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Maximova N, Nisticò D, Riccio G, Maestro A, Barbi E, Faganel Kotnik B, Marcuzzi A, Rimondi E, Di Paolo A. Advantage of First-Line Therapeutic Drug Monitoring-Driven Use of Infliximab for Treating Acute Intestinal and Liver GVHD in Children: A Prospective, Single-Center Study. Cancers (Basel) 2023; 15:3605. [PMID: 37509268 PMCID: PMC10376946 DOI: 10.3390/cancers15143605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
The high serum concentrations of TNF-α characterize acute graft-versus-host disease (aGVHD), for which infliximab treatment may be beneficial. In 28 pediatric patients, four doses of 10 mg/kg infliximab every seven days were administered after steroid failure (Standard Group, n = 14) or as a first-line therapy (Early Group, n = 14). Population pharmacokinetic analyses and evaluation of serum cytokines were performed. After two months of treatment, complete response in gastrointestinal and liver aGVHD was achieved in 43% and 100% of patients in the Standard and Early groups, respectively. During follow-up, four patients in the Standard Group (but none in the Early Group) experienced an aGVHD recurrence. Viral infections occurred more frequently in the Standard Group after the fifth dose. Infliximab clearance did not differ between groups or according to treatment outcome for each organ involved in aGVHD, whereas serum levels of cytokines significantly differed. Therefore, present findings show that use of first-line, TDM-driven infliximab to treat aGVHD in children may result in better clinical outcomes and tolerability, with a different pattern of cytokines generated according to the moment of beginning of treatment.
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Affiliation(s)
- Natalia Maximova
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Daniela Nisticò
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Guglielmo Riccio
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Egidio Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Barbara Faganel Kotnik
- Department of Hematology and Oncology, University Children's Hospital, 1000 Ljubljana, Slovenia
| | - Annalisa Marcuzzi
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Erika Rimondi
- Department of Translational Medicine and LTTA Centre, University of Ferrara, 44121 Ferrara, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Fragoulis GE, Nikiphorou E, Dey M, Zhao SS, Courvoisier DS, Arnaud L, Atzeni F, Behrens GM, Bijlsma JW, Böhm P, Constantinou CA, Garcia-Diaz S, Kapetanovic MC, Lauper K, Luís M, Morel J, Nagy G, Polverino E, van Rompay J, Sebastiani M, Strangfeld A, de Thurah A, Galloway J, Hyrich KL. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2022; 82:742-753. [PMID: 36328476 DOI: 10.1136/ard-2022-223335] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
ObjectivesTo develop EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD).MethodsAn international Task Force (TF) (22 members/15 countries) formulated recommendations, supported by systematic literature review findings. Level of evidence and grade of recommendation were assigned for each recommendation. Level of agreement was provided anonymously by each TF member.ResultsFour overarching principles (OAP) and eight recommendations were developed. The OAPs highlight the need for infections to be discussed with patients and with other medical specialties, in accordance with national regulations. In addition to biologic/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) for which screening for latent tuberculosis (TB) should be performed, screening could be considered also before conventional synthetic DMARDs, glucocorticoids and immunosuppressants. Interferon gamma release assay should be preferred over tuberculin skin test, where available. Hepatitis B (HBV) antiviral treatment should be guided by HBV status defined prior to starting antirheumatic drugs. All patients positive for hepatitis-C-RNA should be referred for antiviral treatment. Also, patients who are non-immune to varicella zoster virus should be informed about the availability of postexposure prophylaxis should they have contact with this pathogen. Prophylaxis againstPneumocystis jiroveciiseems to be beneficial in patients treated with daily doses >15–30 mg of prednisolone or equivalent for >2–4 weeks.ConclusionsThese recommendations provide guidance on the screening and prevention of chronic and opportunistic infections. Their adoption in clinical practice is recommended to standardise and optimise care to reduce the burden of opportunistic infections in people living with AIIRD.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Rheumatology Department, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
| | | | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), University Hospitals Strasbourg, Strasbourg, France
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Georg Mn Behrens
- Department for Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Johannes Wj Bijlsma
- Dept of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Peter Böhm
- Forschungspartner, German League against rheumatism, Bonn, Germany
| | | | - Silvia Garcia-Diaz
- Rheumatology Department, Complex Hospitalari Moises Broggi, Barcelona, Spain
| | | | - Kim Lauper
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- Division of Rheumatology, University of Geneva, Geneva, Switzerland
| | - Mariana Luís
- Rheumatology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Jacques Morel
- Department of Rheumatology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - György Nagy
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias CIBERES, Barcelona, Spain
| | - Jef van Rompay
- Belgium Patient Partner Program, EULAR People with Arthritis/Rheumatism across Europe (PARE), Antwerpen, Belgium
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Centre (DRFZ) Berlin and Charite University Medicine, Berlin, Germany
| | - Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester NHS Foundation Trust, Manchester, UK
