clinical Disease Activity Index (CDAI) scores followed by a followup visit. Index date was the second of 2 visits in which a patient had sustained remission (CDAI ≤2.8), low disease activity (LDA; 2.8 < CDAI ≤10), or moderate‐to‐high disease activity (MHDA; CDAI >10). Followup extended from the index date until first serious infection (requiring intravenous antibiotics or hospitalization) or last followup visit. The crude incidence rate (IR) per 100 patient‐years for serious infections was calculated for the sustained remission, LDA, and MHDA groups. The multivariable‐adjusted incidence rate ratio (IRR) (adjusted for age, sex, and prednisone dose) compared serious infection rates across disease activity groups. Results Most patients were female (>70%); mean age was approximately 60 years. The crude IR (95% confidence interval [95% CI]) per 100 patient‐years for serious infections was 1.03 (0.85–1.26) in the sustained remission group (n = 3,355), 1.92 (1.68–2.19) in the sustained LDA group (n = 3,912), and 2.51 (2.23–2.82) in the sustained MHDA group (n = 5,062). Compared to sustained remission, the serious infection rate was higher in sustained LDA (adjusted IRR 1.69 [95% CI 1.32–2.15]). Compared to sustained LDA, the serious infection rate was higher in sustained MHDA (adjusted IRR 1.30 [95% CI 1.09–1.56]). Conclusion In this study, lower RA disease activity was associated with lower serious infection rates. This finding may motivate patients and health care providers to strive for remission rather than only LDA.
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Affiliation(s)
| | | | - Mei Liu
- Corrona LLC, Southborough, Massachusetts
| | | | | | - Youfu Li
- University of Massachusetts, Worcester
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Jones G, Hall S, Bird P, Littlejohn G, Tymms K, Youssef P, Chung E, Barrett R, Button P. A retrospective review of the persistence on bDMARDs prescribed for the treatment of rheumatoid arthritis in the Australian population. Int J Rheum Dis 2017; 21:1581-1590. [PMID: 29205926 DOI: 10.1111/1756-185x.13243] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To describe the persistence of biologic disease modifying anti-rheumatic drugs (bDMARDs) in Australian rheumatoid arthritis (RA) patients, and assess the influence of methotrexate and other conventional DMARD (cDMARD) concomitant medications, and treatment line on bDMARD persistence and glucocorticoids usage. METHOD RA patients, from the 10% Australian Medicare random sample, aged ≥18 for whom bDMARDs were dispensed were included. Individual sub-cutaneous (SC) anti-tumor necrosis factor-α (anti-TNFα) agents were combined as they were equivalent. RESULTS Data from 1230 patients were analyzed. For all patients the 12-month persistence rates (based on Kaplan-Meier estimates) were 76% for intravenous (IV) tocilizumab, 63% abatacept (SC/IV), 61% SC-anti-TNFs and 36% IV-infliximab. Persistence rates on first-line bDMARDs were 79% (tocilizumab and abatacept), 64% (SC-anti-TNFs) and 13% (infliximab); rates were sustained for tocilizumab but dropped to 49% for abatacept and 51% for SC-anti-TNFs in the second-line setting. Median treatment persistence was 40 months tocilizumab (95% CI: 30-ND), 33 months abatacept (95% CI: 20-ND); 22 months SC-anti-TNF (95% Cl: 18-27), and 4 months infliximab (95% CI: 2-13). Longer persistence was observed for SC-anti-TNFs and abatacept combined with methotrexate or other cDMARDs. For tocilizumab, persistence was robust with or without concomitant medications. The median oral glucocorticoid doses decreased from 4.1 mg/day (min 0, max 21) to 2.0 mg/day (min 0, max 17.3) over 2 years. CONCLUSIONS Treatment persistence was longer on tocilizumab followed by abatacept then SC-anti-TNF therapy and was influenced by co-therapy. Glucocorticoid dosage decreased with bDMARD use. This real-world data highlights that persistence on bDMARDs differs according to biologics mode of action and co-therapy.
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Affiliation(s)
- Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Paul Bird
- University of New South Wales and Combined Rheumatology Practice, Kogarah, NSW, Australia
| | - Geoff Littlejohn
- Monash University and Monash Medical Centre, Clayton, Victoria, Australia
| | - Kathleen Tymms
- Australian National University and Canberra Rheumatology, Canberra, ACT, Australia
| | - Peter Youssef
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Rina Barrett
- Roche Products Pty Limited, Sydney, NSW, Australia
| | - Peter Button
- Roche Products Pty Limited, Sydney, NSW, Australia
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Ramiro S, Sepriano A, Chatzidionysiou K, Nam JL, Smolen JS, van der Heijde D, Dougados M, van Vollenhoven R, Bijlsma JW, Burmester GR, Scholte-Voshaar M, Falzon L, Landewé RBM. Safety of synthetic and biological DMARDs: a systematic literature review informing the 2016 update of the EULAR recommendations for management of rheumatoid arthritis. Ann Rheum Dis 2017; 76:1101-1136. [DOI: 10.1136/annrheumdis-2016-210708] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/28/2016] [Accepted: 02/19/2017] [Indexed: 12/25/2022]
Abstract
ObjectivesTo assess the safety of synthetic (s) and biological (b) disease-modifying antirheumatic drugs (DMARDs) for the management of rheumatoid arthritis (RA) to inform the European League Against Rheumatism recommendations for the management of RA.MethodsSystematic literature review (SLR) of observational studies comparing any DMARD with another intervention for the management of patients with RA. All safety outcomes were included. A comparator group was required for the study to be included. Risk of bias was assessed with the Hayden's tool.ResultsTwenty-six observational studies addressing diverse safety outcomes of therapy with bDMARDs met eligibility criteria (15 on serious infections, 4 on malignancies). Substantial heterogeneity precluded meta-analysis. Together with the evidence from the 2013 SLR, based on 15 studies, 7 at low risk of bias, patients on bDMARDs compared with patients on conventional sDMARDs had a higher risk of serious infections (adjusted HR (aHR) 1.1 to 1.8)—without differences across bDMARDs—a higher risk of tuberculosis (aHR 2.7 to 12.5), but no increased risk of infection by herpes zoster. Patients on bDMARDs did not have an increased risk of malignancies in general, lymphoma or non-melanoma skin cancer, but the risk of melanoma may be slightly increased (aHR 1.5).ConclusionsThese findings confirm the known safety pattern of bDMARDs, including both tumour necrosis factor-α inhibitor (TNFi) and non-TNFi, for the treatment of RA.
