Safety of antitumour necrosis factor (anti-TNF) therapy in patients with chronic viral infections: hepatitis C, hepatitis B, and HIV infection

Infections in psoriatic arthritis: association with treatment

Serious infections (SIs) remain one of the most significant comorbidities in patients with inflammatory arthritides including psoriatic arthritis (PsA). Apart from methotrexate (MTX) and biologics such as tumor necrosis factor (TNFi), interleukin-12/23 (IL-12/23i), and IL-17 inhibitors (IL-17i), traditionally used for the treatment of PsA, recently biologics such as IL-23i and targeted synthetic agents like JAK inhibitors (JAKi) have been introduced in the daily clinical practice for the treatment of this disease. Although overall the incidence of SIs in patients with PsA treated with these agents is lower compared to patients with rheumatoid arthritis, still a number of unresolved issues regarding their safety remain. Current evidence is reassuring regarding the safety profile of conventional synthetic disease-modifying anti-rheumatic drugs, such as MTX. The increased risk for reactivation of latent infections, such as tuberculosis and hepatitis B virus (HBV) with the use of TNFi, is well described; nevertheless, it is significantly ameliorated with the appropriate screening and prophylaxis. Regarding IL-12/23i and IL-17i, there are no significant safety signals, except from an increased incidence of usually mild Candida infections with the latter class. Newer biologics such as IL-23i and targeted synthetic agents like JAKi have been recently introduced in the daily clinical practice for the treatment of this disease. While IL-23i has not been shown to increase the risk for common or opportunistic infections, a well-established association of JAKi with herpes zoster warrants the attention of rheumatologists. In this narrative review, we summarize the infectious complications of available treatment options by drug class in patients with PsA.

Effect of sarcopenia and poor balance on vertebral spinal osteoporotic fracture in female rheumatoid arthritis

This study investigated the effect of poor balance and sarcopenia on vertebral spinal osteoporotic fracture (VOPF) in female rheumatoid arthritic (RA) patients. A total of 195 female RA and 126 normal subjects were enrolled, and the correlations between sarcopenia, poor balance and VOPF were analyzed. Furthermore, we explored the relationships between sarcopenia or poor balance with disease related indexes of female RA. Binary logistic regression analyses were performed to identify potential risk factors for VOPF in female RA. We found that female RA had an increased risk of sarcopenia, poor balance (Berg balance scale, BBS ≤ 40) and VOPF than controls (P < 0.0001). Female RA with VOPF were more likely to have poor balance and sarcopenia than those without VOPF (P < 0.0001-0.05). Meanwhile, female RA with sarcopenia and poor balance often had higher disease activity, more serious joint damage and worse joint function (P < 0.05) compared with those without sarcopenia and poor balance. Binary logistic regression analysis (LR backwald) revealed that age (OR = 1.112, 95% CI 1.065-1.160, P < 0.0001), OP (OR = 10.137, 95% CI 4.224-24.330, P < 0.0001) and GCs usage (OR = 3.532, 95% CI 1.427-8.741, P = 0.006) were risk factors, while SMI (OR = 0.386, 95% CI 0.243-0.614, P < 0.0001) and BBS (OR = 0.952, 95% CI 0.929-0.976, P < 0.0001) were protective factors for VOPF in female RA. Hence, sarcopenia and poor balance are associated with a higher risk for VOPF and are closely related to disease activity and joint structure damage of female RA.

Viral infections in inflammatory bowel disease: Tips and tricks for correct management

Over the past decades, the treatment of inflammatory bowel diseases (IBD) has become more targeted, anticipating the use of immune-modifying therapies at an earlier stage. This top-down approach has been correlated with favorable short and long-term outcomes, but it has also brought with it concerns regarding potential infectious complications. This large IBD population treated with immune-modifying therapies, especially if combined, has an increased risk of severe infections, including opportunistic infections that are sustained by viral, bacterial, parasitic, and fungal agents. Viral infections have emerged as a focal safety concern in patients with IBD, representing a challenge for the clinician: they are often difficult to diagnose and are associated with significant morbidity and mortality. The first step is to improve effective preventive strategies, such as applying vaccination protocols, adopt adequate prophylaxis and educate patients about potential risk factors. Since viral infections in immunosuppressed patients may present atypical signs and symptoms, the challenges for the gastroenterologist are to suspect, recognize and diagnose such complications. Appropriate treatment of common viral infections allows us to minimize their impact on disease outcomes and patients’ lives. This practical review supports this standard of care to improve knowledge in this subject area.

A Review of the Use of Biological Agents in Human Immunodeficiency Virus Positive Patients With Rheumatological Diseases

After approval, initial biologics etanercept, infliximab, and adalimumab became useful in the therapeutic armamentarium to treat rheumatoid arthritis (RA) patients who had an inadequate response to disease-modifying anti-rheumatic drugs (DMARDs). However, all phase-III clinical trials submitted to the FDA, by design, excluded patients who were human immunodeficiency virus (HIV) positive. They are another subset of patients with low immunity due to their HIV-positive status. Very little information is available about the use of biologics in this new group of patients if they fail to respond to DMARDS. The available literature is limited to case reports about HIV-positive RA patients with reported side effects. These side effects range from no opportunistic infections (OIs) in some to acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulopathy (DIC) reported in others. Some HIV cases may initially present with rheumatological manifestations. With growing epidemiologic evidence of frequent joint manifestations in HIV-positive patients, HIV testing should be done more frequently in patients with RA, even those who deny risk factors for HIV. This review may help develop future guidelines on how to manage HIV-positive RA patients.

