The risk of gastrointestinal perforations in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the BSRBR-RA

Gastrointestinal perforations in patients with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs in Sweden: a nationwide cohort study

OBJECTIVES

To compare incidence rates of gastrointestinal (GI) perforations between patients with RA and the general population, and between patients treated with tumour necrosis factor inhibitors (TNFi) and non-TNFi biologics.

METHODS

In this nationwide cohort study, a total of 63 532 patients with RA, with 26 050 biological treatment episodes (TNFi, rituximab, abatacept or tocilizumab) and 76 304 general population controls, were followed between 2009 and 2017 until the first outcome event. The main outcome was hospitalisation or death due to lower GI perforations, identified according to a prespecified list of ICD-10 (International Classification of Diseases, 10th revision) codes. Inverse probability of treatment weighting was used for adjustment.

RESULTS

The sex-standardised and age-standardised incidence rates of lower GI perforations were 1.1 (95% CI 1.0 to 1.3) events per 1000 person-years among general population controls, 1.6 (1.5-1.7) among bionaïve patients and ranged from 1.8 (1.4-3.6) (TNFi) to 4.5 (2.7-10.4) (tocilizumab) among biologics-treated patients. After adjustment for glucocorticoid use, the risk in bionaïve, TNFi-treated, abatacept-treated or rituximab-treated patients with RA was no longer different from the general population, while for tocilizumab it remained significantly higher. Comparing tocilizumab to TNFi, the adjusted HR for lower GI perforations was 2.2 (1.3-3.8), corresponding to one additional GI perforation per 451 patient-years treated with tocilizumab instead of TNFi.

CONCLUSION

Tocilizumab was associated with a higher risk of lower GI perforations compared with alternative biologics. In absolute numbers, the risk remained low on all biologics commonly used to treat RA, but the accumulated evidence across settings and outcome definitions supports that this risk should be considered in treatment guidelines for RA.

Negative surgical exploration in suspected gastrointestinal perforation: trend, preoperative predictors, and etiologies

Background

Despite the rapid improvement of clinical science and imaging technology including computed tomography, the entity of negative surgical exploration in suspected gastrointestinal perforation (N-GIP) still exist. However, few studies have focused on this issue and most studies are case reports. We undertook this study to investigate the rates of N-GIP, and explore a set of possible preoperative predictors associated with N-GIP.

Methods

This was a retrospective study performed at the department of general surgery in our treatment center. All patients included were suspected gastrointestinal perforation (GIP) cases, aged 14 years and over, and underwent emergency surgery between 2009 and 2019. A predictive multivariable model of the presence of N-GIP was developed using logistic regression analysis.

Results

A total of 973 patients were identified and 30 (3.1%) were found to have no evidence of perforated gastrointestinal tract. The mean age of patients was 59.74 (range, 14–97) years, and 67.2 percent of the patients were males. The rates of N-GIP did not have a significant change over time (P=0.212 for trend). In multivariable analysis, absence of generalized peritonitis, duration of abdominal pain >19.6 hours, and neutrophil-to-lymphocyte ratio (NLR) <3.80 were significant predictors of N-GIP. N-GIP was more common in patients with gastrointestinal tumors and foreign bodies. Five patients (16.7%) in N-GIP group experienced complications and the 90-day mortality rate was 6.7%.

Conclusions

The rates of N-GIP did not change significantly over time. N-GIP was associated with the absence of generalized peritonitis, duration of abdominal pain >19.6 hours, and NLR <3.80.

Established and Emerging Immunological Complications of Biological Therapeutics in Multiple Sclerosis

Biologic immunotherapies have transformed the treatment landscape of multiple sclerosis. Such therapies include recombinant proteins (interferon beta), as well as monoclonal antibodies (natalizumab, alemtuzumab, daclizumab, rituximab and ocrelizumab). Monoclonal antibodies show particular efficacy in the treatment of the inflammatory phase of multiple sclerosis. However, the immunological perturbations caused by biologic therapies are associated with significant immunological adverse reactions. These include development of neutralising immunogenicity, secondary immunodeficiency and secondary autoimmunity. These complications can affect the balance of risks and benefits of biologic agents, and 2018 saw the withdrawal from the market of daclizumab, an anti-CD25 monoclonal antibody, due to concerns about the development of severe, unpredictable autoimmunity. Here we review established and emerging risks associated with multiple sclerosis biologic agents, with an emphasis on their immunological adverse effects. We also discuss the specific challenges that multiple sclerosis biologics pose to drug safety systems, and the potential for improvements in safety frameworks.

Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND

Sepsis is fatal in patients with gastrointestinal perforation (GIP). However, few studies have focused on this issue.

AIM

To investigate the risk factors for postoperative sepsis in patients with GIP.

METHODS

This was a retrospective study performed at the Department of General Surgery in our treatment center. From January 2016 to December 2018, the medical records of patients with GIP who underwent emergency surgery were reviewed. Patients younger than 17 years or who did not undergo surgical treatment were excluded. The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group. Clinical data for both groups were collected and compared, and the risk factors for postoperative sepsis were investigated. The institutional ethical committee of our hospital approved the study.

RESULTS

Two hundred twenty-six patients were admitted to our department with GIP. Fourteen patients were excluded: Four were under 17 years old, and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members. Two hundred twelve patients were finally enrolled in the study; 161 were men, and 51 were women. The average age was 62.98 ± 15.65 years. Postoperative sepsis occurred in 48 cases. The prevalence of postoperative sepsis was 22.6% [95% confidence interval (CI): 17.0%-28.3%]. Twenty-eight patients (13.21%) died after emergency surgery. Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery [odds ratio (OR) = 1.021, 95%CI: 1.005-1.038, P = 0.006], colonic perforation (OR = 2.761, CI: 1.821–14.776, P = 0.007), perforation diameter (OR = 1.062, 95%CI: 1.007-1.121, P = 0.027), and incidence of malignant tumor-related perforation (OR = 5.384, 95%CI: 1.762-32.844, P = 0.021) were associated with postoperative sepsis.

CONCLUSION

The time interval from abdominal pain to surgery, colonic perforation, diameter of perforation, and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.

The role of registries in the treatment of rheumatoid arthritis with biologic disease-modifying anti-rheumatic drugs

Registries characterize the effectiveness and safety of therapeutic interventions in daily clinical practice. Data from registries enable mining the records of tens of thousands of patients towards determining the effectiveness, safety, and cost-benefit of any given therapeutic. The strengths of registries include real-life settings, greater power than clinical trials to detect rare events, and the study of multiple outcomes and several research questions. Registries also have their weaknesses. They are expensive, less accurate than clinical trials, affected by channelling bias, often require links to external sources or use historic and selected control cohorts or combine datasets to increase power, and have the risk of multiple confounders. Since the beginning of biological era, registries were developed to profile emerging treatments. This article reviews the role of registries in the treatment of rheumatoid arthritis with biologic disease-modifying anti-rheumatic drugs.

The Association between Absence of Abdominal Pain and Mortality in Lower Intestinal Perforation in Patients with Autoimmune Rheumatic Diseases

Objective

To determine mortality and predictive factors for lower intestinal perforation (LIP) among patients with autoimmune rheumatic diseases.

Methods

This retrospective, single-center, observational study analyzed mortality rates in 31 autoimmune rheumatic disease patients with LIP who were admitted to our hospital from January 2002 to June 2017. The primary outcome was the mortality rate during hospitalization.

Results

The median age at the time of LIP was 61 years, and the survival rate at discharge was 64.5%. Eleven patients died of sepsis during hospitalization. Cox univariable analysis for mortality during hospitalization showed that absence of abdominal pain (hazard ratio (HR) 5.61, 95% confidence interval (CI) 1.38–22.9), higher age (HR 1.06, 95% CI 1.01–1.11), chronic kidney disease (HR 6.89, 95% CI 1.85–25.7), systemic vasculitis (HR 3.95, 95% CI 1.14–13.6), higher blood urea nitrogen (HR 1.02, 95% CI 1.01–1.04), higher serum creatinine (HR 1.41, 95% CI 1.06–1.87), and LIP due to malignancy (HR 14.3, 95% CI 1.95–105.1) significantly increased mortality.