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Dose relationship between oral glucocorticoids and tumor necrosis factor inhibitors and the risk of hospitalized infectious events among patients with rheumatoid arthritis. Rheumatol Int 2017; 37:1075-1082. [PMID: 28255642 PMCID: PMC5486791 DOI: 10.1007/s00296-017-3679-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/07/2017] [Indexed: 11/23/2022]
Abstract
The objective of this study was to evaluate the impact of oral glucocorticoid (GC) dose on rates of hospitalized infectious events (HIEs) among RA patients newly exposed to tumor necrosis factor inhibitor (TNFi) therapy. This retrospective cohort study used data from the MarketScan claims database. Incident and prevalent adult RA patients newly exposed to TNFi therapy were identified and assigned to three cohorts: no GC, low-dose GC (≤7.5 mg), and high-dose GC (>7.5 mg); patients could contribute exposure time to multiple cohorts if they changed dose or discontinued GC. The primary outcome was estimated incidence rate (IR) of HIEs per 100 patient-years of GC exposure. A total of 40,933 eligible patients were identified (mean age 53.0 years; 77.4% female). HIE risk increased with increasing GC dose: the IR [95% confidence interval (CI)] was 3.9 (3.63–4.13) for no GC; 6.4 (5.68–7.16) for low-dose GC; and 13.3 (11.9–15.5) for high-dose GC. Adjusted rate ratios (95% CI) were 1.4 (1.21–1.60) for low-dose vs no GC; 2.8 (2.32–3.34) for high-dose vs no GC, and 2.0 (1.66–2.45) for high-dose vs low-dose GC. The risk of HIEs increased with increasing age. HIE risk did not increase with longer exposure to GCs. Oral GCs, regardless of dose, significantly increased the risk of HIEs among RA patients newly initiating TNFi therapy. Steroid dosing must be considered when assessing infection risk in treatment decisions for RA patients.
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Kelly C, Iqbal K, Iman-Gutierrez L, Evans P, Manchegowda K. Lung involvement in inflammatory rheumatic diseases. Best Pract Res Clin Rheumatol 2016; 30:870-888. [PMID: 27964793 DOI: 10.1016/j.berh.2016.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/05/2016] [Accepted: 10/13/2016] [Indexed: 02/08/2023]
Abstract
This chapter describes the involvement of the lung in systemic inflammatory joint disease (IJD) with a particular focus on rheumatoid arthritis, although the topics of pulmonary involvement in ankylosing spondylitis and psoriatic arthritis are also addressed. Interstitial lung disease is the most lethal pulmonary complication of IJD and the chapter describes recent advances in both our understanding of this complication and the therapeutic options that offer real hope for improved outcomes. Although less well recognised, airways disease is just as common and its association with IJD is described in some detail, with a section devoted to the recent surge in interest in bronchiectasis. Acute pulmonary infection is common in IJD and its management is reviewed in some detail. Although pleural disease is less common than it once was, its treatment is explored. We conclude by reviewing the relationship between the drug therapies employed in IJD and their effects on the lung.
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Affiliation(s)
- Clive Kelly
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK.
| | - Kundan Iqbal
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK
| | | | - Phil Evans
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK
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Varela H, Villamañán E, Plasencia C, Romero JA, Ruano M, Balsa A, Herrero A. Safety of antitumour necrosis factor treatments in chronic rheumatic diseases: therapy discontinuations related to side effects. J Clin Pharm Ther 2016; 41:306-9. [DOI: 10.1111/jcpt.12393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 04/01/2016] [Indexed: 11/28/2022]
Affiliation(s)
- H. Varela
- Pharmacy; La Paz University Hospital; Madrid Spain
| | | | - C. Plasencia
- Rheumatology; La Paz University Hospital; Madrid Spain
| | - J. A. Romero
- Pharmacy; La Paz University Hospital; Madrid Spain
| | - M. Ruano
- Pharmacy; La Paz University Hospital; Madrid Spain
| | - A. Balsa
- Rheumatology; La Paz University Hospital; Madrid Spain
| | - A. Herrero
- Pharmacy; La Paz University Hospital; Madrid Spain
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Md Yusof MY, Vital EM, Buch MH. B Cell Therapies, Approved and Emerging: a Review of Infectious Risk and Prevention During Use. Curr Rheumatol Rep 2016; 17:65. [PMID: 26290110 DOI: 10.1007/s11926-015-0539-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The development of B cell-targeted biologics represents a major advance in the treatment of autoimmune rheumatic diseases. As with other immunosuppressive agents, risk of infection is a key clinical concern. This review summarises safety data from 15 years of experience of rituximab in autoimmune diseases with a particular focus on opportunistic infection and class-specific complications and infection risk. Rarely, cases of progressive multifocal leucoencephalopathy in rituximab-treated patients (5/100 000) have accumulated over time although no proven causal association has yet been shown. With repeat cycles of therapy, hypogammaglobulinaemia has been observed in a larger proportion of patients and is associated with increased risk of serious infections. The infection profile of the newer B cell-targeted agent, belimumab, in patients with active systemic lupus erythematosus is also discussed. Data from registries are needed to extend insights further and also to evaluate for any impact with the difference in mode of action of belimumab and infection risk in this population.