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Fragoulis GE, Dey M, Zhao S, Schoones J, Courvoisier D, Galloway J, Hyrich KL, Nikiphorou E. Systematic literature review informing the 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. RMD Open 2022; 8:rmdopen-2022-002726. [PMID: 36323488 PMCID: PMC9639159 DOI: 10.1136/rmdopen-2022-002726] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To conduct a systematic literature review (SLR) on the screening and prophylaxis of opportunistic and chronic infections in autoimmune inflammatory rheumatic diseases (AIIRD). METHODS SLR (inception-12/2021) based on the following search domains: (1) infectious agents, (2) AIIRD, (3) immunosuppressives/immunomodulators used in rheumatology, (4) screening terms and (5) prophylaxis terms. Articles were retrieved having the terms from (1) AND (2) AND (3) plus terms from (4) OR(5). Databases searched: PubMed, Embase and Cochrane Library. EXCLUSION CRITERIA studies on postoperative infections, paediatric AIIRD, COVID-19, vaccinations and non-Εnglish literature. Study quality was assessed with Newcastle-Ottawa scale for non-randomised controlled trials (RCTs), RoB-Cochrane for RCTs, AMSTAR2 for SLRs. RESULTS From 5641 studies were retrieved, 568 full-text articles were assessed for eligibility, with 194 articles finally included. For tuberculosis, tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. For hepatitis B virus (HBV): risk of reactivation is increased in patients positive for hepatitis B surface antigen. Anti-HBcore positive patients are at low risk for reactivation but should be monitored periodically with liver function tests and/or HBV-viral load. Risk for Hepatitis C reactivation is existing but low in patients treated with biological DMARDs. For Pneumocystis jirovecii, prophylaxis treatment should be considered in patients treated with prednisolone ≥15-30 mg/day for >2-4 weeks. CONCLUSIONS Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Zhao
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Jan Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | | | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
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Li L, Jiang X, Fu L, Zhang L, Feng Y. Reactivation rates of hepatitis B or C or HIV in patients with psoriasis using biological therapies: a systematic review and meta-analysis. Clin Exp Med 2022:10.1007/s10238-022-00827-y. [PMID: 35499793 DOI: 10.1007/s10238-022-00827-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/22/2022] [Indexed: 02/05/2023]
Abstract
Some biological therapies for psoriasis can cause the reactivation of viral infections. Although recent studies suggest no increased rate of reactivation with biological therapies, some life-threatening cases have been reported. Therefore, this meta-analysis examined the rate of virus reactivation in patients with psoriasis with biological therapies and concurrent hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV) infection. PubMed, Embase, and the Cochrane Library were searched for available papers from inception to December 2021. The outcome was the number of patients with virus reactivation after using biological therapies. The random-effect model was used in all analyses. Fourteen reports (1033 patients) were included. The pooled overall rate of virus reactivation was 0.04 (95%CI 0.01-0.09; I2 = 67.7%, P < 0.001). The pooled rates of HBV, HCV, and HIV reactivation were 0.04 (95%CI 0.00-0.10; I2 = 79.9%, P < 0.001), 0.07 (95%CI 0.02-0.14; I2 = 23.7%, P = 0.24), and 0.12 (95%CI 0.00-0.40), respectively. The pooled rates of HBV and HCV reactivation were 0.10 (95%CI 0.03-0.19) and 0.08 (95%CI 0.03-0.15) in Asia, but 0.00 (95%CI 0.00-0.01) and 0.04 (95%CI 0.00-0.21) in Europe. The publication type also influenced the results. The use of biological therapy in patients with psoriasis and HBV, HCV, or HIV infection might be associated with the rate of viral reactivation, but this meta-analysis had limitations, and the evidence might be weak. Nevertheless, it might suggest that at least a consultation with an infection specialist might be warranted in patients with psoriasis in whom biological therapies are considered.
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Affiliation(s)
- Lin Li
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Xian Jiang
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Lixin Fu
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Liwen Zhang
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Yanyan Feng
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
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Chiu YM, Chen DY. Infection risk in patients undergoing treatment for inflammatory arthritis: non-biologics versus biologics. Expert Rev Clin Immunol 2020; 16:207-228. [PMID: 31852268 DOI: 10.1080/1744666x.2019.1705785] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Despite the therapeutic effectiveness of biologics targeting immune cells or cytokines in patients with inflammatory arthritis, which reflects their pathogenic roles, an increased infection risk is observed in those undergoing biological treatment. However, there are limited data regarding the comparison of infection risks in inflammatory arthritis patients treated with non-biologics (csDMARDs), biologics (bDMARDs), including tumor necrosis factor (TNF) inhibitors and non-TNF inhibitors, or targeted synthetic (ts)DMARDs.Areas covered: Through a review of English-language literature as of 30 June 2019, we focus on the existing evidence on the risk of infections caused by bacteria, Mycobacterium tuberculosis, and hepatitis virus in inflammatory arthritis patients undergoing treatment with csDMARDs, bDMARDs, or tsDMARDs.Expert opinion: While the risks of bacterial and mycobacterial infection are increased in arthritis patients treated with csDMARDs, the risks are further higher in those receiving bDMARDs therapy, particularly TNF inhibitors. Regarding HBV infection, antiviral therapy may effectively prevent HBV reactivation in patients receiving bDMARDs, especially rituximab. However, more data are needed to establish effective preventive strategies for HBsAg-negative/HBcAb-positive patients. It seems safe to use cyclosporine and TNF inhibitors in patients with HCV infection, while those undergoing rituximab therapies should be frequently monitored for HCV activity.Abbreviations: ABT: abatacept; ADA: adalimumab; AS: ankylosing spondylitis; bDMARDs: biologic disease-modifying anti-rheumatic drugs; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; CS: corticosteroids; CsA: cyclosporine A; csDMARDs: conventional synthetic disease-modifying anti-rheumatic drugs; CZP: certolizumab; DAAs: direct-acting antiviral agents; DM: diabetes mellitus; DOT: directly observed therapy; EIN: Emerging Infections Network; ETN: etanercept; GOL: golimumab; GPRD: General Practice Research Database; HBV: hepatitis B virus; HBVr: HBV reactivation; HBsAg+: HBsAg-positive; HBsAg-/anti-HBc+: HBsAg-negative anti-HBc antibodies-positive; HCV: hepatitis C virus; HCQ: hydroxychloroquine: IFX: infliximab; IL-6: interleukin-6; JAK: Janus kinase; LEF: leflunomide; LTBI: latent tuberculosis infection; mAb: monoclonal antibody; MTX: methotrexate; OR: odds ratio; PsA: psoriatic arthritis; PMS: post-marketing surveillance; RA: rheumatoid arthritis; TNF: tumor necrosis factor; TNFi: tumor necrosis factor inhibitor; SCK: secukinumab; SSZ: sulfasalazine; TOZ: tocilizumab; RCT: randomized controlled trial; RR: relative risk; RTX: rituximab; 3HP: 3-month once-weekly isoniazid plus rifapentine; TB: tuberculosis; tsDMARDs: targeted synthetic disease-modifying anti-rheumatic drugs; UTK: ustekinumab; WHO: World Health Organization.