Conclusion

Abdominal pain was absent in 16% of LIP patients with autoimmune rheumatic diseases, and this absence was a poor prognostic factor in this cohort. Moreover, higher age, chronic kidney disease, systemic vasculitis, and LIP due to malignancy were associated with significantly increased mortality. Physicians should be aware of LIP in autoimmune disease patients with higher age, chronic kidney diseases, or systemic vasculitis even if patients reveal mild abdominal symptoms.

Gastrointestinal Perforations with Biologics in Patients with Rheumatoid Arthritis: Implications for Clinicians

Gastrointestinal (GI) perforations are rare events in rheumatoid arthritis (RA) patients, but cause significant morbidity and mortality. Several studies indicate that RA patients may be at higher risk of GI perforation. Traditional RA treatments such as glucocorticoids and non-steroidal anti-inflammatory drugs increase the risk of perforation. In the past two decades, a new class of therapeutic agents called biologics has been added to the RA treatment armamentarium. Biologics are effective in controlling disease activity and are generally well tolerated; however, reports of GI perforations in association with biologics have arisen. In particular, drugs that inhibit the interleukin (IL)-6 cytokine receptor have demonstrated a higher risk of perforation compared with other therapies. Recent reports also suggest that janus kinase inhibitors may increase the risk of perforation, perhaps via downstream effects on IL-6 signaling. In this review, we discuss current data on the risk of GI perforations among RA patients receiving targeted therapies and its clinical relevance.

Anti-Inflammatory Biologics and Anti-Tumoral Immune Therapies-Associated Colitis: A Focused Review of Literature

An increasing number of drugs including monoclonal antibodies and small molecules, either anti-inflammatory or immunity-enhancing, have been developed to treat human diseases and the number of medications in these classes is likely to expand in the future. The two most commonly used categories of such therapies are the anti-inflammatory group (anti- tumor necrosis factor (TNF) α, anti-interleukins/interleukin receptors, and anti-integrin bodies) and the anti-tumoral agents (immune checkpoint inhibitors, anti-CD20, and anti-endothelial growth factor). Although the anti-inflammatory biologics have brought about a revolutionary effect in the management of a variety of autoimmune disorders including rheumatologic diseases, inflammatory bowel disease, and inflammatory dermatological diseases, their ability to induce colitis in patients without a prior history of colitis or exacerbate quiescent colitis has been increasingly and unexpectedly recognized. While the use of immune-augmenting monoclonal antibody therapies results in a significant survival benefit in a subset of patients with malignancies, these monoclonal antibodies also have the ability to cause colitis through an apparent autoimmune mechanism. Colitis associated with these medications may demonstrate multiple histologic patterns including increased apoptosis (graft versus host disease (GVHD)-like), autoimmune enteropathy pattern, acute colitis pattern, ischemic colitis, inflammatory bowel disease pattern, either ulcerative colitis-like, Crohn’s disease-like, or fulminant colitis-like. In addition, anti-inflammatory biologics are known to cause or reactivate latent infections such as tuberculosis and increase the risk for malignancies including high-grade lymphomas as well as indolent lymphoproliferative disorders. Thus, the differential diagnosis for colitis in patients receiving therapeutic anti-inflammatory biologics or anti-tumoral agents can be broad. Optimal diagnosis and treatment requires a multidisciplinary approach. This review aims to provide an overview of the literature on the clinical features, histology, and treatment of these newly recognized anti-inflammatory biologic and anti-tumoral immune therapy-induced colitises and hopes this outlines will raise the vigilance of all clinicians of these entities.

Procalcitionin as a diagnostic marker to distinguish upper and lower gastrointestinal perforation

AIM

To assess the accuracy of serum procalcitionin (PCT) as a diagnostic marker in verifying upper and lower gastrointestinal perforation (GIP).

METHODS

This retrospective study included 46 patients from the surgical intensive care unit (ICU) of the Second Affiliated Hospital of Harbin Medical University who were confirmed to have GIP between June 2013 and December 2016. Demographic and clinical patient data were recorded on admission to ICU. Patients were divided into upper (n = 19) and lower (n = 27) GIP groups according to the perforation site (above or below Treitz ligament). PCT and WBC count was obtained before laparotomy and then compared between groups. Meanwhile, the diagnostic accuracy of PCT was analyzed.