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Affiliation(s)
- Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
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Pereira R, Lago P, Faria R, Torres T. Safety of Anti-TNF Therapies in Immune-Mediated Inflammatory Diseases: Focus on Infections and Malignancy. Drug Dev Res 2015; 76:419-27. [DOI: 10.1002/ddr.21285] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/02/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Rui Pereira
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
| | - Paula Lago
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
- Department of Gastroenterology; Centro Hospitalar do Porto; Portugal
| | - Raquel Faria
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
- Clinical Immunology Unit; Centro Hospitalar do Porto; Portugal
| | - Tiago Torres
- Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar do Porto; Portugal
- Department of Dermatology; Centro Hospitalar do Porto; Portugal
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Infections and biologic therapy for rheumatoid arthritis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00067-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Selmi C, Ceribelli A, Naguwa SM, Cantarini L, Shoenfeld Y. Safety issues and concerns of new immunomodulators in rheumatology. Expert Opin Drug Saf 2014; 14:389-99. [PMID: 25518908 DOI: 10.1517/14740338.2015.993605] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The development of biologic therapies has been an enormous leap in the management of patients with rheumatoid and psoriatic arthritis. Since the first anti-TNF-α therapies, numerous molecules have been identified as targets of immunomodulatory therapies, such as IL-1 (anakinra, canakinumab), IL-6 (tocilizumab), CD20(+) B cells (rituximab), CTLA4 (abatacept) and two additional anti-TNF-α therapies (certolizumab pegol, golimumab). AREAS COVERED In the present review, we will describe the safety issues related to the immunosuppressive action of these biologic drugs that are mainly represented by infection and malignancy. The risk of infection should be identified before initiating a biologic treatment and markers checked over time, in particular for tuberculosis and hepatitis B and C viruses. Other infections (bacterial, viral, parasitic; opportunistic; surgery-related) and safety issues may require temporary interruption of the treatment until complete resolution. No significantly increased risk of malignancy, both hematological and solid, has been associated with the use of biologic agents. In all cases, it is difficult to dissect the risks related to biologics from those related to baseline treatments. EXPERT OPINION Detailed medical history and laboratory screening should be performed before starting biologic therapies. Clinicians should be aware of the different safety profiles associated with different molecules and they should follow up data coming out of the existing registries for biologics in regard to new or old side effects.
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Affiliation(s)
- Carlo Selmi
- Humanitas Research Hospital, Division of Rheumatology and Clinical Immunology , Rozzano, Milan , Italy
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30
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Westra J, van Assen S, Wilting KR, Land J, Horst G, de Haan A, Bijl M. Rituximab impairs immunoglobulin (Ig)M and IgG (subclass) responses after influenza vaccination in rheumatoid arthritis patients. Clin Exp Immunol 2014; 178:40-7. [PMID: 24889761 DOI: 10.1111/cei.12390] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 01/02/2023] Open
Abstract
Rituximab (RTX) treatment in rheumatoid arthritis (RA) patients severely hampers humoral response after influenza vaccination as determined by haemagglutination inhibition assay (HI). It is not known whether HI reflects both immunoglobulin (Ig)M and IgG (subclass) influenza response, and whether IgM antibodies contribute to the low rate of influenza infection seen in RA patients. Twenty RA patients on methotrexate (MTX), 23 on RTX and 28 healthy controls (HC) received trivalent influenza subunit vaccination. Before and 28 days after vaccination, H1N1- and H3N2-specific antibodies were measured by HI and by IgM and IgG (subclass) enzyme-linked immunosorbent assay (ELISA). B cell activating factor (BAFF) levels were determined in serum samples before vaccination. Vaccination induced a significant increase of IgM and IgG (IgG1 and IgG3) antibodies against both strains in the HC and MTX groups (all P < 0·01), but not in the RTX group. HI correlated significantly in all cases with IgG (IgG1) but not with IgM. In RTX late patients (RTX treatment 6-10 months before vaccination), IgG (IgG1 and IgG3) response to vaccination was restored, but not IgM response. BAFF levels were significantly increased in RA-RTX patients and correlated with total IgG levels. Haemagglutination inhibition assay, used as gold standard, detects primarily IgG (IgG1) responses. IgM- and IgG influenza-specific antibodies increase after vaccination in HC and RA patients except in patients on RTX treatment. BAFF levels are increased in both early and late RTX-treated patients, but do not correlate with an influenza-specific antibody response.
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Affiliation(s)
- J Westra
- Department of Rheumatology and Clinical Immunology, University of Groningen, Groningen, the Netherlands
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Chiang YC, Kuo LN, Yen YH, Tang CH, Chen HY. Infection risk in patients with rheumatoid arthritis treated with etanercept or adalimumab. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2014; 116:319-327. [PMID: 25022467 DOI: 10.1016/j.cmpb.2014.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 05/23/2014] [Accepted: 06/13/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To compare the risk of infection for rheumatoid arthritis (RA) patients who took etanercept or adalimumab medication in a nationwide population. METHODS RA patients who took etanercept or adalimumab were identified in the Taiwan's National Health Insurance Research Database. The composite outcome of serious infections, including hospitalization for infection, reception of an antimicrobial injection, and tuberculosis were followed for 365 days. A Kaplan-Meier survival curve with a log-rank test and Cox proportional hazards regression were used to compare risks of infection between the two cohorts of tumor necrosis factor (TNF)-α antagonists users. Hazard ratios (HRs) were obtained and adjusted with propensity scores and clinical factors. Sensitivity analyses and subgroup analyses were also performed. RESULTS In total, 1660 incident etanercept users and 484 incident adalimumab users were eligible for the analysis. The unadjusted HR for infection of the etanercept users was significantly higher than that of the adalimumab users (HR: 1.93; 95% confidence interval (CI): 1.09-3.42; p=0.024). The HRs were 2.04 (95% CI: 1.14-3.65; p=0.016) and 2.02 (95% CI: 1.13-3.61; p=0.018) after adjusting for propensity scores and for propensity scores in addition to clinical factors, respectively. The subgroup analyses revealed that HRs for composite infection was significantly higher in patient subgroups of older age, female, as well as patients who did not have DM, COPD, and hospitalization history at the baseline. CONCLUSION In this head-to-head cohort study involving a nationwide population of patients with RA, etanercept users demonstrated a higher risk of infection than adalimumab users. Results of this study suggest the possible existence of an intra-class difference in infection risk among TNF-α antagonists.
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Affiliation(s)
- Yi-Chun Chiang
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Li-Na Kuo
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Yu-Hsuan Yen
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Hsiang-Yin Chen
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Pharmacy, Taipei Medical University, Taipei, Taiwan.