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Affiliation(s)
- Ying-Ming Chiu
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Der-Yuan Chen
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan.,Translational Medicine Laboratory, Rheumatic Diseases Research Center, China Medical University Hospital, Taichung, Taiwan.,Program in Translational Medicine and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Institute of Biochemistry, Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
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6
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Managing Psoriasis in Patients with HBV or HCV Infection: Practical Considerations. Am J Clin Dermatol 2019; 20:829-845. [PMID: 31222626 DOI: 10.1007/s40257-019-00457-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Considered more efficacious and safer than traditional systemic drugs, biologic therapies have dramatically improved the quality of life of patients with psoriasis. Recently, there has been a proliferation of new targeted treatment options, including anti-interleukin-17, anti-interleukin-12/23, as well as small-molecule drugs such as apremilast. There are nevertheless some concerns regarding their use, especially in patients with chronic infections such as hepatitis B virus (HBV) and hepatitis C virus (HCV). It has been estimated that two billion individuals are infected with HBV worldwide and approximately 240 million have chronic HBV infection. Moreover, there are approximately 71 million individuals with chronic HCV infection worldwide, with a high percentage of them unaware of being infected. As patients with HBV and HCV infections are excluded from controlled clinical trials investigating new drugs, data regarding their safety in patients with psoriasis are based almost exclusively on case reports and small retrospective cohort studies and need to be constantly updated. The risk of HBV reactivation can be defined as: high risk (≥ 10%), moderate risk (1-10%), and low risk (< 1%) depending on the type of immunosuppressive therapy stratified by the presence or absence of hepatitis B surface antigen but positivity to anti-hepatitis B core antigen. Hepatitis B surface antigen-positive patients treated with tumor necrosis factor-α inhibitors, ustekinumab, or cyclosporine carry a high or moderate risk of HBV reactivation and should be considered candidates for prophylactic anti-HBV therapy. Once therapy is commenced, it is important to check HBV DNA levels every 3 months. Hepatitis B virus reactivation typically occurs with immune reconstitution and therefore antiviral therapy should continue for 6-12 months after stopping immunosuppression. Hepatitis B surface antigen-positive patients who are prescribed methotrexate, acitretin, or apremilast have a low risk and need to be monitored for viral reactivation by determining alanine aminotransferase and HBV DNA levels every 3 months. No conclusive data are available for interleukin-17 and interleukin-23 inhibitors. Anti-hepatitis B core antigen-positive patients treated with tumor necrosis factor-α inhibitors, ustekinumab, and cyclosporine are linked to a moderate risk of reactivation, and they should preferably undergo HBV DNA or hepatitis B surface antigen and alanine aminotransferase testing rather than be subjected to routine pre-emptive therapy. Anti-hepatitis B core antigen-positive patients receiving methotrexate, acitretin, or apremilast have a low risk of reactivation and do not require anti-HBV therapy, nor should monitoring be considered mandatory. No conclusive data are available for interleukin-17 and interleukin-23 inhibitors.
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7
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Leon L, Peñuelas M, Candel FJ, Freites D, Rodriguez-Rodriguez L, Fernandez-Gutierrez B, Jover JA, Abasolo L. Indicator opportunistic infections after biological treatment in rheumatoid arthritis, 10 years follow-up in a real-world setting. Ther Adv Musculoskelet Dis 2019; 11:1759720X19878004. [PMID: 31636721 PMCID: PMC6783660 DOI: 10.1177/1759720x19878004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/30/2019] [Indexed: 12/26/2022] Open
Abstract
Background: This research describes the incidence and factors associated with
opportunistic infections in rheumatoid arthritis (RA) patients treated with
biological disease-modifying antirheumatic drugs (bDMARDs). Methods: A retrospective longitudinal study was carried out from 2007 to 2018. We
included RA patients treated with a tumor necrosis factor (TNF)-targeted
bDMARD or non-TNF-targeted bDMARD from the start of bDMARDs. An independent
variable was the development of an indicator of opportunistic infection
after biological (IOIb) treatment. Secondary variables included
sociodemographic, clinical, and treatments. We used survival techniques to
estimate the incidence of IOIb, per 1000 patient-years (95% CI). We
performed a Cox multivariate regression analysis model to compare the risk
of IOIb. Results were expressed as a hazard ratio (HR). Results: A total of 441 RA patients were included, that started 761 different courses
of bDMARDs. A total of 81% were women with a mean age at first bDMARD of
57.3 ± 14 years. A total of 71.3% of the courses were TNF-targeted bDMARDs
and 28.7% were non-TNF-targeted bDMARDs. There were 37 IOIb (25 viral, 6
fungal, 5 bacterial, 1 parasitic). Nine of these required hospitalization
and one died. The global incidence of IOIb was 23.2 (16.8–32). TNF-targeted
bDMARDs had 25 IOIb, incidence 20.5 (13.9–30.4), and non-TNF-targeted
bDMARDs had 12 IOIb, incidence 31.7 (18–55.9). In the multivariate analysis,
glucocorticosteroids (HR 2.17, p = 0.004) and lower
lymphocyte count increased the risk for IOIb (HR 0.99,
p = 0.005). Conclusions: The incidence of IOIb due to bDMARDs was 23 cases per 1000 patient-years.
Close monitoring should be taken in the RA patients treated with bDMARDs and
glucocorticosteroids, mainly in elderly patients and those with a low total
lymphocyte count at the beginning of bDMARD treatment.
