Opposite effects of statins on the risk of tuberculosis and herpes zoster in patients with diabetes: A population-based cohort study

Interaction of Glycemic Control and Statin Use on Diabetes-Tuberculosis Treatment Outcome: A Nested Case-Control Study

This study aims to explore the interaction of glycemic control and statin use on the treatment outcomes of pulmonary tuberculosis-diabetes comorbidity (PTB-DM) patients. A nested case-control study was conducted in a tuberculosis patients' cohort. We defined cases as patients who experienced unfavorable outcomes. Glycemic control was estimated at the baseline. Statin use was obtained from medical records. The multivariate logistic regression models were developed, and the interaction table invented by Andersson was adopted to analyze the interaction of glycemic control and statin use on treatment outcomes. A total of 2,047 patients were included in this study. There was a significant interaction between glycemic control and statin use on the treatment outcomes. Patients with good glycemic control and no statin use (OR = 0.464, 95% CI: 0.360-0.623) had a lower risk of unfavorable outcomes than those with poor glycemic control and statin use (OR = 0.604, 95% CI: 0.401-0.734). Patients with good glycemic control and statin use had the lowest risk of unfavorable outcomes (OR = 0.394, 95% CI: 0.264-0.521). Glycemic control in diabetes-tuberculosis treatment should be paid considerable attention. Patients can benefit from statin use even if they have poor glycemic control. Patients with good glycemic control and statin use can have the best outcomes.

The State of Use and Utility of Negative Controls in Pharmacoepidemiologic Studies

Uses of real-world data in drug safety and effectiveness studies are often challenged by various sources of bias. We undertook a systematic search of the published literature through September 2020 to evaluate the state of use and utility of negative controls to address bias in pharmacoepidemiologic studies. Two reviewers independently evaluated study eligibility and abstracted data. Our search identified 184 eligible studies for inclusion. Cohort studies (115, 63%) and administrative data (114, 62%) were, respectively, the most common study design and data type used. Most studies used negative control outcomes (91, 50%), and for most studies the target source of bias was unmeasured confounding (93, 51%). We identified 4 utility domains of negative controls: 1) bias detection (149, 81%), 2) bias correction (16, 9%), 3) P-value calibration (8, 4%), and 4) performance assessment of different methods used in drug safety studies (31, 17%). The most popular methodologies used were the 95% confidence interval and P-value calibration. In addition, we identified 2 reference sets with structured steps to check the causality assumption of the negative control. While negative controls are powerful tools in bias detection, we found many studies lacked checking the underlying assumptions. This article is part of a Special Collection on Pharmacoepidemiology.

Host-directed therapy against mycobacterium tuberculosis infections with diabetes mellitus

Tuberculosis (TB) is caused by the bacterial pathogen Mycobacterium tuberculosis (MTB) and is one of the principal reasons for mortality and morbidity worldwide. Currently, recommended anti-tuberculosis drugs include isoniazid, rifampicin, ethambutol, and pyrazinamide. TB treatment is lengthy and inflicted with severe side-effects, including reduced patient compliance with treatment and promotion of drug-resistant strains. TB is also prone to other concomitant diseases such as diabetes and HIV. These drug-resistant and complex co-morbid characteristics increase the complexity of treating MTB. Host-directed therapy (HDT), which effectively eliminates MTB and minimizes inflammatory tissue damage, primarily by targeting the immune system, is currently an attractive complementary approach. The drugs used for HDT are repositioned drugs in actual clinical practice with relative safety and efficacy assurance. HDT is a potentially effective therapeutic intervention for the treatment of MTB and diabetic MTB, and can compensate for the shortcomings of current TB therapies, including the reduction of drug resistance and modulation of immune response. Here, we summarize the state-of-the-art roles and mechanisms of HDT in immune modulation and treatment of MTB, with a special focus on the role of HDT in diabetic MTB, to emphasize the potential of HDT in controlling MTB infection.