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Fortunet C, Pers YM, Lambert J, Godfrin-Valnet M, Constant E, Devilliers H, Gaudin P, Jorgensen C, Prades BP, Wendling D, Maillefert JF. Tocilizumab induces corticosteroid sparing in rheumatoid arthritis patients in clinical practice. Rheumatology (Oxford) 2014; 54:672-7. [DOI: 10.1093/rheumatology/keu339] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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[Medicinal prophylaxis during intensified immunosuppression in children and adolescents : part 2]. Z Rheumatol 2014; 72:896-909. [PMID: 23929242 DOI: 10.1007/s00393-013-1203-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The goal of modern antirheumatic therapy is to achieve an optimized disease control. This is individually achieved by an intensified immunosuppression (IS) frequently combining different immunosuppressive agents. Intensified IS should be accompanied by a standardized protocol to monitor immunological changes in the patient. This should include checklists (see Part 1 Screening during intensified IS in children and adolescents). An individual risk stratification according to the planned IS allows a prediction of infectious disease risks for the patient and, thus, individual infection prophylaxis. In addition, standardized management of patients with fever while receiving intensified IS may prevent further complications.
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Alawneh KM, Ayesh MH, Khassawneh BY, Saadeh SS, Smadi M, Bashaireh K. Anti-TNF therapy in Jordan: a focus on severe infections and tuberculosis. Biologics 2014; 8:193-8. [PMID: 24790412 PMCID: PMC4003144 DOI: 10.2147/btt.s59574] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background A high rate of infection has been reported in patients receiving treatment with anti-tumor necrosis factor (anti-TNF). This study describes the rate of and risk factors for serious infections in patients receiving anti-TNF agents in Jordan. Methods This retrospective observational study was conducted at a large tertiary referral center in the north of Jordan. Between January 2006 and January 2012, 199 patients who received an anti-TNF agent (infliximab, adalimumab, or etanercept) were included. Patients received the anti-TNF treatment for rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, or other conditions. A serious infection was defined as any bacterial, viral, or fungal infection that required hospitalization, administration of appropriate intravenous antimicrobial therapy, and temporary withholding of anti-TNF treatment. Results The mean duration of anti-TNF treatment was 26.2 months. Steroids were used in 29.1% of patients, while 54.8% were given additional immunosuppressant therapy (methotrexate or azathioprine). Only one anti-TNF agent was given in 70.4% of patients, while 29.6% received different anti-TNF agents for the duration of treatment. Serious infections were documented in 39 patients (19.6%), including respiratory tract infections (41%), urinary tract infections (30.8%), and skin infections (20.5%), and extrapulmonary tuberculosis in three patients (7.7%). Exposure to more than one anti-TNF agent was the only factor associated with a significant increase in the rate of infection (relative risk 1.9, 95% confidence interval 1.06–4.0, P=0.03). Conclusion Serious infections, including tuberculosis, were a common problem in patients receiving anti-TNF agents, and exposure to more than one anti-TNF agent increased the risk of serious infection.
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Affiliation(s)
- Khaldoon M Alawneh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Mahmoud H Ayesh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Basheer Y Khassawneh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Salwa Shihadeh Saadeh
- Department of Medicine, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Mahmoud Smadi
- College of Science, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaldoun Bashaireh
- Department of Special Surgery, College of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
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Ramiro S, Gaujoux-Viala C, Nam JL, Smolen JS, Buch M, Gossec L, van der Heijde D, Winthrop K, Landewé R. Safety of synthetic and biological DMARDs: a systematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis. Ann Rheum Dis 2014; 73:529-35. [PMID: 24401994 DOI: 10.1136/annrheumdis-2013-204575] [Citation(s) in RCA: 235] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To update the evidence for the safety of synthetic disease-modifying antirheumatic drugs (sDMARDs), glucocorticoids (GC) and biological DMARDs (bDMARDs) in patients with rheumatoid arthritis (RA) to inform the European League Against Rheumatism (EULAR) recommendations for the management of RA. METHODS Systematic literature review (SLR) of observational studies (including registries). Interventions were any bDMARD (anakinra, infliximab, etanercept, adalimumab, rituximab, abatacept, tocilizumab, golimumab or certolizumab pegol) or sDMARD (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, gold/auranofin, azathioprine, chlorambucil, chloroquine, cyclosporin, cyclophosphamide, mycophenolate, minocycline, penicillamine, tacrolimus or tofacitinib) and a comparator was required. Information on GCs was collected from the included studies. All safety outcomes were included. RESULTS Forty-nine observational studies addressing diverse safety outcomes of therapy with bDMARDs met eligibility criteria. Substantial heterogeneity precluded meta-analysis of any of the outcomes. Patients on tumour necrosis factor inhibitors (TNFi) compared to patients on conventional sDMARDs had a higher risk of serious infections (adjusted HR (aHR) 1.1-1.8), a higher risk of tuberculosis, and an increased risk of infection by herpes zoster cannot be excluded. Patients on TNFi did not have an increased risk for malignancies in general, lymphoma or non-melanoma skin cancer, but the risk of melanoma may be slightly increased (aHR 1.5). From the studies identified on conventional sDMARDs, no new safety signals were found. CONCLUSIONS The findings from this SLR confirm the known safety pattern of sDMARDs and bDMARDs for the treatment of RA.