RESULTS

Patients with lower GIP exhibited significantly higher APACHE II score, SOFA score and serum PCT level than patients with upper GIP (P = 0.017, 0.004, and 0.001, respectively). There was a significant positive correlation between serum PCT level and APACHE II score or SOFA score (r = 0.715 and r = 0.611, respectively), while there was a significant negative correlation between serum PCT level and prognosis (r = -0.414). WBC count was not significantly different between the two groups, and WBC count showed no significant correlation with serum PCT level, APACHE II score, SOFA score or prognosis. The area under the receiver operating characteristic curve of PCT level to distinguish upper or lower GIP was 0.778. Patients with a serum PCT level above 17.94 ng/dL had a high likelihood of lower GIP, with a sensitivity of 100% and a specificity of 42.1%.

CONCLUSION

Serum PCT level is a reliable and accurate diagnostic marker in identifying upper or lower GIP before laparotomy.

Long-term safety of tofacitinib for the treatment of rheumatoid arthritis up to 8.5 years: integrated analysis of data from the global clinical trials

OBJECTIVES

Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). We report an integrated safety summary of tofacitinib from two phase I, nine phase II, six phase III and two long-term extension studies in adult patients with active RA.

METHODS

Data were pooled for all tofacitinib-treated patients (data cut-off: 31 March 2015). Incidence rates (IRs; patients with event/100 patient-years) and 95% CIs are reported for adverse events (AEs) of interest.

RESULTS

6194 patients received tofacitinib for a total 19 406 patient-years' exposure; median exposure was 3.4 patient-years. IR (95% CI) for serious AEs was 9.4 (9.0 to 9.9); IR for serious infections was 2.7 (2.5 to 3.0). IR for (all) herpes zoster was 3.9 (3.6 to 4.2); IR for disseminated or multidermatomal herpes zoster was 0.3 (0.2 to 0.4). IR for opportunistic infections (excluding tuberculosis) was 0.3 (0.2 to 0.4) and was 0.2 (0.1 to 0.3) for tuberculosis. IR for malignancies (excluding non-melanoma skin cancer (NMSC)) was 0.9 (0.8 to 1.0); NMSC IR was 0.6 (0.5 to 0.7). IR for gastrointestinal perforations was 0.1 (0.1 to 0.2). Analysis of IR for serious infections, herpes zoster and malignancies by 6-month intervals did not reveal any notable increase in IR with longer-duration tofacitinib exposure.

CONCLUSION

This analysis of tofacitinib exposure up to 8.5 years allowed estimation of safety events with improved precision versus previous tofacitinib reports. AEs were generally stable over time; no new safety signals were observed compared with previous tofacitinib reports.

TRIAL REGISTRATION NUMBERS

NCT01262118, NCT01484561, NCT00147498, NCT00413660, NCT00550446, NCT00603512, NCT00687193, NCT01164579, NCT00976599, NCT01059864, NCT01359150, NCT00960440, NCT00847613, NCT00814307, NCT00856544, NCT00853385, NCT01039688, NCT00413699, NCT00661661; Results.

What is the impact of biologic therapies on common co-morbidities in patients with rheumatoid arthritis?

Biologic therapies have revolutionised disease control in patients with rheumatoid arthritis (RA). Theoretically, they have the potential to influence co-morbid disease associated with RA through better control of systemic inflammation. Conversely, co-morbidity may occur as an adverse effect of the drugs. The latest evidence from observational data shows an increased risk of infection in the first 6 months of treatment with tumour necrosis factor inhibitor (TNFi) therapies and potentially other biologic therapies. Rates of infection after the first 6 months decrease and become comparable to patients with RA treated with conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs). TNFi also appear to reduce the risk of cardiovascular disease in these patients, in particular ischaemic heart disease. TNFi treatment may be associated with a small increase in the risk of developing squamous cell carcinoma of the skin; in terms of other cancers, rates appears to be no different to those seen in patients treated with csDMARDs. There is a paucity of data on the impact of other biologic therapies and the effect of all biologic therapies on other common co-morbidities.