Resveratrol: a potential medication for the prevention and treatment of varicella zoster virus-induced ischemic stroke

BACKGROUND

Infection rate of varicella zoster virus (VZV) is 95% in humans, and VZV infection is strongly associated with ischemic stroke (IS). However, the underlying molecular mechanisms of VZV-induced IS are still unclear, and there are no effective agents to treat and prevent VZV-induced IS.

OBJECTIVE

By integrating bioinformatics, this study explored the interactions between VZV and IS and potential medication to treat and prevent VZV-induced IS.

METHODS

In this study, the VZV and IS datasets from the GEO database were used to specify the common genes. Then, bioinformatics analysis including Gene Ontology, Kyoto Encyclopedia Genes Genomes and Protein-Protein Interaction network analysis was performed. Further, the hub genes, transcription factor (TF) gene interactions, TF-miRNA co-regulatory network and potential drug were obtained. Finally, validation was performed using molecular docking and molecular dynamics simulations.

RESULTS

The potential molecular mechanisms of VZV-induced IS were studied using multiple bioinformatics tools. Ten hub genes were COL1A2, DCN, PDGFRB, ACTA2, etc. TF genes and miRNAs included JUN, FOS, CREB, BRCA1, PPARG, STAT3, miR-29, etc. A series of mechanism may be involved, such as inflammation, oxidative stress, blood-brain barrier disruption, foam cell generation and among others. Finally, we proposed resveratrol as a potential therapeutic medicine for the prevention and treatment of VZV-induced IS. Molecular docking and molecular dynamics results showed that resveratrol and hub genes exhibited strong binding score.

CONCLUSIONS

Resveratrol could be an alternative for the prevention and treatment of VZV-IS. More in vivo and in vitro studies are needed in the future to fully explore the molecular mechanisms between VZV and IS and for medication development.

Incidence and prevalence of pulmonary tuberculosis among patients with type 2 diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

The epidemic of type 2 diabetes mellitus (T2DM) poses a great challenge to pulmonary tuberculosis (PTB) control. However, the incidence and prevalence of PTB among T2DM patients has not been fully determined. This meta-analysis aimed to provide the estimation on the global incidence and prevalence of PTB among T2DM patients (T2DM-PTB).

METHODS

Online databases including Web of Science, PubMed, China National Knowledge Infrastructure and Cochrane Library were searched for all relevant studies that reported the incidence or prevalence of T2DM-PTB through 31 January 2022. Pooled incidence and prevalence of T2DM-PTB with 95% confidence interval (CI) was estimated by the random-effect model. All statistical analyses were performed using R software.

RESULTS

A total of 24 studies (14 cohort studies, 10 cross-sectional studies) were included. The pooled incidence and prevalence of T2DM-PTB were 129.89 per 100,000 person-years (95% confidence interval (CI): 97.55-172.95) and 511.19 per 100,000 (95% CI: 375.94-695.09), respectively. Subgroup analyses identified that the incidence of T2DM-PTB was significantly higher in Asia (187.20 per 100,000 person-years, 95% CI: 147.76-237.17), in countries with a high TB burden (172.04 per 100,000 person-years, 95% CI: 122.98-240.68) and in studies whose data collection ended before 2011 (219.81 per 100,000 person-years, 95% CI: 176.15-274.28), but lower in studies using International Classification of Diseases-10 codes (73.75 per 100,000 person-years, 95% CI: 40.92-132.91). The prevalence of T2DM-PTB was significantly higher in countries with a high TB burden (692.15 per 100,000, 95% CI: 468.75-1022.04), but lower in Europe (105.01 per 100,000, 95% CI: 72.55-151.98).

CONCLUSIONS

This systematic review and meta-analysis suggests high global incidence and prevalence of PTB among T2DM patients, underlining the necessity of more preventive interventions among T2DM patients especially in countries with a high TB-burden. Key messagesA total of 24 studies (14 cohort studies, 10 cross-sectional studies) containing 2,569,451 T2DM patients were included in this meta-analysis.The pooled incidence and prevalence of T2DM-PTB are 129.89 per 100,000 person-years (95% CI: 97.55-172.95) and 511.19 per 100,000 (95% CI: 375.94-695.09) respectively.The incidence of T2DM-PTB was significantly higher in Asia, in countries with a high TB burden and in studies whose data collection ended before 2011, but lower in studies using International Classification of Diseases-10 codes.The prevalence of T2DM-PTB was significantly higher in countries with a high TB-burden, but lower in Europe.