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Affiliation(s)
- Sofia Ramiro
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, , Amsterdam, The Netherlands
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Kay J, Fleischmann R, Keystone E, Hsia EC, Hsu B, Mack M, Goldstein N, Braun J, Kavanaugh A. Golimumab 3-year safety update: an analysis of pooled data from the long-term extensions of randomised, double-blind, placebo-controlled trials conducted in patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis. Ann Rheum Dis 2013; 74:538-46. [PMID: 24344160 PMCID: PMC4345908 DOI: 10.1136/annrheumdis-2013-204195] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective To assess pooled golimumab safety up to year 3 of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) trials. Methods Golimumab 50 and 100 mg, administered subcutaneously (SC) every 4 weeks (q4wk), were assessed in patients with active RA (methotrexate-naïve, methotrexate-experienced and anti-TNF (tumour necrosis factor)-experienced), PsA or AS, despite conventional therapy. Placebo control continued up to week (wk) 24 (wk 52, methotrexate-naïve), with early escape at wk 16 (wk 28, methotrexate-naïve); subsequently, all patients received golimumab 50 or 100 mg q4wk. After the blinded controlled period, golimumab doses could be adjusted per investigator discretion. Pooled safety analyses reported herein include data from placebo-controlled and uncontrolled study periods up to wk 160. Determinations of incidences/100 patient-years (pt-yrs) for rare events also included RA patients from a phase IIb trial. Results Across five phase III trials of SC golimumab, 639 patients received placebo and 2226 received golimumab 50 mg (n=1249) and/or 100 mg (n=1501) up to wk 160 (patients may be included in more than one group because non-responders were allowed early escape); 1179 patients were treated for ≥156 weeks. For placebo, golimumab 50 mg and golimumab 100 mg, respective adverse event incidences/100 pt-yrs (95% CIs) up to wk 160 were: 0.28 (0.01 to 1.56), 0.30 (0.12 to 0.62), 0.41 (0.23 to 0.69) for death; 5.31 (3.20 to 8.30), 3.03 (2.36 to 3.82), 5.09 (4.36 to 5.90) for serious infection; 0.00 (0.00 to 0.84), 0.17 (0.05 to 0.44), 0.35 (0.18 to 0.62) for tuberculosis; 0.00 (0.00 to 0.84), 0.13 (0.03 to 0.38), 0.24 (0.10 to 0.46) for opportunistic infection; 0.00 (0.00 to 0.84), 0.00 (0.00 to 0.13), 0.12 (0.03 to 0.30) for demyelination; and 0.00 (0.00 to 0.84), 0.04 (0.00 to 0.24), 0.18 (0.06 to 0.38) for lymphoma. Conclusions SC golimumab safety up to 3 years remained consistent with that of other TNF antagonists. Golimumab 100 mg showed numerically higher incidences of serious infections, demyelinating events and lymphoma than 50 mg; safety follow-up up to year 5 continues.
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Affiliation(s)
- Jonathan Kay
- Division of Rheumatology, Department of Medicine, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Roy Fleischmann
- Department of Rheumatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Edward Keystone
- Department of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth C Hsia
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin Hsu
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Mack
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Neil Goldstein
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Jürgen Braun
- Department of Rheumatology, Rheumazentrum Ruhrgebeit, Herne, Germany
| | - Arthur Kavanaugh
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, California, USA
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Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax 2013; 68:1029-36. [PMID: 24130228 PMCID: PMC3812880 DOI: 10.1136/thoraxjnl-2012-202872] [Citation(s) in RCA: 298] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Inhaled corticosteroids (ICS) are known to increase the risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). It is unclear whether the risk of pneumonia varies for different inhaled agents, particularly fluticasone and budesonide, and increases with the dose and long-term duration of use. Methods We formed a new-user cohort of patients with COPD treated during 1990–2005. Subjects were identified using the Quebec health insurance databases and followed through 2007 or until a serious pneumonia event, defined as a first hospitalisation for or death from pneumonia. A nested case–control analysis was used to estimate the rate ratio (RR) of serious pneumonia associated with current ICS use, adjusted for age, sex, respiratory disease severity and comorbidity. Results The cohort included 163 514 patients, of which 20 344 had a serious pneumonia event during the 5.4 years of follow-up (incidence rate 2.4/100/year). Current use of ICS was associated with a 69% increase in the rate of serious pneumonia (RR 1.69; 95% CI 1.63 to 1.75). The risk was sustained with long-term use and declined gradually after stopping ICS use, disappearing after 6 months (RR 1.08; 95% CI 0.99 to 1.17). The rate of serious pneumonia was higher with fluticasone (RR 2.01; 95% CI 1.93 to 2.10), increasing with the daily dose, but was much lower with budesonide (RR 1.17; 95% CI 1.09 to 1.26). Conclusions ICS use by patients with COPD increases the risk of serious pneumonia. The risk is particularly elevated and dose related with fluticasone. While residual confounding cannot be ruled out, the results are consistent with those from recent randomised trials.
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Affiliation(s)
- Samy Suissa
- Departments of Epidemiology and Biostatistics and of Medicine, Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, , Montreal, Québec, Canada
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Ernst D, Schmidt R, Witte T. Sekundäre Immundefizienz bei rheumatologischen Erkrankungen. Z Rheumatol 2013; 72:634-40, 642. [DOI: 10.1007/s00393-013-1160-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jain A, Singh JA. Harms of TNF inhibitors in rheumatic diseases: a focused review of the literature. Immunotherapy 2013; 5:265-99. [PMID: 23444956 DOI: 10.2217/imt.13.10] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A focused review of the risk of harms of anti-TNF inhibitors in adult rheumatic diseases was performed. An increased risk of serious infections, tuberculosis and other opportunistic infections has been reported across various studies, with etanercept appearing to have a modestly better safety profile in terms of tuberculosis and opportunistic infections, and infliximab posing a higher risk of serious infections. Evidence suggests no increase in risk of cancer with anti-TNF biologics, but there is an increased risk of non-melanoma skin cancer. Elderly patients appear to be at increased risk of incident or worsening heart failure with anti-TNF biologic use.
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Affiliation(s)
- Archana Jain
- Department of Medicine at School of Medicine, University of Alabama, Birmingham, AL, USA.
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Curtis JR, Sharma P, Arora T, Bharat A, Barnes I, Morrisey MA, Kilgore M, Saag KG, Wright NC, Yun HG, Delzell E. Physicians' explanations for apparent gaps in the quality of rheumatology care: results from the US Medicare Physician Quality Reporting System. Arthritis Care Res (Hoboken) 2013; 65:235-43. [PMID: 22556118 DOI: 10.1002/acr.21713] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 07/09/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The metrics used to assess quality of care and pay for performance in rheumatology are increasingly important. The Centers for Medicare and Medicaid Services established the Physician Quality Reporting System (PQRS) to allow physicians to report performance measures for many conditions, including osteoporosis and rheumatoid arthritis (RA). We described the frequency and nature of physician-reported reasons why recommended care for individual osteoporosis and RA patients was not provided. METHODS Using national data on Medicare fee-for-service beneficiaries (2007-2009), we identified health care providers reporting on quality of care for any of 3 osteoporosis or 3 RA measures. PQRS reason codes allowed physicians to submit explanations why recommended care was not given. RESULTS In 2009, 1,775 physicians reported on ≥1 osteoporosis PQRS measure and 630 physicians reported on ≥1 RA measure. For the older women whose physician reported on lifetime dual x-ray absorptiometry screening at least once since the age of 60 years via PQRS, 76% received such screening. Among the patients with physician-diagnosed osteoporosis reported via PQRS, 82% received prescription osteoporosis medication in the preceding year. For RA medication use reported via PQRS, 89% of patients received a disease-modifying antirheumatic drug or a biologic agent. For the remaining 11-24% of osteoporosis and RA patients, physicians reported medical, patient, system, or other reasons why care was considered but not provided. CONCLUSION A substantial fraction of Medicare enrollees who did not receive recommended osteoporosis or RA care had physician-documented reasons for why care was not provided. For Medicare and other health plans that implement penalties for apparent nonperformance or delivery of suboptimal care, it will be important to allow physicians to provide reasons that care was considered medically inappropriate, refused, or otherwise not feasible.