Infections in Patients with Rheumatoid Arthritis in the Era of Targeted Synthetic Therapies

The third decade of the 21st century marks the beginning of a new era in the treatment of rheumatoid arthritis (RA). Recently, after the introduction in clinical practice of different biologics in the first decade, three different oral synthetic targeted agents (JAK inhibitors) have been licensed for the treatment of RA, in patients who had failed or are intolerant to disease modifying anti-rheumatic drugs (DMARDs). Despite the significant progress that these agents bring to the care of RA patients, the risk of infections is still present and clear, given that their risk for serious infections is at least comparable with that of biologic DMARDs, whereas the incidence of herpes zoster is higher than that of bDMARDs. Here, we review the most recent data regarding the risk for serious and opportunistic infections in RA patients treated with biologics or JAK inhibitors, as well the up-to-date approach for managing and preventing such infections in RA patients.

Practical Guidelines for Managing Patients With Psoriasis on Biologics: An Update

The paradigm for treating inflammatory diseases has shifted dramatically in the past 10 to 20 years with the discovery of targeted therapeutics or "biologic" agents. Patients with rheumatoid arthritis, inflammatory bowel disease, psoriatic arthritis, and psoriasis, among others, are reaping the benefits of decades of bench to bedside research, allowing them to live more productive lives with less side effects than traditional systemic therapies. Despite these advances, many physicians unfamiliar with biologics are left to care for the basic needs of these patients and may be unaware of the multisystem comorbidities associated with psoriasis and the screening, monitoring, and other special considerations required of biologics patients. This can be overwhelming to primary care physicians and inadvertently expose patients to undue risks. The aim of this review is to provide a practical approach for all health care providers caring for patients with psoriasis being treated with biologics to facilitate communication with their treating dermatologist and ultimately provide patients with more comprehensive care.

Identification of rare HIV-1-infected patients with extreme CD4+ T cell decline despite ART-mediated viral suppression

BACKGROUND

The goal of antiretroviral therapy (ART) is to suppress HIV-1 replication and reconstitute CD4+ T cells. Here, we report on HIV-infected individuals who had a paradoxical decline in CD4+ T cells despite ART-mediated suppression of plasma HIV-1 load (pVL). We defined such an immunological outcome as extreme immune decline (EXID).

METHODS

EXID's clinical and immunological characteristics were compared to immunological responders (IRs), immunological nonresponders (INRs), healthy controls (HCs), and idiopathic CD4+ lymphopenia (ICL) patients. T cell immunophenotyping and assembly/activation of inflammasomes were evaluated by flow cytometry. PBMC transcriptome analysis and genetic screening for pathogenic variants were performed. Levels of cytokines/chemokines were measured by electrochemiluminescence. Luciferase immunoprecipitation system and NK-mediated antibody-dependent cellular cytotoxicity (ADCC) assays were used to identify anti-lymphocyte autoantibodies.

RESULTS

EXIDs were infected with non-B HIV-1 subtypes and after 192 weeks of consistent ART-mediated pVL suppression had a median CD4+ decrease of 157 cells/μl, compared with CD4+ increases of 193 cells/μl and 427 cells/μl in INR and IR, respectively. EXID had reduced naive CD4+ T cells, but similar proportions of cycling CD4+ T cells and HLA-DR+CD38+CD8+ T cells compared with IR and INR. Levels of inflammatory cytokines were also similar in EXID and INR, but the IL-7 axis was profoundly perturbed compared with HC, IR, INR, and ICL. Genes involved in T cell and monocyte/macrophage function, autophagy, and cell migration were differentially expressed in EXID. Two of the 5 EXIDs had autoantibodies causing ADCC, while 2 different EXIDs had an increased inflammasome/caspase-1 activation despite consistently ART-suppressed pVL.

CONCLUSIONS

EXID is a distinct immunological outcome compared with previously described INR. Anti-CD4+ T cell autoantibodies and aberrant inflammasome/caspase-1 activation despite suppressed HIV-1 viremia are among the mechanisms responsible for EXID.

Review article: managing the adverse events caused by anti-TNF therapy in inflammatory bowel disease

BACKGROUND

Biological therapy is currently widely used to treat IBD. Infliximab, adalimumab and golimumab are currently licensed anti-TNF therapies. Biosimilar anti-TNF monoclonal antibodies are increasingly used. Anti-TNF therapies are widely used and their adverse effects are well characterised, and may cause significant morbidity and mortality in a small proportion of exposed patients. Gastroenterologists need to understand the mechanisms for these effects, recognise these swiftly and manage such events appropriately.

AIM

To cover the range of potential adverse reactions as a result of biologic therapy and specifically management of these events.

METHODS

A Medline and Pubmed search was undertaken. Search terms included were "anti-TNF," "infliximab" or "adalimumab" or "golimumab" combined with the keywords "ulcerative colitis" or "Crohn's disease" or "inflammatory bowel disease" and then narrowed to articles containing the keywords "complications," "side effects" or "adverse events" or "safety profile." International guidelines were also reviewed where relevant.

RESULTS

Adverse events discussed in this review include infusion reactions, blood disorders and infections (including bacterial, viral, fungal and opportunistic infections) as well as autoimmune, dermatological disorders, cardiac and neurological conditions. Malignancies including solid organ, haematological and those linked to viral disease are discussed.

CONCLUSIONS

Anti-TNF therapy has wide-ranging effects on the immune system resulting in a spectrum of potential adverse events in a small proportion of patients. Research advances are improving the understanding, recognition and management of these adverse events.

2018 update of the APLAR recommendations for treatment of rheumatoid arthritis

AIM

To update recommendations based on current best evidence concerning the treatment of rheumatoid arthritis (RA), focusing particularly on the role of targeted therapies, to inform clinicians on new developments that will impact their current practice.