Host-directed therapies in pulmonary tuberculosis: Updates on anti-inflammatory drugs

Tuberculosis (TB) is a lethal disease and remains one of the top ten causes of mortality by an infectious disease worldwide. It can also result in significant morbidity related to persistent inflammation and tissue damage. Pulmonary TB treatment depends on the prolonged use of multiple drugs ranging from 6 months for drug-susceptible TB to 6-20 months in cases of multi-drug resistant disease, with limited patient tolerance resulting from side effects. Treatment success rates remain low and thus represent a barrier to TB control. Adjunct host-directed therapy (HDT) is an emerging strategy in TB treatment that aims to target the host immune response to Mycobacterium tuberculosis in addition to antimycobacterial drugs. Combined multi-drug treatment with HDT could potentially result in more effective therapies by shortening treatment duration, improving cure success rates and reducing residual tissue damage. This review explores the rationale and challenges to the development and implementation of HDTs through a succinct report of the medications that have completed or are currently being evaluated in ongoing clinical trials.

Further insights into to the role of statins against active tuberculosis: systematic review and meta-analysis

OBJECTIVES

Tuberculosis is a major cause of global morbidity and mortality. Statins could be associated with a lower risk of some infectious diseases, including tuberculosis. Statins could reduce the risk of latent tuberculosis infection and active tuberculosis, acting as an adjuvant in treating tuberculosis. This study aimed to determine if statins reduce the risk of active tuberculosis.

METHODS

We systematically analyzed 8 databases from inception to December 2021. We included articles without language restriction if they met our inclusion and exclusion criteria and the PECO strategy (Population: adults without active pulmonary tuberculosis; Exposure: treatment with any statin; Comparator: no use of statins; Outcome: active tuberculosis). Odds Ratios (ORs) with 95% confidence intervals (CIs) were pooled using random- effects models regardless of heterogeneity quantified by Cochran's Q and I² statistics. We performed subgroup analyses according to the participants' diabetic status and follow-up length (≤10 years or >10 years).

RESULTS

Twelve articles reporting observational studies involving 3.038.043 participants, including at least 32.668 cases of active tuberculosis. Eight reported retrospective cohort studies, three nested case-control study, and one was a case control study.According to our meta-analysis, statins may reduce the risk of active tuberculosis, in the general population (OR 0.66; 95% CI, 0.54-0.81), in non-diabetic (OR 0.66; 95% CI, 0.54-0.80) and in diabetic patients (OR 0.65; 95% CI, 0.49-0.87). This protective effect did not differ according to the participants' diabetic status nor follow-up length (test for subgroup differences I²=0). We found significant clinical and methodological heterogeneity. Similarly, the forest plot, and the I² and Chi² statistics suggested considerable statistical heterogeneity (I²=95%, p<0.05, respectively). Of the 12 included studies, 9 were at low risk of bias and 3 were at high risk of bias. Similarly, according to the funnel plot, it is very likely that there are important publication biases.

CONCLUSION

Statin use may significantly reduce the risk of tuberculosis in the general population, diabetic and non-diabetic patients. Nevertheless, caution should be exercised when interpreting these conclusions, due to the quality of the evidence, the heterogeneity of the studies, the presence of bias, and the difficulty in extrapolating these results to populations of other races and ethnicities.