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Affiliation(s)
- Leticia Leon
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IDISSC), Hospital Clínico San Carlos, Calle Martín Lagos, s/n, Madrid, 28040, Spain
| | - Marina Peñuelas
- Clinical Microbiology and Infectious Diseases Department and IDISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Francisco Javier Candel
- Clinical Microbiology and Infectious Diseases Department and IDISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Dalifer Freites
- Rheumatology Department and IDISSC, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - Juan Angel Jover
- Rheumatology Department and IDISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Lydia Abasolo
- Rheumatology Department and IDISSC, Hospital Clínico San Carlos, Madrid, Spain
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Murdaca G, Negrini S, Pellecchio M, Greco M, Schiavi C, Giusti F, Puppo F. Update upon the infection risk in patients receiving TNF alpha inhibitors. Expert Opin Drug Saf 2019; 18:219-229. [DOI: 10.1080/14740338.2019.1577817] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Giuseppe Murdaca
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Simone Negrini
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Pellecchio
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Monica Greco
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Chiara Schiavi
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesca Giusti
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Puppo
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
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9
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Shahini E, Iannone A, Romagno D, Armandi A, Carparelli S, Principi M, Viggiani MT, Ierardi E, Di Leo A, Barone M. Clinical relevance of serum non-organ-specific antibodies in patients with HCV infection receiving direct-acting antiviral therapy. Aliment Pharmacol Ther 2018; 48:1138-1145. [PMID: 30375693 DOI: 10.1111/apt.14999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 07/26/2018] [Accepted: 09/05/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is associated with production of different serum non-organ-specific antibodies (NOSA) and risk for developing autoimmune disorders. The clinical significance of these phenomena is not fully understood. AIM To assess non-organ-specific antibodies before and 24 weeks after the end of therapy with direct-acting antivirals in patients with HCV-related infection, to better clarify the clinical relevance of these antibodies in terms of treatment response and prognostic value. METHODS Patients enrolled (191) were considered non-organ-specific antibody-positive for titres ≥1:40 on at least two determinations before treatment. RESULTS At baseline, 46 patients were positive and 145 were negative for autoantibodies. The prevalence of autoimmune thyroiditis was significantly higher in non-organ-specific antibody-positive group than non-organ-specific antibody-negative group (P = 0.02). HCV-RNA 24 weeks after the end of antiviral therapy was 100% negative in patients with antibodies positivity and 98.6% in antibody-negative patients (P = 1.0). In the former group, autoantibodies disappeared in 30 of 46 patients (65.2%). On multivariate analysis, non-organ-specific antibody-negativity was significantly reduced in patients with hepatic hilar lymphadenopathy (OR = 0.17; 95% CI 0.02-0.94, P = 0.04). None of the adverse events occurring during antiviral therapy was related to autoimmune disorders. CONCLUSIONS Hepatitis C virus clearance frequently reduces non-organ-specific antibody positivity suggesting that they represent an epiphenomenon of the viral infection. However, in patients who did not become negative, long-term monitoring would establish whether they could hide an underlying process that may progress into a clear autoimmune or rheumatologic disease. (Trial registration number: NCT03566966).
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Affiliation(s)
- Endrit Shahini
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Andrea Iannone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Domenico Romagno
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Angelo Armandi
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Sonia Carparelli
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Mariabeatrice Principi
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Maria Teresa Viggiani
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Enzo Ierardi
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Michele Barone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
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10
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ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [I]: anti-tumor necrosis factor-α agents). Clin Microbiol Infect 2018; 24 Suppl 2:S10-S20. [DOI: 10.1016/j.cmi.2017.12.025] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/25/2017] [Accepted: 12/30/2017] [Indexed: 12/14/2022]
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11
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Retrospective Study of Patients on Etanercept Therapy for Rheumatic Diseases in Patients With Chronic Hepatitis C Virus. J Clin Rheumatol 2018; 23:252-257. [PMID: 28700530 DOI: 10.1097/rhu.0000000000000536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Treatment of rheumatic diseases with concurrent hepatitis C virus (HCV) infection is a therapeutic challenge. Etanercept has no known hepatotoxicity; however there is a concern for worsening of HCV infection-related liver disease due to immunosuppressive action of the drug. Here, we retrospectively assessed the safety of etanercept in rheumatologic disease in patients with chronic HCV. METHODS A retrospective review was conducted in patients with chronic HCV infection who received etanercept for diagnosis of rheumatoid arthritis and psoriatic arthritis. The primary end point was a serum transaminase level of at least 3 times the upper limit of normal during etanercept therapy. We also recorded HCV RNA load. RESULTS Fourteen patients met the inclusion criteria. Mean age was 52 (SD, 8) years. The median follow-up period after initiation of etanercept was 105 months (range, 13-132 months). During follow-up, 7 of 14 patients had elevation of aspartate aminotransferase and/or alanine aminotransferase 3 times the upper limit of normal. Two of 7 patients had concomitant elevation in transaminases and increase in HCV viral load during etanercept exposure, which could not be attributed to other hepatotoxic disease-modifying antirheumatic drugs. In both patients, transaminase levels normalized upon etanercept discontinuation. CONCLUSIONS In contrast to the majority of previous shorter-duration studies, 2 of 14 patients in our series had possible HCV-related worsening of liver disease while on etanercept therapy. Although no firm conclusion can be drawn, it appears that HCV infection can worsen while on etanercept therapy, and therefore, we propose these patients should be monitored serially.
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12
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Routhouska SB, Korman NJ. Initiating and Monitoring Patients on Biologic Therapy for Psoriasis beyond the FDA: Our more Cautious Approach. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/247553030612a00105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Biologics are offering new hope for patients with moderate to severe chronic plaque psoriasis and psoriatic arthritis, and every day more dermatologists are prescribing these medications for their patients. Prior to prescribing a biologic it is important to conduct the proper screening to determine if your patient is an appropriate candidate. While patients are being treated with biologics they need to be monitored carefully to maximize the benefit of the agent and minimize harmful side effects. Apart from the recommendations and requirements of the U.S. Food and Drug Administration (FDA), there are as yet no consensus statements or guidelines addressing the appropriate approach to initiating and monitoring patients being treated with biologics. In this article we will discuss our own approach to initiating and monitoring that we believe is appropriate for patients being treated with biologics. Our recommendations, which in many ways go beyond the recommendations and requirements of the FDA, should not be interpreted as the standard of care.