MATERIALS AND METHODS

A search of relevant literature from 2014 to 2016 concerning targeted therapies in RA was conducted. The RA Update Working Group evaluated the evidence and proposed updated recommendations using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, to describe the quality of evidence and strength of recommendations. Recommendations were finalized through consensus using the Delphi technique.

RESULTS

This update provides 16 RA treatment recommendations based on current best evidence and expert clinical opinion. Recommendations 1-3 deal with the use of conventional synthetic disease-modifying antirheumatic drugs. The next three recommendations (4-6) cover the need for screening and management of infections and comorbid conditions prior to starting targeted therapy, while the following seven recommendations focus on use of these agents. We address choice of targeted therapy, switch, tapering and discontinuation. The last three recommendations elaborate on targeted therapy for RA in special situations such as pregnancy, cancer, and major surgery.

CONCLUSION

Rheumatoid arthritis remains a significant health problem in the Asia-Pacific region. Patients with RA can benefit from the availability of effective targeted therapies, and these updated recommendations provide clinicians with guidance on their use.

Reactivation rates in patients using biological agents, with resolved HBV infection or isolated anti-HBc IgG positivity

BACKGROUND/AIMS

Tumor necrosis factor-α (TNF-α) inhibitors and ustekunimab are widely used in autoimmune diseases. It is known that these biological agents cause the reactivation of hepatitis B virus (HBV). There is no standardized strategy to prevent the reactivation in patients with evidence of a previous HBV infection. In our study, anti-HBc IgG-positive patients who received a biological agent were evaluated in terms of HBV reactivation.

MATERIALS AND METHODS

Patients who were followed up for the use of biological agents in our clinic were evaluated retrospectively. Patients with isolated anti-HBc IgG positivity were included in the study. The HBV reactivation data were recorded from the patients' files retrospectively.

RESULTS

Two hundred and seventy-eight patients who received biological treatment were evaluated. Twenty-nine patients with isolated anti-HBc IgG positivity or resolved HBV infection were included in the study. The HBV reactivation was seen in 5 patients (17.2%). Of these patients, 3 were using adalimumab, 1 infliximab, and 1 ustekunimab. It was controlled by antiviral therapy that was started in the early period.

CONCLUSION

Drugs that block TNF-α and ustekunimab cause an increase in viral replication. In literature, the HBV reactivation rate was approximately 1% in HBsAg-negative, anti-HBC IgG-positive cases, whereas it was found to be as high as 17.2% in our study. Patients receiving the immunomodulator therapy should be evaluated for HBV serology before treatment and carefully monitored for HBV reactivation during and after treatment.

Safety and effectiveness of conventional systemic therapy and biological drugs in patients with moderate to severe psoriasis and HIV infection: a retrospective multicenter study

Background: The management of HIV-positive patients with psoriasis is controversial and limited to individual cases or short series of patients. Objectives: To evaluate the safety and effectiveness of conventional and biologic immunosuppressive drugs in the treatment of patients with psoriasis and concomitant HIV infection. Methods: A retrospective multicenter study was conducted. The study included data from 2008 to 2016. Inclusion criteria were: HIV adult patients with moderate-to-severe psoriasis, HIV viral load determinations at baseline and at least after 6 months of treatment, and systemic immunosuppressive treatment for at least 6 months. A descriptive analysis was performed. Results: Twenty-three patients with plaque-type psoriasis and HIV infection (five with AIDS) were included. Median follow-up time was 3.2 years. The main drugs used were etanercept, methotrexate, and ustekinumab. In most cases, viral load and CD4 cell count not only remained stable but also improved throughout the follow-up. Six patients presented severe adverse events during the follow-up, four of them in the AIDS stage. At the end of the follow-up period, 76.5% of the patients had achieved a PASI 75. Conclusion: Biologic drugs, both anti-TNF alpha agents and ustekinumab, seem to have an acceptable safety profile and high effectiveness in HIV-positive patients.

Safety of biologic agents for psoriasis in patients with viral hepatitis

INTRODUCTION

Biologics are highly effective, important treatment options for moderate-to-severe psoriasis. Biologics are well tolerated and have few side effects. However, the use of biologics in patients with concomitant chronic viral hepatitis is debatable. Recent reports have suggested a very low associated risk of reactivation of chronic hepatitis B (HBV) and C (HCB).

OBJECTIVE

To evaluate the safety and effectiveness of biologics for moderate to severe psoriasis patients with concomitant chronic viral hepatitis.

METHODS

We followed 39 patients with psoriasis and concurrent chronic viral hepatitis (chronic inactive and occult cases) with no clinical signs and/or lab indication of active liver disease) treated with biologic agents for at least 24 weeks. Patients were regularly monitored for reactivation of viral hepatitis with liver enzymes, viral DNA load, and viral markers.

RESULTS

There was no evidence of viral reactivation until the last available lab investigation results (done three months after stopping the medication). None of the patients showed signs or symptoms of liver failure.

CONCLUSION

The use of biologic therapy appeared safe and effective in this small cohort of selected patients with chronic HBV and HCV infection. Close monitoring for HBV and HCV viral load is recommended for patients with high-risk factors.

Tuberculosis and viral hepatitis infection in Eastern Europe, Asia, and Latin America: impact of tumor necrosis factor-α inhibitors in clinical practice

Tumor necrosis factor-α (TNF-α) inhibitors are increasingly becoming the standard of care for treating a number of inflammatory diseases. However, treatment with TNF-α inhibitors carries an inherent risk of compromising the immune system, resulting in an increased susceptibility to infections and malignancies. This increased risk of infection is of particular concern in Asia, Eastern Europe, and Latin America where tuberculosis (TB) and viral hepatitis are endemic. In this brief review, we examine the literature and review the impact of TNF-α inhibitors on the incidence and the reactivation of latent disease with respect to TB, hepatitis C infection, and hepatitis B infection. Our findings show that TNF-α inhibitors are generally safe, if used with caution. Patients should be screened prior to the initiation of TNF-α inhibitor treatment and given prophylactic treatment if needed. In addition, patients should be monitored during treatment with TNF-α inhibitors and after treatment has stopped to ensure that infections, if detected, are treated promptly and effectively. Our analysis is consistent with other reports and guidelines.