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Johnston SS, Turpcu A, Shi N, Fowler R, Chu BC, Alexander K. Risk of infections in rheumatoid arthritis patients switching from anti-TNF agents to rituximab, abatacept, or another anti-TNF agent, a retrospective administrative claims analysis. Semin Arthritis Rheum 2013; 43:39-47. [PMID: 23453683 DOI: 10.1016/j.semarthrit.2012.12.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 12/20/2012] [Accepted: 12/24/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study compared the incidence and hazard of ICD-9-CM-coded infections and severe infections in rheumatoid arthritis (RA) patients treated with subsequent-line (SL) BIOs (BIO) after switching from first-line (FL) anti-TNF therapy (anti-TNF). METHODS Retrospective analysis of a large U.S. claims database. RA patients initiating an FL anti-TNF between 1/1/2004 and 3/31/2010 were identified and followed forward in time to capture all SL BIO episodes through 3/31/2010. SL BIO episodes were classified into: abatacept, adalimumab, etanercept, infliximab, or rituximab. Multivariate mixed-effects survival models compared the hazard of infections and severe infections across the SL BIO episodes with adjustment for demographic and clinical confounders. RESULTS In total, 4332 SL BIO episodes were identified: mean age 55 years; 80% female. In adjusted analyses: when compared to rituximab, the hazard of all infections was significantly higher for adalimumab (hazard ratio [HR] = 1.31, 95% confidence interval [CI] = 1.09-1.55), etanercept (HR = 1.44, 95% CI = 1.20-1.72), and infliximab (HR = 1.30, 95% CI = 1.07-1.57), and insignificantly different for abatacept (HR = 1.18, 95% CI = 0.98-1.41); when compared to rituximab, the hazard of severe infection was significantly higher for infliximab (HR = 1.62, 95% CI = 1.03-2.55), and insignificantly different for abatacept (HR = 1.21, 95% CI = 0.78-1.88), adalimumab (HR = 1.10, 95% CI = 0.72-1.68), and etanercept (HR = 1.27, 95% CI = 0.83-1.95). CONCLUSIONS In RA patients treated with SL BIO, a 30-44% higher hazard of all infection was observed in anti-TNFs versus rituximab with a 62% higher hazard of severe infection observed in infliximab versus rituximab. This study used a non-randomized, observational design and is therefore subject to confounding from unmeasured factors that influence both treatment choice and infection risk.
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Affiliation(s)
- Stephen S Johnston
- Outcomes Research, Truven Health Analytics, 7700 Old Georgetown Road, Bethesda, MD 20814, USA.
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Glehr M, Fritsch-Breisach M, Lohberger B, Walzer SM, Moazedi-Fuerst F, Rinner B, Gruber G, Graninger W, Leithner A, Windhager R. Influence of resveratrol on rheumatoid fibroblast-like synoviocytes analysed with gene chip transcription. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2013; 20:310-318. [PMID: 23137833 DOI: 10.1016/j.phymed.2012.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 08/16/2012] [Accepted: 09/21/2012] [Indexed: 06/01/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease that primarily attacks joints and is therefore a common cause of chronic disability and articular destruction. The hyperplastic growth of RA-fibroblast-like synoviocytes (FLSs) and their resistance against apoptosis are considered pathological hallmarks of RA. The natural antioxidant resveratrol is known for its antiproliferative and pro-apoptotic properties. This study investigated the effect of resveratrol on RA-FLS. RA-FLS were isolated from the synovium of 10 RA patients undergoing synovectomy or joint replacement surgery. RA-FLS were first stressed by pre-incubation with interleukin 1beta (IL-1β) and then treated with 100 μM resveratrol for 24h. In order to evaluate the influence of resveratrol on the transcription of genes, a Gene Chip Human Gene 1.0 ST Array was applied. In addition, the effect of dexamethasone on proliferation and apoptosis of RA-FLS was compared with that of resveratrol. Gene array analysis showed highly significant effects of resveratrol on the expression of genes involved in mitosis, cell cycle, chromosome segregation and apoptosis. qRT-PCR, caspase-3/7 and proliferation assays confirmed the results of gene array analysis. In comparison, dexamethasone showed little to no effect on reducing cell proliferation and apoptosis. Our in vitro findings point towards resveratrol as a promising new therapeutic approach for local intra-articular application against RA, and further clinical studies will be necessary.
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Affiliation(s)
- Mathias Glehr
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria
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Curtis JR, Xie F, Chen L, Muntner P, Grijalva CG, Spettell C, Fernandes J, McMahan RM, Baddley JW, Saag KG, Beukelman T, Delzell E. Use of a disease risk score to compare serious infections associated with anti-tumor necrosis factor therapy among high- versus lower-risk rheumatoid arthritis patients. Arthritis Care Res (Hoboken) 2013; 64:1480-9. [PMID: 22833479 DOI: 10.1002/acr.21805] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate whether rates of serious infection with anti-tumor necrosis factor (anti-TNF) therapy in rheumatoid arthritis (RA) patients differ in magnitude by specific drugs and patient characteristics. METHODS Among new nonbiologic disease-modifying antirheumatic drug users enrolled in Medicare and Medicaid or a large US commercial health plan, we created and validated a person-specific infection risk score based on age, demographics, insurance type, glucocorticoid dose, and comorbidities to identify patients at high risk for hospitalized infections. We then applied this risk score to new users of infliximab, etanercept, and adalimumab and compared the observed 1-year rates of infection to one another and to the predicted infection risk score estimated in the absence of anti-TNF exposure. RESULTS Among 11,657 RA patients initiating anti-TNF therapy, the observed 1-year rate of infection was 14.2 infections per 100 person-years in older patients (age ≥65 years) and 4.8 in younger patients (age <65 years). There was a relatively constant rate difference of ~1-4 infections per 100 person-years associated with anti-TNF therapy across the range of the infection risk score. Infliximab had a significantly greater adjusted rate of infection compared to etanercept and adalimumab in both high- and lower-risk RA patients. CONCLUSION The rate of serious infections for anti-TNF agents was incrementally increased by a fixed absolute difference irrespective of age, comorbidities, and other factors that contributed to infections. Older patients and those with high comorbidity burdens should be reassured that the magnitude of their incremental risk with anti-TNF agents is not greater than for lower-risk patients.