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Affiliation(s)
- Shannon B. Routhouska
- Clinical Research Fellow Department of Dermatology Case Western Reserve University University Hospitals of Cleveland
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13
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Chen YH, de Carvalho HM, Kalyoncu U, Llamado LJQ, Solano G, Pedersen R, Lukina G, Lichauco JJ, Vasilescu RS. Tuberculosis and viral hepatitis infection in Eastern Europe, Asia, and Latin America: impact of tumor necrosis factor-α inhibitors in clinical practice. Biologics 2018; 12:1-9. [PMID: 29391775 PMCID: PMC5769557 DOI: 10.2147/btt.s148606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Yi-Hsing Chen
- Division of Allergy, Immunology, and Rheumatology, Taichung Veterans General Hospital, Taichung City, Taiwan
| | | | - Umut Kalyoncu
- Department of Internal Medicine, Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
| | | | | | | | | | - Juan J Lichauco
- Section of Rheumatology, Department of Medicine, St. Luke's Medical Center, Quezon City, Manila, Philippines
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14
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Kwon HM, Shin K, Moon JY, Lee SS, Chung WT, Lee J, Lee SH, Kang SW, Suh CH, Hong SJ, Song R, Choe JY, Song YW. Transaminase Changes in Korean Rheumatoid Arthritis Patients with Chronic Hepatitis C after Biologic Therapy. JOURNAL OF RHEUMATIC DISEASES 2018. [DOI: 10.4078/jrd.2018.25.2.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hyun Mi Kwon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jin Young Moon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Shin-Seok Lee
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Won Tae Chung
- Division of Rheumatology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Sang-Heon Lee
- Division of Rheumatology, Department of Internal Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Seong-Wook Kang
- Division of Rheumatology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Chang Hee Suh
- Division of Rheumatology, Department of Internal Medicine, Ajou University Hospital, Suwon, Korea
| | - Seung-Jae Hong
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Ran Song
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jung-Yoon Choe
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine, Medical Research Center, Seoul National University, Seoul, Korea
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15
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Imperatore N, Castiglione F, Rispo A, Sessa A, Caporaso N, Morisco F. Timing Strategies of Direct-Acting Antivirals and Biologics Administration in HCV-Infected Subjects with Inflammatory Bowel Diseases. Front Pharmacol 2017; 8:867. [PMID: 29209223 PMCID: PMC5702483 DOI: 10.3389/fphar.2017.00867] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/10/2017] [Indexed: 02/06/2023] Open
Abstract
Background: In the last years, inflammatory bowel disease (IBD) and hepatitis C virus (HCV) infection management has completely changed. However, the role of direct-acting antivirals (DAAs) and the correct timing of antiviral drugs administration in IBD patients needing biologics has not been evaluated. Objective: To discuss the management of HCV-infected IBD patients, focusing our attention on the timing of DAAs administration subjects needing biologics. Methods: Relevant articles addressing HCV management in patients needing biologics were identified by searching from PubMed, MEDLINE and Scopus. Results: Three possible timing strategies were identified: (1) sequential strategy, meaning the choice of treating firstly the active IBD with biologics and then, once the acute phase has been controlled, treating the HCV infection; (2) concomitant strategy, that is the contemporaneous beginning of DAAs and biologics administration; (3) inverted sequential strategy-the administration of antiviral therapy before biologics in HCV-infected IBD patients. The potential pharmacological interactions between biologics and DAAs have also been reported. Conclusions: Clinical management of HCV-infected IBD patients remains a challenging problem for clinicians, especially in terms of timing choice. Recent published data about DAAs are very encouraging also in IBD patients. All strategies could be considered safe and effective. However, further data are immediately required in order to evaluate hepatic toxicity of novel immunosuppressive drugs in IBD.
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Affiliation(s)
- Nicola Imperatore
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine “Federico II” of Naples, Naples, Italy
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Review of Routine Laboratory Monitoring for Patients with Rheumatoid Arthritis Receiving Biologic or Nonbiologic DMARDs. Int J Rheumatol 2017; 2017:9614241. [PMID: 29225625 PMCID: PMC5684575 DOI: 10.1155/2017/9614241] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022] Open
Abstract
Safety concerns associated with many drugs indicated for the treatment of rheumatoid arthritis (RA) can be attenuated by the early identification of toxicity through routine laboratory monitoring; however, a comprehensive review of the recommended monitoring guidelines for the different available RA therapies is currently unavailable. The aim of this review is to summarize the current guidelines for laboratory monitoring in patients with RA and to provide an overview of the laboratory abnormality profiles associated with each drug indicated for RA. Recommendations for the frequency of laboratory monitoring of serum lipids, liver transaminases, serum creatinine, neutrophil counts, and platelet counts in patients with RA were compiled from a literature search for published recommendations and guidelines as well as the prescribing information for each drug. Laboratory abnormality profiles for each drug were compiled from the prescribing information for each drug and a literature search including meta-analyses and primary clinical trials data.
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17
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Murdaca G, Negrini S, Magnani O, Penza E, Pellecchio M, Gulli R, Mandich P, Puppo F. Update upon efficacy and safety of etanercept for the treatment of spondyloarthritis and juvenile idiopathic arthritis. Mod Rheumatol 2017; 28:417-431. [DOI: 10.1080/14397595.2017.1366006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Giuseppe Murdaca
- Department of Internal Medicine, Scleroderma Unit, Clinical Immunology Unit, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Simone Negrini
- Department of Internal Medicine, Scleroderma Unit, Clinical Immunology Unit, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Ottavia Magnani
- Department of Internal Medicine, Scleroderma Unit, Clinical Immunology Unit, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Elena Penza
- Department of Internal Medicine, Scleroderma Unit, Clinical Immunology Unit, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Marco Pellecchio
- Department of Internal Medicine, Scleroderma Unit, Clinical Immunology Unit, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Rossella Gulli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, Section of Medical Genetics, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Paola Mandich
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, Section of Medical Genetics, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Francesco Puppo
- Department of Internal Medicine, Scleroderma Unit, Clinical Immunology Unit, University of Genova and IRCCS-Azienda Ospedaliera Universitaria San Martino, Genova, Italy
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18
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Yalniz FF, Hefazi M, McCullough K, Litzow MR, Hogan WJ, Wolf R, Alkhateeb H, Kansagra A, Damlaj M, Patnaik MM. Safety and Efficacy of Infliximab Therapy in the Setting of Steroid-Refractory Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2017; 23:1478-1484. [PMID: 28495641 DOI: 10.1016/j.bbmt.2017.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/01/2017] [Indexed: 12/17/2022]
Abstract
Acute graft-versus-host disease (aGVHD) is the leading cause of morbidity and mortality after allogenic hematopoietic cell transplantation (HCT). Corticosteroids are the first-line treatment; however, less than one-half of patients achieve durable remission. Studies suggest that TNF-α, a cytokine released from the bone marrow during conditioning, is involved in the pathogenesis of aGVHD. We retrospectively evaluated the outcome of anti-TNF-α therapy with infliximab in 35 patients with steroid refractory (SR) aGVHD. Infliximab was administered intravenously at 10 mg/kg for a median of 4 doses (range, 1 to 6) on a weekly basis. The overall response rates were 40% (17% complete response [CR], 23% partial response [PR]) at 4 weeks, 23% (9% CR, 14% PR) at 8 weeks, and 17% (all CR) at 12 weeks. Twenty-nine (83%) patients had infectious complications within 12 weeks of initiation of infliximab. These infections included 40 bacterial infections, 6 invasive fungal infections, and 5 viral reactivations. Twelve patients (34%) died secondary to infections. Overall survival at 12 weeks and 6 months from the start of infliximab therapy was 37% (13 of 35) and 17% (6 of 35), respectively; with most deaths secondary to complications from GVHD and infections. In conclusion; the use of infliximab therapy in patients with SR-aGVHD is associated with a modest poorly sustained response along with a heightened risk of severe infections. Future studies with more effective and less toxic therapies are needed for these patients.