Soybean-derived Bowman-Birk inhibitor (BBI) blocks HIV entry into macrophages

Bowman-Birk inhibitor (BBI) is a soybean-derived protease inhibitor that has anti-inflammation and anti-HIV effect. Here, we further investigated the anti-HIV action of BBI in macrophages, focusing on its effect on viral entry. We found that BBI could significantly block HIV entry into macrophages. Investigation of the mechanism(s) of the BBI action on HIV inhibition showed that BBI down-regulated the expression of CD4 receptor (as much as 80%) and induced the production of the CC chemokines (up to 60 folds at protein level) in macrophages. This inhibitory effect of BBI on HIV entry could be blocked by the neutralization antibodies to CC chemokines. These findings indicate that BBI may have therapeutic potential as a viral entry inhibitor for the prevention and treatment of HIV infection.

Targeting TNF and TNF Receptor Pathway in HIV-1 Infection: from Immune Activation to Viral Reservoirs

Several cellular functions such as apoptosis, cellular proliferation, inflammation, and immune regulation involve the tumor necrosis factor-α (TNF)/TNF receptor (TNFR) pathway. Human immunodeficiency virus 1 (HIV-1) interacts with the TNF/TNFR pathway. The activation of the TNF/TNFR pathway impacts HIV-1 replication, and the TNF/TNFR pathway is the target of HIV-1 proteins. A hallmark of HIV-1 infection is immune activation and inflammation with increased levels of TNF in the plasma and the tissues. Therefore, the control of the TNF/TNFR pathway by new therapeutic approaches could participate in the control of immune activation and impact both viral replication and viral persistence. In this review, we will describe the intricate interplay between HIV-1 proteins and TNF/TNFR signaling and how TNF/TNFR activation modulates HIV-1 replication and discuss new therapeutic approaches, especially anti-TNF therapy, that could control this pathway and ultimately favor the clearance of infected cells to cure HIV-infected patients.

Cardiac Disease Associated with Human Immunodeficiency Virus Infection

Over the last 2 decades human immunodeficiency virus (HIV) infection has become a chronic disease requiring long-term management. Aging, antiretroviral therapy, chronic inflammation, and several other factors contribute to the increased risk of cardiovascular disease in patients infected with HIV. In low-income and middle-income countries where antiretroviral therapy access is limited, cardiac disease is most commonly related to opportunistic infections and end-stage manifestations of HIV/acquired immunodeficiency syndrome, including HIV-associated cardiomyopathy, pericarditis, and pulmonary arterial hypertension. Cardiovascular screening, prevention, and risk factor management are important factors in the management of patients infected with HIV worldwide.

Inflammatory dermatoses in human immunodeficiency virus

Various inflammatory dermatoses have been described in association with human immunodeficiency virus (HIV) infection. These either present in the usual way or in varied atypical presentations. This article gives a brief review about the etiopathogenesis and clinical presentation of the common inflammatory dermatoses associated with HIV such as psoriasis, reactive arthritis, seborrheic dermatitis, eosinophilic folliculitis, pruritic papular eruption, photosensitivity disorders prurigo nodularis, atopic dermatitis, and ichthyosis.

Soybean-derived Bowman-Birk Inhibitor (BBI) Inhibits HIV Replication in Macrophages

The Bowman-Birk inhibitor (BBI), a soybean-derived protease inhibitor, is known to have anti-inflammatory effect in both in vitro and in vivo systems. Macrophages play a key role in inflammation and immune activation, which is implicated in HIV disease progression. Here, we investigated the effect of BBI on HIV infection of peripheral blood monocyte-derived macrophages. We demonstrated that BBI could potently inhibit HIV replication in macrophages without cytotoxicity. Investigation of the mechanism(s) of BBI action on HIV showed that BBI induced the expression of IFN-β and multiple IFN stimulated genes (ISGs), including Myxovirus resistance protein 2 (Mx2), 2',5'-oligoadenylate synthetase (OAS-1), Virus inhibitory protein (viperin), ISG15 and ISG56. BBI treatment of macrophages also increased the expression of several known HIV restriction factors, including APOBEC3F, APOBEC3G and tetherin. Furthermore, BBI enhanced the phosphorylation of IRF3, a key regulator of IFN-β. The inhibition of IFN-β pathway by the neutralization antibody to type I IFN receptor (Anti-IFNAR) abolished BBI-mediated induction of the anti-HIV factors and inhibition of HIV in macrophages. These findings that BBI could activate IFN-β-mediated signaling pathway, initialize the intracellular innate immunity in macrophages and potently inhibit HIV at multiple steps of viral replication cycle indicate the necessity to further investigate BBI as an alternative and cost-effective anti-HIV natural product.

TNFα Impairs Rhabdoviral Clearance by Inhibiting the Host Autophagic Antiviral Response

TNFα is a pleiotropic pro-inflammatory cytokine with a key role in the activation of the immune system to fight viral infections. Despite its antiviral role, a few viruses might utilize the host produced TNFα to their benefit. Some recent reports have shown that anti-TNFα therapies could be utilized to treat certain viral infections. However, the underlying mechanisms by which TNFα can favor virus replication have not been identified. Here, a rhabdoviral infection model in zebrafish allowed us to identify the mechanism of action by which Tnfa has a deleterious role for the host to combat certain viral infections. Our results demonstrate that Tnfa signals through its receptor Tnfr2 to enhance viral replication. Mechanistically, Tnfa does not affect viral adhesion and delivery from endosomes to the cytosol. In addition, the host interferon response was also unaffected by Tnfa levels. However, Tnfa blocks the host autophagic response, which is required for viral clearance. This mechanism of action provides new therapeutic targets for the treatment of SVCV-infected fish, and advances our understanding of the previously enigmatic deleterious role of TNFα in certain viral infections.