Diabetes-Associated Susceptibility to Tuberculosis: Contribution of Hyperglycemia vs. Dyslipidemia

Diabetes is a major risk factor for tuberculosis (TB). Diabetes increases the risk of the progression from latent tuberculosis infection (LTBI) to active pulmonary TB and TB patients with diabetes are at greater risk of more severe disease and adverse TB treatment outcomes compared to TB patients without co-morbidities. Diabetes is a complex disease, characterised not only by hyperglycemia but also by various forms of dyslipidemia. However, the relative contribution of these underlying metabolic factors to increased susceptibility to TB are poorly understood. This review summarises our current knowledge on the epidemiology and clinical manifestation of TB and diabetes comorbidity. We subsequently dissect the relative contributions of body mass index, hyperglycemia, elevated cholesterol and triglycerides on TB disease severity and treatment outcomes. Lastly, we discuss the impact of selected glucose and cholesterol-lowering treatments frequently used in the management of diabetes on TB treatment outcomes.

Disease progression in patients with nontuberculous mycobacterial lung disease of nodular bronchiectatic (NB) pattern: the role of cavitary NB and soluble programmed death protein-1

BACKGROUND

In patients with nodular bronchiectatic (NB) nontuberculous mycobacterial-lung disease (NTM-LD), risk factors for disease progression have not been clearly investigated. The roles of cavitary NB and soluble programmed death protein-1 (sPD-1), an immune-related biomarker, in the disease course of NB NTM-LD remain unknown.

METHODS

Patients with NB NTM-LD were enrolled from two medical centers in 2014-2020. We identified cavitary NB, measured sPD-1 levels, and analyzed factors associated with cavitary NB and predictors for disease progression of NB NTM-LD.

RESULTS

Of 120 cases of NB NTM-LD, 87 (72.5%) were caused by Mycobacterium avium complex. sPD-1 levels were lower in 13 (10.8%) patients with cavitary NB than in non-cavitary patients (P = 0.020). Over 1.41 ± 1.43 years of follow-up, 12 (92.3%) patients in the cavitary and 66 (61.7%) in the non-cavitary group developed disease progression (P = 0.032). In multivariate analysis, body mass index (BMI) (Kg/m 2, adjusted hazard ratio [aHR], 0.895 [95% CI, 0.811-0.988]), sputum smear grade (aHR, 1.247 [1.014-1.534), cavitary NB (aHR, 2.008 [1.052-3.834]) and sPD-1 (per 10-pg/mL increase, aHR, 0.889 [0.816-0.967]) were predictive for disease progression. Notably, sPD-1 showed a dose-dependent association with disease progression (sPD-1 ≤ 23.5 pg/ml; aHR, 3.306 [1.664-6.567], and sPD-1: 23.6-53.7 pg/ml; aHR, 2.496 [1.390-4.483]) compared with the reference (sPD-1 > 53.7 pg/ml).

CONCLUSIONS

Patients with NB NTM-LD and low sPD-1, low BMI, high smear grade and cavitary NB were at high risk for disease progression. sPD-1 was low in patients with cavitary NB phenotype and dose-responsively associated with disease progression.

Risk of herpes zoster in psoriasis patients receiving systemic therapies: a nationwide population-based cohort study

The incidence of herpes zoster in psoriasis patients is higher than in the general population. However, the association between herpes zoster risk and different systemic therapies, especially biologic agents, remains controversial. This study investigated the association between herpes zoster risk and several systemic antipsoriasis therapies. This prospective open cohort study was conducted using retrospectively collected data from the Taiwan National Health Insurance Research Database. We included 92,374 patients with newly diagnosed psoriasis between January 1, 2001, and December 31, 2013. The exposure of interest was the “on-treatment” effect of systemic antipsoriasis therapies documented by each person-quarter. The outcome was the occurrence of newly diagnosed herpes zoster. During a mean follow-up of 6.8 years, 4834 (5.2%) patients were diagnosed with herpes zoster after the index date. Among the systemic antipsoriasis therapies, etanercept (hazard ratio [HR] 4.78, 95% confidence interval [CI] 1.51–15.17), adalimumab (HR 5.52, 95% CI 1.72–17.71), and methotrexate plus azathioprine (HR 4.17, 95% CI 1.78–9.82) were significantly associated with an increased risk of herpes zoster. By contrast, phototherapy (HR 0.76, 95% CI 0.60–0.96) and acitretin (HR 0.39, 95% CI 0.24–0.64) were associated with a reduced risk of herpes zoster. Overall, this study identified an association of both etanercept and adalimumab with an increased risk of herpes zoster among psoriasis patients. Acitretin and phototherapy were associated with a reduced risk.