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Affiliation(s)
- Fevzi F Yalniz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Mehrdad Hefazi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Mark R Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Robert Wolf
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | | | - Ankit Kansagra
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Moussab Damlaj
- Division of Hematology, King Abdulaziz University, Riyadh, Saudi Arabia
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19
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Piaserico S, Dapavo P, Conti A, Gisondi P, Russo FP. Adalimumab is a safe option for psoriasis patients with concomitant hepatitis B or C infection: a multicentre cohort study of 37 patients and review of the literature. J Eur Acad Dermatol Venereol 2017; 31:1853-1859. [PMID: 28146345 DOI: 10.1111/jdv.14146] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 01/16/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Little data are available about the safety of TNF-α inhibitors in patients with HCV and HBV infection. In particular, data concerning the use of adalimumab in patients with psoriasis and concomitant viral hepatitis are lacking and little is known about the drug's real safety in this context. OBJECTIVE To assess the long-term safety of adalimumab in a group of 17 consecutive psoriatic patients affected by chronic HBV infection and 20 consecutive psoriatic patients affected by chronic HCV infection. METHODS Thirty-seven consecutive patients with psoriasis and concomitant HBV or HCV infection being treated with adalimumab at four Italian referral centres (Modena, Padova, Verona and Turin) were assessed before the treatment and at the end of follow-up. Viral load and radiological studies (echography, Fibroscan) were also carried out in some of the patients. RESULTS The patients responded well to treatment and did not show any HBV or HCV reactivation in a mean follow-up period of 27 and 40 months, respectively. The fibrosis score in eight HCV patients showed a slight reduction: pretreatment mean value 5.83 and post-treatment mean value 5.65. CONCLUSION The use of adalimumab seems to be safe in patients with severe psoriasis and HBV or HCV infection. Nevertheless, large-scale prospective studies will be able to provide vital information on the impact of anti-TNF treatment on hepatic function in patients with psoriasis and concomitant chronic HCV or HBV infection and appropriate monitoring scheduling.
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Affiliation(s)
- S Piaserico
- Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - P Dapavo
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - A Conti
- Dermatology Unit, Department of Medicine and Medical Specialties, University of Modena, Modena, Italy
| | - P Gisondi
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - F P Russo
- Gastroenterology Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
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20
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Singh JA, Saag KG, Bridges SL, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O'Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2015; 68:1-26. [PMID: 26545940 DOI: 10.1002/art.39480] [Citation(s) in RCA: 1307] [Impact Index Per Article: 145.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/14/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To develop a new evidence-based, pharmacologic treatment guideline for rheumatoid arthritis (RA). METHODS We conducted systematic reviews to synthesize the evidence for the benefits and harms of various treatment options. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence. We employed a group consensus process to grade the strength of recommendations (either strong or conditional). A strong recommendation indicates that clinicians are certain that the benefits of an intervention far outweigh the harms (or vice versa). A conditional recommendation denotes uncertainty over the balance of benefits and harms and/or more significant variability in patient values and preferences. RESULTS The guideline covers the use of traditional disease-modifying antirheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids in early (<6 months) and established (≥6 months) RA. In addition, it provides recommendations on using a treat-to-target approach, tapering and discontinuing medications, and the use of biologic agents and DMARDs in patients with hepatitis, congestive heart failure, malignancy, and serious infections. The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. CONCLUSION This RA guideline should serve as a tool for clinicians and patients (our two target audiences) for pharmacologic treatment decisions in commonly encountered clinical situations. These recommendations are not prescriptive, and the treatment decisions should be made by physicians and patients through a shared decision-making process taking into account patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | | | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon, and McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | | | | | - Deborah Parks
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | - Amye Leong
- Healthy Motivation, Santa Barbara, California
| | | | - John T Schousboe
- University of Minnesota and Park Nicollet Clinic, St. Louis Park
| | | | - Seth Ginsberg
- Global Healthy Living Foundation, New York, New York
| | - James Grober
- NorthShore University Health System, Evanston, Illinois
| | | | | | - Amy S Miller
- American College of Rheumatology, Atlanta, Georgia
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21
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Singh JA, Saag KG, Bridges SL, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O'Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St.Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2015; 68:1-25. [DOI: 10.1002/acr.22783] [Citation(s) in RCA: 794] [Impact Index Per Article: 88.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/14/2015] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Elie A. Akl
- American University of Beirut, Beirut, Lebanon, and McMaster University; Hamilton Ontario Canada
| | | | | | | | | | | | | | | | | | - Deborah Parks
- Washington University School of Medicine; St. Louis Missouri
| | | | | | | | - Amye Leong
- Healthy Motivation; Santa Barbara California
| | | | | | | | | | - James Grober
- NorthShore University Health System; Evanston Illinois
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22
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Cordero-Coma M, Salazar-Méndez R, Yilmaz T. Treatment of severe non-infectious uveitis in high-risk conditions (Part 2): systemic infections; management and safety issues. Expert Opin Drug Saf 2015; 14:1353-71. [PMID: 26118392 DOI: 10.1517/14740338.2015.1061992] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Management of patients with severe immune-mediated uveitis requires the use of immunosuppressive (IS) drugs in selected cases. This may be particularly challenging in certain patients with associated conditions, which may increase the risk of side effects or modify guidelines for the use of such drugs. Chronic viral and mycobacterial infections in the setting of non-infectious uveitis create a number of diagnostic but also therapeutic dilemmas to clinicians because they can be exacerbated by IS therapies with detrimental effects. AREAS COVERED In this review, we will focus on very specific chronic infections that can be affected by IS therapies: human immunodeficiency virus infection, chronic hepatitis virus infection and tuberculosis. The main aim of this review is to provide an updated and comprehensive practical guide for practitioners regarding the therapeutic decision-making and management of patients with non-infectious uveitis affected by the aforementioned infectious conditions. EXPERT OPINION Clinicians should be aware of the risk of viral and mycobacterial reactivation of an underlying infection during IS therapy. However, most of these conditions do not represent an absolute contraindication if one were able to apply an appropriate prior screening and close monitoring of such therapy.