Tumor necrosis factor alpha (TNFα) is one of the main pro-inflammatory cytokines produced in response to a broad type of infections [1]. Although TNFα has a crucial role in protecting the host organism from pathogens, its deregulation can promote susceptibility to pathogens by impairing pathogen clearance and, ultimately, promoting maintenance of infection and death. In addition, some viruses might utilize the host produced TNFα to their benefit. Thus, anti-TNFα therapies could be utilized to treat certain viral infections. However, the underlying mechanisms by which TNFα can favor certain virus replication have not been identified. Here, we have used a viral infection model in zebrafish to identify the mechanism of action by which TNFα has a deleterious role for the host to combat certain viral infections. Our results demonstrate that Tnfa does not affect viral ability to infect host cells or to antagonize the main host antiviral pathway, namely the interferon pathway. However, Tnfa impairs viral clearance by blocking the host autophagy response, which is usually used by host cells to degrade unnecessary or dysfunctional cellular components, and that we found to be critical to eliminate intracellular viral particles. This mechanism of action provides new therapeutic targets for the treatment of SVCV-infected fish in aquaculture and probably to other viral infection affecting cattle industry and human.

Exploring interaction of TNF and orthopoxviral CrmB protein by surface plasmon resonance and free energy calculation

Inhibition of the activity of the tumor necrosis factor (TNF) has become the main strategy for treating inflammatory diseases. The orthopoxvirus TNF-binding proteins can bind and efficiently neutralize TNF. To analyze the mechanisms of the interaction between human (hTNF) or mouse (mTNF) TNF and the cowpox virus N-terminal binding domain (TNFBD-CPXV), also the variola virus N-terminal binding domain (TNFBD-VARV) and to define the amino acids most importantly involved in the formation of complexes, computer models, derived from the X-ray structure of a homologous hTNF/TNFRII complex, were used together with experiments. The hTNF/TNFBD-CPXV, hTNF/TNFBD-VARV, mTNF/TNFBD-CPXV, and mTNF/TNFBD-VARV complexes were used in the molecular dynamics (MD) simulations and MM/GBSA free energy calculations. The complexes were ordered as hTNF/TNFBD-CPXV, hTNF/TNFBD-VARV, mTNF/TNFBD-CPXV and mTNF/TNFBD-VARV according to increase in the binding affinity. The calculations were in agreement with surface plasmon resonance (SPR) measurements of the binding constants. Key residues involved in complex formation were identified.

Sarcopenia in women with rheumatoid arthritis

OBJECTIVE

To assess sarcopenia status in women with rheumatoid arthritis (RA).

MATERIAL AND METHODS

Thirty female patients with RA and 30 female controls without RA were enrolled in this study. Sarcopenia status in patients with RA was evaluated by assessing body composition using dual X-ray absorptiometry (DXA). C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) were measured, and body mass index (BMI) and Disease Activity Score (DAS28) were calculated. Because sarcopenia differs between men and women, the study groups comprised only females.

RESULTS

It was found that skeletal muscle index (SMI) was lower in patients with RA (5.83±0.807) than in controls (7.30±1.640). Sarcopenia (in females with an SMI of ≤5.75 kg/m2) was more common in the RA group and the difference was statistically significant (p=0.004). Sarcopenia was more common in patients with RA who were normal or overweight than in those who were obese according to their BMI. There was no relationship between sarcopenia and DAS28 in the RA group (p=0.530), whereas CRP levels were significantly higher in patients with sarcopenia (p=0.230). No relationship was found between drug use and sarcopenia in the RA group.

CONCLUSION

It was found that SMI was decreased and sarcopenia risk was elevated in patients with RA and the risk was higher in non-obese patients.

The use of ustekinumab in a patient with severe psoriasis and positive HBV serology

Psoriasis is a chronic inflammatory, immune-mediated disease that affects 1% to 2% of the world's population. Immunobiological medications are prescribed for certain patients with severe forms of psoriasis, however, these drugs increase the risk of reactivation of viral diseases such as hepatitis B. We report the case of a patient with severe psoriasis with positive serology for the Hepatitis B virus, who received ustekinumab (a human monoclonal antibody against interleukin 12 and 23). In this patient, the use of ustekinumab did not reactivate the Hepatitis B virus. Given the high prevalence of chronic viral infections in patients who are candidates for biologic therapy, as well as the potential for reactivate chronic viral illness, randomized controlled studies are needed to assess the risks and benefits of such therapy in these populations.

The use of ustekinumab in a patient with severe psoriasis and positive HBV serology

Psoriasis is a chronic inflammatory, immune-mediated disease that affects 1% to 2% of the world's population. Immunobiological medications are prescribed for certain patients with severe forms of psoriasis, however, these drugs increase the risk of reactivation of viral diseases such as hepatitis B. We report the case of a patient with severe psoriasis with positive serology for the Hepatitis B virus, who received ustekinumab (a human monoclonal antibody against interleukin 12 and 23). In this patient, the use of ustekinumab did not reactivate the Hepatitis B virus. Given the high prevalence of chronic viral infections in patients who are candidates for biologic therapy, as well as the potential for reactivate chronic viral illness, randomized controlled studies are needed to assess the risks and benefits of such therapy in these populations.