Statin use and impact on tuberculosis risk

Introduction: Tuberculosis, a chronic infection caused by Mycobacterium tuberculosis (MTB), is one of the 10 leading causes of death in the world. The current treatment is a combination antimicrobial therapy administered for 6-9 months. It is important to find therapeutic strategy to shorten the treatment during and strengthen the host immune response against MTB.Areas covered: There is evidence that MTB uses cholesterol in the host macrophage to infect and survive inside the host macrophage. Statins inhibit the synthesis of cholesterol and aid in reducing the levels of cholesterol in human, which have been associated with better outcome in infectious diseases. In this narrative review, we discuss recent studies that investigated the effects of statins on the prevention or treatment of TB infection.Expert opinion: The evaluation of the published evidence suggests that statins may be beneficial in the treatment of patients with TB infections. Future studies may focus not only on the beneficial effects of statins, but also on distinguishing the effects of different statins.

Impact of different subspecies on disease progression in initially untreated patients with Mycobacterium avium complex lung disease

OBJECTIVE

Disease progression is a strong indicator of treatment for Mycobacterium avium complex lung disease (MAC-LD). The impact of MAC subspecies on the risk of disease progression remains uncertain in MAC-LD patients.

METHODS

In this cohort study, we included MAC-LD patients from 2013 to 2018 and classified them into M. intracellulare, M. avium, M. chimaera and other subspecies groups by genotype. We observed the disease progression of MAC-LD, indicated by antibiotic initiation and/or radiographic progression. We used Cox regression analysis to assess predictors for disease progression.

RESULTS

Of 105 MAC isolates from unique MAC-LD patients, 35 (33%) were M. intracellulare, 41 (39%) M. avium, 16 (15%) M. chimaera and 13 (12%) other subspecies. After a mean follow-up time of 1.3 years, 56 (53%) patients developed disease progression: 71% (25/35), 54% (22/41), 31% (4/13) and 31% (5/16) in patients with M. intracellulare, M. avium, others and M. chimaera, respectively. The independent predictors for disease progression were M. chimaera subspecies (HR 0.356, 95% CI (0.134-0.943)), compared with the reference group of M. intracellulare, body mass index ≤20 kg/m² (HR 1.788 (1.022-3.130)) and initial fibrocavitary pattern (HR 2.840 (1.190-6.777)) after adjustment for age, sex and sputum smear positivity. Among patients without fibrocavitary lesions (n = 94), the risk of disease progression significantly decreased in patients with other subspecies (HR 0.217 (0.050-0.945)) and remained low in those with M. chimaera (HR 0.352 (0.131-0.947)).

CONCLUSIONS

Mycobacterium chimaera was not uncommon in this study; unlike M. intracellulare, it was negatively correlated with disease progression of MAC-LD, suggesting a role of MAC subspecies identification in prioritizing patients.

Statin Use May Be Associated With Reduced Active Tuberculosis Infection: A Meta-Analysis of Observational Studies

Background: Tuberculosis remains one of the leading causes of mortality among the infectious diseases, while statins were suggested to confer anti-infective efficacy in experimental studies. We aimed to evaluate the association between statin use and tuberculosis infection in a meta-analysis.