Successful Use of Tocilizumab in a Patient with Coexisting Rheumatoid Arthritis and Ulcerative Colitis

Tocilizumab is an interleukin-6 receptor inhibitor licensed for moderate to severe rheumatoid arthritis (RA). We report a case of Tocilizumab monotherapy for severe active RA in a patient with coexisting ulcerative colitis (UC). The patient was intolerant to multiple disease-modifying drugs, so Tocilizumab monotherapy was commenced. We found clinical improvement in both RA and UC. There was no major adverse event after 2 years. Manufacturer advised caution in using Tocilizumab in patient with gastrointestinal ulceration due to an increased risk of bowel perforation. However, alternative treatments such as glucocorticoid and nonsteroidal anti-inflammatory drugs may carry a higher bowel perforation risk. The presence of gastrointestinal ulceration therefore should not constitute an absolute contraindication for Tocilizumab therapy. Future studies of registry data will inform clinician of the Tocilizumab-related risk of gastrointestinal toxicity in "real-life" settings. Contrary to previous case report, we found Tocilizumab therapy to have a positive effect on UC. Laboratory studies supported a role for interleukin-6 in the pathophysiology of UC. Further clinical trial to evaluate the therapeutic role of Tocilizumab in UC would be warranted.

Risk for lower intestinal perforations in patients with rheumatoid arthritis treated with tocilizumab in comparison to treatment with other biologic or conventional synthetic DMARDs

Objective

To investigate the risk of developing lower intestinal perforations (LIPs) in patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ).

Methods

In 13 310 patients with RA observed in the German biologics register Rheumatoid Arthritis: Observation of Biologic Therapy, 141 serious gastrointestinal events possibly associated with perforations were reported until 31 October 2015. All events were validated independently by two physicians, blinded for treatment exposure.

Results

37 LIPs (32 in the colon/sigma) were observed in 53 972 patient years (PYs). Only two patients had a history of diverticulitis (one in TCZ). Age, current/cumulative glucocorticoids and non-steroidal anti-inflammatory drugs were significantly associated with the risk of LIP. The crude incidence rate of LIP was significantly increased in TCZ (2.7/1000 PYs) as compared with all other treatments (0.2−0.6/1000 PYs). The adjusted HR (ref: conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs)) in TCZ was 4.48 (95% CI 2.0 to 10.0), in tumour necrosis factor-α inhibitor (TNFi) 1.04 (0.5 to 2.3) and in other biologic DMARDs 0.33 (0.1 to 1.4). 4/11 patients treated with TCZ presented without typical symptoms of LIP (acute abdomen, severe pain). Only one patient had highly elevated C reactive protein (CRP). One quarter of patients died within 30 days after LIP (9/37), 5/11 under TCZ, 2/13 under TNFi and 2/11 under csDMARD treatment.

Conclusions

The incidence rates of LIP under TCZ found in this real world study are in line with those seen in randomised controlled trials of TCZ and higher than in all other DMARD treatments. To ensure safe use of TCZ in daily practice, physicians and patients should be aware that, under TCZ, LIP may occur with mild symptoms only and without CRP elevation.

A Case of Diverticular Perforation in a Young Patient with Rheumatoid Arthritis on Methotrexate

Background. Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (MTX), are associated with gastrointestinal toxicity. MTX inhibits dihydrofolate reductase, but it is unclear if polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene predict toxicity. Case. We describe a 33-year-old male with polyarticular rheumatoid arthritis who developed sigmoid diverticular perforation while receiving methotrexate, folic acid, prednisone, and naproxen. He tested heterozygous for the C677T allele MTHFR gene. Discussion. Rheumatoid arthritis and its treatments are associated with increased risk of gastrointestinal disease. In one study, perforation was highest among individuals with concomitant exposure to NSAIDs, nonbiologic DMARDs, and glucocorticoids. Multiple mutations of the MTHFR gene have been identified, but their association with MTX toxicity is unclear. This case adds to a growing body of literature that could help inform the treatment of others in the future.