Risk of infections with biological agents

An increasing proportion of patients with inflammatory bowel disease (IBD) are treated with biological medications. The risk of infectious complications remains a significant concern in patients treated with biologics. Treatment with biological agents in IBD is generally safe, but there may be an increased risk of certain opportunistic infections. Some of the infectious risks are class specific, whereas others are a common concern for all biologics. A careful screening, surveillance, and immunization program, in accordance with available guidelines, is important to minimize any risk of infectious complications.

Preventing infective complications in inflammatory bowel disease

Over the past decade there has been a dramatic change in the treatment of patients with Crohn’s disease and ulcerative colitis, which comprise the inflammatory bowel diseases (IBD). This is due to the increasing use of immunosuppressives and in particular the biological agents, which are being used earlier in the course of disease, and for longer durations, as these therapies result in better clinical outcomes for patients. This, however, has the potential to increase the risk of opportunistic and serious infections in these patients, most of which are preventable. Much like the risk for potential malignancy resulting from the use of these therapies long-term, a balance needs to be struck between medication use to control the disease with minimization of the risk of an opportunistic infection. This outcome is achieved by the physician’s tailored use of justified therapies, and the patients’ education and actions to minimize infection risk. The purpose of this review is to explore the evidence and guidelines available to all physicians managing patients with IBD using immunomodulating agents and to aid in the prevention of opportunistic infections.

TNF and TNF receptor superfamily members in HIV infection: new cellular targets for therapy?

Tumor necrosis factor (TNF) and TNF receptors (TNFR) superfamily members are engaged in diverse cellular phenomena such as cellular proliferation, morphogenesis, apoptosis, inflammation, and immune regulation. Their role in regulating viral infections has been well documented. Viruses have evolved with numerous strategies to interfere with TNF-mediated signaling indicating the importance of TNF and TNFR superfamily in viral pathogenesis. Recent research reports suggest that TNF and TNFRs play an important role in the pathogenesis of HIV. TNFR signaling modulates HIV replication and HIV proteins interfere with TNF/TNFR pathways. Since immune activation and inflammation are the hallmark of HIV infection, the use of TNF inhibitors can have significant impact on HIV disease progression. In this review, we will describe how HIV infection is modulated by signaling mediated through members of TNF and TNFR superfamily and in turn how these latter could be targeted by HIV proteins. Finally, we will discuss the emerging therapeutics options based on modulation of TNF activity that could ultimately lead to the cure of HIV-infected patients.

The influence of anti-TNF therapy on the course of chronic hepatitis C virus infection in patients with inflammatory bowel disease

BACKGROUND

The immunosuppressive potential of anti-tumor necrosis factor (TNF) in exacerbating chronic hepatitis C virus (HCV) infection has been a major concern. We aim to critically analyze the impact of anti-TNF on the course of chronic HCV infection in patients with concurrent inflammatory bowel disease (IBD) and HCV infection.

MATERIALS AND METHODS

Patients with diagnosis of IBD and HCV were identified retrospectively through the University of Pennsylvania Health System electronic database. Data assessed included demographics, duration of IBD and HCV infection, HCV RNA levels, HCV genotype, liver histology, hepatic biochemical tests (HBT) and IBD disease activity index.

RESULTS

A total of 4,274 IBD and 3,523 HCV patients were identified from 10/1998 to 05/2010. Thirty-seven patients had concurrent HCV infection and IBD, of which 23 patients were eligible (61 % CD; 39 % UC). Five patients (22 %) received anti-TNF therapy (infliximab). Two patients received pegylated interferon and ribavirin (both were non-responders). Overall, three patients had clinical remission and one patient had clinical response to infliximab. When compared to baseline, one patient had HBT improvement, three patients remained stable and one patient had HBT elevation, which was likely due to progressive liver disease in view of HIV co-infection.

CONCLUSION

This represents the first critical analysis assessing the impact of anti-TNF therapy on the course of chronic HCV in IBD patients. Concurrent HCV infection in IBD patients is uncommon. Treatment of IBD with infliximab in HCV patients did not result in flares in hepatic biochemical tests while there was an improvement in the IBD disease activity score.

Long-term safety of anti-TNF adalimumab in HBc antibody-positive psoriatic arthritis patients: a retrospective case series of 8 patients

Immunosuppressive drugs commonly used in the treatment of psoriatic arthritis make patients more susceptible to viral, bacterial, and fungal infections because of their mechanism of action. They not only increase the risk of new infections but also act altering the natural course of preexisting infections. While numerous data regarding the reactivation of tuberculosis infection are available in the literature, poor information about the risk of reactivation or exacerbation of hepatitis viruses B and C infections during treatment with biologics has been reported. Furthermore, reported series with biological therapy included short periods of followup, and therefore, they are not adequate to verify the risk of reactivation in the long-term treatment. Our study evaluated patients with a history of hepatitis B and psoriatic arthritis treated with adalimumab and monitored up to six years. During the observation period, treatment was effective and well tolerated in all patients, and liver function tests and viral load levels remained unchanged.