Method: Relevant studies were obtained via systematically search of PubMed and Embase databases. A random or a fixed effect model was applied to pool the results according to the heterogeneity among the included studies. Subgroup analyses according to the gender and diabetic status of the participants were performed. We assessed the quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results: Nine observational studies were included. Significant heterogeneity was detected among the studies (p for Cochrane's Q test <0.001, I² = 93%). The GRADE approach showed generally low quality of evidence. Pooled results showed that statin use was associated with reduced active tuberculosis infection (risk ratio [RR]: 0.60, 95% confidence interval [CI]: 0.45 to 0.75, p < 0.001). Subgroup analyses showed that the negative association between statin use and active tuberculosis infection was consistent in men (RR: 0.63, p = 0.01) and women (RR: 0.58, p < 0.001), in participants with (RR: 0.63, p = 0.02) and without diabetes (RR: 0.50, p < 0.001), in retrospective cohort studies (RR: 0.56, p = 0.02), prospective cohort studies (RR: 0.76, p = 0.03), nested case-controls studies (RR: 0.57, p < 0.001), and case-control studies (RR: 0.60, p < 0.001), and in studies with statin used defined as any use within 1 year (RR: 0.59, p < 0.001) or during follow-up (RR: 0.61, p < 0.001). Significant publication bias was detected (p for Egger's regression test = 0.046). Subsequent “trim and fill” analyses retrieved an unpublished study to generate symmetrical funnel plots, and meta-analysis incorporating this study did not significantly affect the results (RR: 0.72, 95% CI: 0.68 to 0.76, p < 0.001).

Conclusions: Statin use may be associated with reduced active tuberculosis infection. Randomized controlled trials (RCTs) are needed to confirm the potential preventative role of statin use on tuberculosis infection.

Anti-tuberculous Effects of Statin Therapy: A Review of Literature

Tuberculosis (TB) is a chronic infection caused by Mycobacterium tuberculosis (M. TB). It is transmitted through respiratory droplets. Increased cholesterol level is a predisposing factor for TB. M. TB uses cholesterol in the host macrophage membranes to bind and enter the macrophages. Statins are the drugs that are prescribed to hyperlipidemic patients to maintain their lipid levels in the normal range, thereby reducing the risk of stroke and cardiovascular events. Moreover, statins aid in reducing the levels of cholesterol in human macrophages. Therefore, a reduction in the membrane cholesterol minimizes the entry of TB pathogen inside macrophages. Furthermore, acting as vitamin D3 analogs and positively influencing pancreatic beta-cell function in a chronic diabetic state, statins minimize the occurrence of M. TB infection among diabetic population as well. This review aims to provide a comprehensive detail of all in vitro, in vivo, and retrospective studies that investigated the effects of statins in relation to the prevention or treatment of TB infection.

Opposite effects of statins on the risk of tuberculosis and herpes zoster in patients with diabetes: A population-based cohort study

It remains uncertain whether statin use is associated with the risks of tuberculosis (TB) and herpes zoster in patients with type 2 diabetes. This study aims to assess the effects of statins vs nonstatin lipid-lowering agents on the risk of these infectious diseases in patients with diabetes.

METHODS

Participants in the Taiwan National Health Insurance Research Database diagnosed with type 2 diabetes in 2001-2013 were classified as statin users, nonstatin users and lipid-lowering drug-free groups. Participants were observed for incident TB and herpes zoster from diabetes diagnosis until treatment crossover or December 2013. Statin user and nonstatin user were the time-dependent variables in Cox regression analysis.

RESULTS

Over 240 782 person-years of observation, statin users (n = 17 696) were associated with a lower TB risk than nonstatin users (n = 5327) and the drug-free group (n = 22 316) (adjusted hazard ratio [aHR]: 0.66; 95% confidence interval [CI]: 0.44-0.99 and aHR: 0.57; 95% CI: 0.44-0.73). Compared with nonstatin users, statin users showed a dose-dependent association with TB risk (low-potency statin users, aHR: 0.692; 95% CI: 0.455-1.053; high-potency users, aHR: 0.491; 95% CI: 0.241-0.999). Statin users presented with a higher risk of herpes zoster than nonstatin users and the drug-free group (aHR: 1.23; 95% CI: 1.01-1.50 and aHR: 1.20; 95% CI: 1.09-1.33). The risks of TB and herpes zoster were not statistically different between nonstatin users and the drug-free group.

CONCLUSION

Compared with nonstatin drugs, statin use was specifically associated with a decreased risk of TB but a moderately increased risk of herpes zoster in this cohort study.