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Affiliation(s)
- Miguel Cordero-Coma
- a 1 University of León, Instituto Biomedicina (IBIOMED), University Hospital of León , León, Spain +34 654403609 ; +34 987 233322 ;
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Lin KM, Cheng TT, Lin JC, Chen CJ. Tumor necrosis factor-α antagonist therapy for concomitant rheumatoid arthritis and hepatitis C virus infection: a case series study. Clin Rheumatol 2015; 34:1039-46. [PMID: 25939523 DOI: 10.1007/s10067-015-2962-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 04/07/2015] [Accepted: 04/26/2015] [Indexed: 12/19/2022]
Abstract
The aim of this study was to investigate treatment response and hepatic safety of anti-tumor necrosis factor-α therapy among patients with concomitant rheumatoid arthritis (RA) and hepatitis C virus (HCV) infection. We reviewed the charts of 101 consecutive RA patients who were eligible for anti-TNF-α therapy in the Chiayi Branch of Chang Gung Memorial Hospital. Group A patients were sero-positive for anti-HCV antibodies and had HCV RNA but were negative for hepatitis B surface antigen (HBsAg). Group B (the control group) patients were sero-negative for both anti-HCV antibodies and HBsAg. Response to anti-TNF-α treatment was assessed by calculating disease activity score at 28 joints (DAS28) at baseline and 5, 8, and 11 months after the start of TNF-α antagonist therapy. Percentage change in DAS28 from baseline to month 5 was 21.36 ± 8.01 % in group A and 26.98 ± 10.43 % in group B (p = 0.011). However, there was no obvious difference in treatment response between groups at other time points. Anti-TNF-α therapy was discontinued within 1 year of starting treatment in two subjects in group A and 4 in group B. Response to anti-TNF-α was better in group B than in group A at 5 months, but there was no substantial difference in response at the 1-year evaluation. Although the study sample was small, our results suggest that the safety of anti-TNF-α therapy is similar in RA patients with and without concomitant HCV infection.
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Affiliation(s)
- Ko-Ming Lin
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Chiayi, Taiwan
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Felis-Giemza A, Olesińska M, Świerkocka K, Więsik-Szewczyk E, Haładyj E. Treatment of rheumatic diseases and hepatitis B virus coinfection. Rheumatol Int 2015; 35:385-92. [PMID: 25549599 PMCID: PMC4335127 DOI: 10.1007/s00296-014-3195-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/17/2014] [Indexed: 12/26/2022]
Abstract
We often encounter rheumatological patients coinfected with hepatitis B in daily practice. In this paper, we will discuss the basic characteristics of the virus of hepatitis B, course of infection, the safety of rituximab, tocilizumab, abatacept treatment and therapeutic recommendations in management of patients with rheumatic diseases.
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Affiliation(s)
- Anna Felis-Giemza
- Institute of Rheumatology, Connective Tissue Department, 1 Spartanska Street, Warsaw, Poland
| | - Marzena Olesińska
- Institute of Rheumatology, Connective Tissue Department, 1 Spartanska Street, Warsaw, Poland
| | - Katarzyna Świerkocka
- Institute of Rheumatology, Connective Tissue Department, 1 Spartanska Street, Warsaw, Poland
| | - Ewa Więsik-Szewczyk
- Institute of Rheumatology, Connective Tissue Department, 1 Spartanska Street, Warsaw, Poland
| | - Ewa Haładyj
- Institute of Rheumatology, Connective Tissue Department, 1 Spartanska Street, Warsaw, Poland
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The Clinical Significance of Autoantibodies in Hepatitis C Patients Submitted to Interferon Treatment. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:24-27. [PMID: 28868365 PMCID: PMC5580009 DOI: 10.1016/j.jpge.2014.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/05/2014] [Indexed: 11/21/2022]
Abstract
Hepatitis C virus is associated with several immune-mediated phenomena, presented usually as extra-hepatic hepatitis C manifestations. A predisposition to autoimmunity associated with the presence of baseline autoantibodies has been demonstrated in interferon mediated autoimmune diseases. We report a male patient, 34 years old, with genotype 1, chronic hepatitis C (hepatitis C viremia 1.432.463 UI/mL) and family history of psoriasis. He had high levels of transaminases and immunology showed positive antinuclear antibodies (1/320) and anti-smooth-muscle antibodies, with elevated immunoglobulin G (1740 mg/dL). Liver biopsy revealed a F1/2 Metavir score, histologic activity index of 3 and mild piecemeal necrosis. Antiviral treatment was started with peg-interferon α2a 180 mcg plus ribavirin 1200 mg, and the patient had rapid virologic response, normalization of transaminases, negativation of antinuclear antibodies positivity and decrease of immunoglobulin levels. However, at week 22, he developed psoriatic-like eczema and arthritis with functional limitation. Due to suspicion of latent psoriatic arthritis not previously diagnosed, he was started on methotrexate 10 mg/weekly with improvement of psoriatic plaques, arthritis and functional limitation. Patient achieved sustained virologic response, with normal transaminases and no significant changes in immunology. Post-treatment median hepatic elastography was 3.6 kPa. Autoimmunity in hepatitis C infection is not limited to surrogate autoantibody seropositivity, but may embrace the full spectrum of autoimmune disorders.