Hepatitis B and inflammatory bowel disease: Role of antiviral prophylaxis

Hepatitis B virus (HBV) is a very common infection worldwide. Its reactivation in patients receiving immunosuppression has been widely described as being associated with significant morbidity and mortality unless anti-viral prophylaxis is administered. Treatment in inflammatory bowel disease (IBD) patients has changed in recent years and immunosuppression and biological therapies are now used more frequently than before. Although current studies have reported an incidence of hepatitis B in inflammatory bowel disease patients similar to that in the general population, associated liver damage remains an important concern in this setting. Liver dysfunction may manifest in several ways, from a subtle change in serum aminotransferase levels to fulminant liver failure and death. Patients undergoing double immunosuppression are at a higher risk, and reactivation usually occurs after more than one year of treatment. As preventive measures, all IBD patients should be screened for HBV markers at diagnosis and those who are positive for the hepatitis B surface antigen should receive antiviral prophylaxis before undergoing immunosuppression in order to avoid HBV reactivation. Tenofovir/entecavir are preferred to lamivudine as nucleos(t)ide analogues due to their better resistance profile. In patients with occult or resolved HBV, viral reactivation does not appear to be a relevant issue and regular DNA determination is recommended during immunosuppression therapy. Consensus guidelines on this topic have been published in recent years. The prevention and management of HBV infection in IBD patients is addressed in this review in order to address practical recommendations

Biological therapies for inflammatory bowel disease: controversies and future options

Over the last few years, advances in understanding the pathogenesis of inflammatory bowel disease, together with progress in biotechnology, have led to the availability of several biological drugs that have dramatically changed the therapeutic approach to these disorders. Indeed, several molecules targeting crucial inflammatory cytokines, blocking T-cell activation/proliferation or the recruitment of inflammatory cells into the inflamed bowel, have been discovered and commercialized. However, the increasing use of biological agents has raised some concerns regarding their short- and long-term safety. This review offers a critical evaluation of the efficacy and safety of biological agents in the management of both Crohn's disease and ulcerative colitis. In addition, promising therapeutic options are discussed.

A fatal case of hepatitis B virus (HBV) reactivation during long-term, very-low-dose steroid treatment in an inactive HBV carrier

Hepatitis B virus (HBV) may be reactivated after chemotherapy or immunosuppressive therapy, and therefore administration of antiviral agents before such treatment is recommended. Most reported cases of reactivation are associated with high doses of immunosuppressive agents or combination therapy. We present a case of a previously inactive HBV carrier with an acute severe flare-up during a long-term, very-low-dose (2.5 mg/day) steroid treatment for rheumatoid arthritis. We suggest that even a minimal dose of single-regimen oral steroid can cause reactivation of indolent, inactive HBV.

Gastroprotective activities of Turnera diffusa Willd. ex Schult. revisited: Role of arbutin

ETHNOPHARMACOLOGICAL RELEVANCE

Turnera diffusa Willd. ex Schult. has been used for the treatment of several human disorders including peptic ulcer.

OBJECTIVES OF THE STUDY

The current study is an attempt to evaluate the anti-ulcerogenic activities of arbutin, a major constituent of Turnera diffusa on two ulcer models. The possible involvement of lipid peroxidation, nitric oxide, IL-6, IL-10, TNF-α and mucus barrier mechanism has been investigated.

MATERIALS AND METHODS

Effects of arbutin on ulcer index, gastric juice acidity, mucus content and histochemistry, gross and histological gastric lesions, nitric oxide, cytokines levels (IL-6, IL-10 and TNF-α), and thiobarbituric acid reactive substances (TBARS), were evaluated in aspirin or ethanol-induced ulcer in vivo. Acute toxicity of arbutin was also examined in rodent model. MTT assay was used to assess the cytotoxicity of the compound on normal liver cells (WRL-68).

RESULTS

Pre-treatment with arbutin or omeprazole protected the gastric mucosa as seen by reduction in ulcer area and mucosal content, reduced or absence of edema, inflammation and leucocytes infiltration on both models. Arbutin significantly (P<0.05) lowered the elevated TBARS level into gasteric homogenate. Arbutin did not produce significant inhibition of NO. This natural compound has modulated the levels of interleukin-6, interleukin-10 and TNF-α. No in vitro or in vivo toxicities for arbutin were observed.

CONCLUSION

Thus it can be concluded that Turnera diffusa possesses anti-ulcer activity, which could be attributed to lipid peroxidation inhibitory, immuno modulatory and anti-oxidant mechanisms of arbutin but not to the intervention with nitric oxide inflammation pathway.

Prospective study of HBV reactivation risk in rheumatoid arthritis patients who received conventional disease-modifying antirheumatic drugs

Studies that reported hepatitis B virus (HBV) reactivation in rheumatoid arthritis (RA) patients have caused attention of disease-modifying antirheumatic drug (DMARD)-related HBV reactivation. Most of the studies were focused on HBV reactivation risk of biologic DMARDs; insufficient data are available to identify the exact risk of conventional DMARD (c-DMARD)-related HBV reactivation. This prospective study aimed to investigate the risk of HBV reactivation in HBV-infected RA patients who received c-DMARDs. A total of 476 RA patients were screened in this prospective non-randomized, non-controlled study. HBV-infected patients characterized by hepatitis B surface antigen (HBsAg) positive or HBsAg negative/anti-hepatitis B core antigen (anti-HBc) positive were analyzed for HBV DNA, followed with HBV DNA monitoring scheduled every 3 months, serum alanine aminotransferase test at 2-month intervals, or more frequently. Prevalence of HBsAg positive and HBsAg negative/anti-HBc positive was 6.51 and 51.1 %, respectively, among the 476 RA patients. Among 211 patients (23 patients were HBsAg positive and 188 patients were HBsAg negative/anti-HBc positive) who received c-DMARDs without antiviral prophylactic treatment, 4 patients developed HBV reactivation. Both HBsAg positive and HBsAg negative/anti-HBc positive patients have the possibility of developing HBV reactivation. There was no correlation between HBV reactivation and any specific c-DMARD. Glucocorticoid coadministration and negative anti-hepatitis B surface antigen (anti-HBs) at baseline showed correlation with reactivation. In conclusion, it would be rational to initiate antiviral prophylaxis according to risk stratification rather than universal prophylaxis for HBV-infected RA patients. Conventional DMARDs are relatively safe to HBV-infected patients with low reactivation risk (low HBV DNA level, no GCs administration, and anti-HB positive).