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Winthrop KL. Infections and biologic therapy in rheumatoid arthritis: our changing understanding of risk and prevention. Rheum Dis Clin North Am 2012; 38:727-45. [PMID: 23137579 DOI: 10.1016/j.rdc.2012.08.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with rheumatoid arthritis are at higher risk for serious infections and death from infection than the general public. Prednisone and biologic agents increase this risk, although the risk associated with biologics can be mitigated when such agents act as prednisone-sparing therapies. Some of the important causes of infectious morbidity in this setting are preventable with screening (eg, tuberculosis) or vaccination (eg, herpes zoster).
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Affiliation(s)
- Kevin L Winthrop
- Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR, USA.
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The expression of interleukin-12 is increased by MAP kinase phosphatase-1 through a mechanism related to interferon regulatory factor 1. Mol Immunol 2012; 51:219-26. [PMID: 22464096 DOI: 10.1016/j.molimm.2012.03.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 03/05/2012] [Accepted: 03/06/2012] [Indexed: 12/27/2022]
Abstract
Mitogen-activated protein kinase phosphatase-1 (MKP-1) is a nuclear tyrosine/threonine phosphatase that inhibits p38 mitogen-activated protein kinase (MAPK) activity. We and others have shown that MKP-1 deficiency leads to excessive activation of innate immunity and inflammatory gene expression. Surprisingly, the present study shows that MKP-1 is a positive regulator of IL-12 expression in macrophages suggesting a stimulatory effect on Th1 type immune response. In the present study, we found that LPS-induced expression of IL-12p40 was lower in primary mouse peritoneal macrophages (PMs) and bone marrow-derived macrophages from MKP-1 deficient mice than in cells from wild-type mice whereas TNF expression was enhanced as expected. Correspondingly, the inhibition of p38 MAPK by pharmacologic inhibitors BIRB 796 and SB 202190 enhanced LPS-induced IL-12p40 production. Silencing of interferon regulatory factor 1 (IRF1) by siRNA inhibited the expression of IL-12p40 in J774 macrophages, showing that IRF1 is an important factor regulating IL-12p40 expression. BIRB 796 enhanced LPS-induced expression of IRF1 in J774 macrophages and in PMs from wild-type mice, and IRF1 expression was reduced in PMs from MKP-1 deficient mice. In conclusions, our results show that MKP-1 increases and p38 MAPK decreases the expression of IL-12 by enhancing the expression of IRF1. MKP-1, through regulation of IRF1 and IL-12, therefore may be an important factor supporting the development of Th1 type of immune response and anti-microbial defense.
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Reply to the letter by Jean-Marie Berthelot. Joint Bone Spine 2012. [DOI: 10.1016/j.jbspin.2011.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Grijalva CG, Chen L, Delzell E, Baddley JW, Beukelman T, Winthrop KL, Griffin MR, Herrinton LJ, Liu L, Ouellet-Hellstrom R, Patkar NM, Solomon DH, Lewis JD, Xie F, Saag KG, Curtis JR. Initiation of tumor necrosis factor-α antagonists and the risk of hospitalization for infection in patients with autoimmune diseases. JAMA 2011; 306:2331-9. [PMID: 22056398 PMCID: PMC3428224 DOI: 10.1001/jama.2011.1692] [Citation(s) in RCA: 264] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT Although tumor necrosis factor (TNF)-α antagonists are increasingly used in place of nonbiologic comparator medications, their safety profile remains incomplete. OBJECTIVES To determine whether initiation of TNF-α antagonists compared with nonbiologic comparators is associated with an increased risk of serious infections requiring hospitalization. DESIGN, SETTING, AND PATIENTS Within a US multi-institutional collaboration, we assembled retrospective cohorts (1998-2007) of patients with rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and psoriasis, psoriatic arthritis, or ankylosing spondylitis (psoriasis and spondyloarthropathies) combining data from Kaiser Permanente Northern California, New Jersey and Pennsylvania Pharmaceutical Assistance programs, Tennessee Medicaid, and national Medicaid/Medicare. TNF-α antagonists and nonbiologic regimens were compared in disease-specific propensity score (PS)-matched cohorts using Cox regression models with nonbiologics as the reference. Baseline glucocorticoid use was evaluated as a separate covariate. MAIN OUTCOME MEASURE Infections requiring hospitalization (serious infections) during the first 12 months after initiation of TNF-α antagonists or nonbiologic regimens. RESULTS Study cohorts included 10,484 RA, 2323 IBD, and 3215 psoriasis and spondyloarthropathies matched pairs using TNF-α antagonists and comparator medications. Overall, we identified 1172 serious infections, most of which (53%) were pneumonia and skin and soft tissue infections. Among patients with RA, serious infection hospitalization rates were 8.16 (TNF-α antagonists) and 7.78 (comparator regimens) per 100 person-years (adjusted hazard ratio [aHR], 1.05 [95% CI, 0.91-1.21]). Among patients with IBD, rates were 10.91 (TNF-α antagonists) and 9.60 (comparator) per 100 person-years (aHR, 1.10 [95% CI, 0.83-1.46]). Among patients with psoriasis and spondyloarthropathies, rates were 5.41 (TNF-α antagonists) and 5.37 (comparator) per 100 person-years (aHR, 1.05 [95% CI, 0.76-1.45]). Among patients with RA, infliximab was associated with a significant increase in serious infections compared with etanercept (aHR, 1.26 [95% CI, 1.07-1.47]) and adalimumab (aHR, 1.23 [95% CI, 1.02-1.48]). Baseline glucocorticoid use was associated with a dose-dependent increase in infections. CONCLUSION Among patients with autoimmune diseases, compared with treatment with nonbiologic regimens, initiation of TNF-α antagonists was not associated with an increased risk of hospitalizations for serious infections.