Rheumatoid arthritis and the era of biologic therapy

Biologic disease modifying anti-rheumatic drugs have transformed the management of rheumatoid arthritis (RA) since their introduction into clinical practice over a decade ago. Following large-scale clinical trials, a number of biologics, with different mechanisms of action, have been licensed for the condition. In this review, we will summarise the current evidence for biologic use in RA with an emphasis on their efficacy and tolerability. In addition, we will provide a commentary on the current limitations and unmet needs in this area and discuss the future of biologic intervention.

Use of biological disease-modifying anti-rheumatic drugs in patients with concurrent rheumatic disease and hepatitis B

BACKGROUND

Biological disease-modifying anti-rheumatic drugs (bDMARDs) are effective in the management of inflammatory arthritides. Reactivation of hepatitis B virus (HBV) is a potential adverse outcome in patients treated with bDMARDs. There is currently no consensus on the approach to identifying and treating these patients with underlying HBV infection.

AIM

The aims of this study were to assess the risk of HBV reactivation in patients treated with bDMARDs, and to determine whether HBV screening should be carried out in all patients prior to commencing bDMARDs.

METHODS

A literature search was undertaken to identify all reports of patients with inflammatory arthritides and concurrent HBV infection being treated with bDMARDs.

RESULTS

Forty-three patients with HBV infection were identified, of whom eight patients developed HBV reactivation after exposure to bDMARDs. Of the patients who experienced reactivation, two had unknown infection that surfaced during bDMARD therapy. Patients who experienced reactivation were promptly treated with antiviral therapy and saw clinical improvement. There are no long-term data on these patients.

CONCLUSIONS

HBV reactivation may result in serious consequences, including death. Tuberculosis screening prior to bDMARD treatment is already standard practice, as is HBV screening for patients undergoing cancer chemotherapy. Implementing HBV screening for all patients prior to bDMARD treatment can identify patients with chronic HBV who may require antiviral therapy.

The safety of etanercept for the treatment of plaque psoriasis

Effective treatment with etanercept results from a congregation of immunological signaling and modulating roles played by tumor necrosis factor-alpha (TNF-alpha), a pervasive member of the TNF super-family of cytokines participating in numerous immunologic and metabolic functions. Macrophages, lymphocytes and other cells produce TNF as part of the deregulated immune response resulting in psoriasis or other chronic inflammatory disorders. Tumor necrosis factor is also produced by macrophages and lymphocytes responding to foreign antigens as a primary response to potential infection. Interference with cytokine signaling by etanercept yields therapeutic response. At the same time, interference with cytokine signaling by etanercept exposes patients to potential adverse events. While the efficacy of etanercept for the treatment of psoriasis is evident, the risks of treatment continue to be defined. Of the potential serious adverse events, response to infection is the best characterized in terms of physiology, incidence, and management. Rare but serious events: activation of latent tuberculosis, multiple sclerosis, lymphoma, and others, have been observed but have questionable or yet to be defined association with therapeutic uses of etanercept. The safe use of etanercept for the treatment of psoriasis requires an appreciation of potential adverse events as well as screening and monitoring strategies designed to manage patient risk

Safety of anti-tumour necrosis factor agents in patients with chronic hepatitis C infection: a systematic review

OBJECTIVES

To identify all of the patients affected by chronic hepatitis C infection treated with TNF-α blockers (adalimumab, certolizumab pegol, etanercept, golimumab and infliximab) in order to evaluate the safety profile.

METHODS

A systematic review of the literature from January 1990 to October 2010.

RESULTS

In total, 37 publications with data on 153 patients who were treated with anti-TNF-α agents in the setting of HCV infection were found. The mean anti-TNF-α treatment duration was 11.9 months. Ninety-one patients had RA, 22 had psoriasis, 6 had Crohn's disease and 14 patients had other chronic inflammatory diseases. To date, etanercept is the biological agent that has been most extensively used in the patients with HCV infection, with only one definitely confirmed case of HCV hepatitis worsening and five suspected cases (elevation of transaminases not associated with an increase in the HCV viral load and vice versa) in 110 treated patients. Treatment with this agent resulted in stable levels of liver transaminases and a stable viral load in 74 patients, with an improvement in HCV chronic liver disease in combination with IFN-ribavirin therapy in 29 patients.

CONCLUSIONS

The safety profile of anti-TNF-α agents in the setting of HCV infection seems to be acceptable, even if differences in the hepatotoxic profile are apparent between different agents. In the absence of long-term and large, controlled clinical trials a definitive statement on the safety of anti-TNF-α therapies in the setting of chronic HCV infection cannot be made.

Induction of clinical remission with adalimumab-methotrexate combination therapy in a patient with rheumatoid arthritis and concomitant hepatitis C virus infection

The patient described here is a 49-year-old woman who had hepatitis C virus (HCV) infection and rheumatoid arthritis (RA). Her RA had been successfully managed with methotrexate for about 10 years. After a sustained virological response was achieved with interferon therapy, treatment with adalimumab was instituted. This resulted in a rapid and sustained remission that lasted for more than a year, without HCV reactivation. The results in this case suggest that a sequential strategy, with initial HCV clearance followed by the targeting of remission with biologics, may be a favorable option in patients with RA and concomitant HCV infection.

Current and future pharmacologic treatment of sarcopenia

Sarcopenia is a complex multifactorial condition that can by treated with multimodal approaches. No pharmacologic agent to prevent or treat sarcopenia has been as efficacious as exercise (mainly resistance training) in combination with nutritional intervention (adequate protein and energy intake). However, performing resistance training sessions and following nutritional advice can be challenging, especially for frail, sarcopenic, elderly patients, and results remain only partial. Therefore, new pharmacologic agents may substantially reduce the functional decline in older people. This article reviews the new pharmacologic agents currently being assessed for treating sarcopenia.