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Affiliation(s)
- Carlos G Grijalva
- Division of Pharmacoepidemiology, Department of Preventive Medicine, Vanderbilt University School of Medicine, 1500 21st Ave S, Ste 2600, The Village at Vanderbilt, Nashville, TN 37212, USA.
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Koike T, Harigai M, Ishiguro N, Inokuma S, Takei S, Takeuchi T, Yamanaka H, Tanaka Y. Safety and effectiveness of adalimumab in Japanese rheumatoid arthritis patients: postmarketing surveillance report of the first 3,000 patients. Mod Rheumatol 2011; 22:498-508. [PMID: 21993918 DOI: 10.1007/s10165-011-0541-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 09/18/2011] [Indexed: 11/29/2022]
Abstract
This interim analysis of postmarketing surveillance data for adalimumab-treated rheumatoid arthritis (RA) patients summarizes safety and effectiveness during the first 24 weeks of therapy for the first 3,000 patients treated in Japan (June 2008-December 2009). Patient eligibility for antitumor necrosis factor therapy was based on the Japanese College of Rheumatology treatment guidelines and Japanese labeling. All patients were screened for tuberculosis. Approximately 50% of the population was biologic naïve, 66% received concomitant methotrexate (MTX), and 72% received concomitant glucocorticoids. The overall incidence rate of adverse events was 31% (5.5% serious) and that of adverse drug reactions (ADRs) was 27% (4.1% serious). Incidence rates of ADRs and serious ADRs were similar regardless of prior biologic therapy or concomitant MTX use but were significantly higher in patients receiving glucocorticoids compared with those not receiving glucocorticoids. Bacterial/bronchial pneumonia occurred in 1.2% of patients; interstitial pneumonia, 0.6%; Pneumocystis jirovecii pneumonia, 0.3%; tuberculosis, 0.13%; and administration-site reactions, 6.1%. Mean 28-joint Disease Activity Scores decreased significantly after 24 weeks from 5.29 to 3.91. All subgroups showed significant improvement, particularly the biologic-naïve patients receiving concomitant MTX. No new safety concerns were identified. ADR Incidence rates were similar to those of other biologic agents approved for RA.
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Affiliation(s)
- Takao Koike
- Sapporo Medical Center NTT EC, S-1, W-15, Chuo-ku, Sapporo, Hokkaido, 060-0061, Japan,
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Dixon WG, Suissa S, Hudson M. The association between systemic glucocorticoid therapy and the risk of infection in patients with rheumatoid arthritis: systematic review and meta-analyses. Arthritis Res Ther 2011; 13:R139. [PMID: 21884589 PMCID: PMC3239382 DOI: 10.1186/ar3453] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 07/16/2011] [Accepted: 08/31/2011] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Infection is a major cause of morbidity and mortality in patients with rheumatoid arthritis (RA). The objective of this study was to perform a systematic review and meta-analysis of the effect of glucocorticoid (GC) therapy on the risk of infection in patients with RA. METHODS A systematic review was conducted by using MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials database to January 2010 to identify studies among populations of patients with RA that reported a comparison of infection incidence between patients treated with GC therapy and patients not exposed to GC therapy. RESULTS In total, 21 randomised controlled trials (RCTs) and 42 observational studies were included. In the RCTs, GC therapy was not associated with a risk of infection (relative risk (RR), 0.97 (95% CI, 0.69, 1.36)). Small numbers of events in the RCTs meant that a clinically important increased or decreased risk could not be ruled out. The observational studies generated a RR of 1.67 (1.49, 1.87), although significant heterogeneity was present. The increased risk (and heterogeneity) persisted when analyses were stratified by varying definitions of exposure, outcome, and adjustment for confounders. A positive dose-response effect was seen. CONCLUSIONS Whereas observational studies suggested an increased risk of infection with GC therapy, RCTs suggested no increased risk. Inconsistent reporting of safety outcomes in the RCTs, as well as marked heterogeneity, probable residual confounding, and publication bias in the observational studies, limits the opportunity for a definitive conclusion. Clinicians should remain vigilant for infection in patients with RA treated with GC therapy.
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Affiliation(s)
- William G Dixon
- Arthritis Research UK Epidemiology Unit, Manchester Academic Health Science Centre, Stopford Building, The University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
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Hoshi D, Nakajima A, Inoue E, Shidara K, Sato E, Kitahama M, Seto Y, Tanaka E, Urano W, Ichikawa N, Koseki Y, Momohara S, Taniguchi A, Nishimoto N, Yamanaka H. Incidence of serious respiratory infections in patients with rheumatoid arthritis treated with tocilizumab. Mod Rheumatol 2011; 22:122-7. [PMID: 21735355 DOI: 10.1007/s10165-011-0488-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 06/03/2011] [Indexed: 12/20/2022]
Abstract
We aimed to demonstrate the incidence of serious respiratory infections in patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ) monotherapy. We analyzed the incidence of serious respiratory infections in 601 RA patients enrolled in TCZ clinical trials and their extension studies (TCZ cohort) and in 601 age- and sex-standardized RA patients treated in daily clinical practice at Tokyo Women's Medical University (IORRA subsample cohort). The rates of serious respiratory infections were 1.77 per 100 patient-years from 1999 to 2008 in the TCZ cohort and 0.53 per 100 patient-years from 2000 to 2009 in the IORRA subsample cohort. With the IORRA subsample cohort regarded as a standard population, the standardized incidence ratio (SIR) of serious respiratory infection in the TCZ cohort was 3.64 [95% confidence interval (CI) 2.56-5.01], standardized for age and sex; 2.35 (95% CI 1.66-3.24), standardized for age sex, and corticosteroid use; 1.85 (95% CI 1.30-2.55), standardized for age sex, and pre-existing pulmonary involvement; and 2.41 (95% CI 1.68-3.34) standardized for age sex, and disease activity. The risk of serious respiratory infection in the TCZ cohort was approximately double that in the IORRA subsample cohort after standardizing for corticosteroid use, pre-existing pulmonary involvement, or disease activity. This is comparable to the risk reported when tumor necrosis factor (TNF) inhibitors are used.
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Affiliation(s)
- Daisuke Hoshi
- Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo 162-0054, Japan.
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