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Vilarrasa E, Puig L. Psoriasis: Biologic treatment and liver disease. World J Dermatol 2014; 3:76-85. [DOI: 10.5314/wjd.v3.i4.76] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 03/28/2014] [Accepted: 09/17/2014] [Indexed: 02/07/2023] Open
Abstract
Patients with moderate or severe psoriasis have a high prevalence of chronic liver disease. Chronic liver disease in these patients is related to metabolic syndrome, alcohol abuse or viral infections. Therefore, treatment of these patients is challenging. Classic systemic treatments may be contraindicated because of their immunosuppressive and hepatotoxic potential. First-line therapy in this setting is generally ultraviolet B phototherapy combined with topical treatment, but its feasibility and efficacy are sometimes limited. The therapeutic options are further restricted by concomitant psoriatic arthritis. Biologic treatments have shown to be effective in psoriasis and psoriatic arthritis, and they are largely devoid of liver toxicity. Anti-tumor necrosis factor-alpha (TNF-α) treatments have proven to be effective and safe in patients with chronic hepatitis C virus (HCV) infections and other non-infectious chronic liver disorders, including alcoholic and non-alcoholic liver diseases. However, in chronic hepatitis B virus (HBV), anti-TNF-α treatments carry a potential risk of HBV reactivation. Anti-interleukin-12/23 treatments are also effective in patients with psoriasis, but data regarding their safety in chronic hepatitis infections are still limited. Safety reports in patients with psoriasis and chronic HCV infection are contradictory, and in chronic HBV evidence indicate a high risk of viral reactivation. Moreover, concerns remain about the long-term safety of both TNF-α antagonists and ustekinumab. Non-viral liver diseases such as alcoholic and non-alcoholic liver diseases are more prevalent in patients with psoriasis than in the general population. TNF-α antagonists have also been prescribed in these patients. Although data are still scarce in this setting, results suggest a favorable profile in patients with psoriasis and non-alcoholic liver diseases. We review the literature regarding all these aspects.
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Approach and management of patients with chronic hepatitis B and C during the course of inflammatory bowel disease. Inflamm Bowel Dis 2014; 20:2142-50. [PMID: 25072501 DOI: 10.1097/mib.0000000000000126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease and chronic viral hepatitis are 2 distinct but common conditions throughout the world. Mostly, both need life-long follow-up. Since immunosuppressive drugs remain corner stones of inflammatory bowel disease management, one should be aware of the concomitant presence of chronic viral hepatitis in such patients to prevent serious (even fatal) outcomes. Recently, new treatment options have become available in the treatment of both inflammatory bowel disease and chronic viral hepatitis. In this review, we have discussed and summarized current treatment and follow-up strategies for those 2 important public health issues in light of available literature.
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Temel T, Cansu DÜ, Korkmaz C, Kaşifoğlu T, Özakyol A. The long-term effects of anti-TNF-α agents on patients with chronic viral hepatitis C and B infections. Int J Rheum Dis 2014; 18:40-5. [PMID: 25195983 DOI: 10.1111/1756-185x.12467] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM To evaluate the long-term effects of anti-tumor necrosis factor-alpha (TNF-α) therapy on patients with chronic hepatitis B and C infections. METHODS Rheumatoid arthritis, ankylosing spondylitis and Crohn's disease patients administered anti-TNF-α therapy for at least 36 months were retrospectively reviewed for hepatitis B or C serology, liver function tests, viral load, genotype and liver biopsy results, if performed. Nine relevant cases receiving anti-TNF-α were evaluated: six patients had chronic hepatitis C, one had chronic dual hepatitis B and C and two had chronic hepatitis B infection. RESULTS The patient with dual infection exhibited virologic breakthrough for hepatitis C and required treatment. Two patients with occult hepatitis B infection developed hepatitis B surface antigen (HBsAg) reversion and low-level viremia at the end of the study. CONCLUSION Long-term use of anti-TNF-α treatments may result in viral replication that requires anti-viral therapy. Before determining the safety of anti-TNF drugs in the treatment of autoimmune diseases in patients with hepatitis C infection, studies with large homogeneous patient groups must be performed, and the exact group of hepatitis C virus infected patients for whom anti-TNF treatment would be deemed safe should be identified. Prior to anti-TNF-α treatment, it seems logical to screen all patients for HBsAg and anti-HB core immunoglobulin G status, especially in endemic regions. These patients must be followed periodically by means of alanine aminotransferase, HBsAg and hepatitis B virus DNA to identify HBsAg reversion and active viral replication that might require anti-viral prophylaxis or treatment.
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Affiliation(s)
- Tuncer Temel
- Division of Gastroenterology, Faculty of Medicine, Department of Internal Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey
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Cansu DÜ, Güncan S, Bilge NŞY, Kaşifoğlu T, Korkmaz C. Does isoniazid chemoprophylaxis increase the frequency of hepatotoxicity in patients receiving anti-TNF-α agent with a disease-modifying antirheumatic drug? Eur J Rheumatol 2014; 1:62-66. [PMID: 27708877 DOI: 10.5152/eurjrheumatol.2014.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/23/2014] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The aim of this study is to determine the incidence of isoniazid (INH)-related hepatotoxicity in patients with rheumatologic diseases receiving tumor necrosis factor-α (TNF-α) antagonists along with a disease-modifying antirheumatic drug (DMARD). MATERIAL AND METHODS We have retrospectively evaluated 87 patients receiving anti-TNFα agents who were followed up between June 2005 and February 2010 at our rheumatology department. Sixty-one of 87 patients have received INH prophylaxis for 9 months for latent tuberculosis infection. RESULTS A total of 61 (70.1%) of 87 patients used INH prophylaxis (Group I), while the remaining 26 (29.9%) (Group II) had not; 53 patients had used any DMARD in Group I, while 21 patients had used in Group II. No significant differences were found among Group I and II with respect to clinical features. When two groups were compared, in Group I, elevations of liver enzymes were detected in five patients (8.1%) who had normal baseline values. Among these patients, hepatotoxicity developed in two patients. Hepatotoxicity developed one patient in Group II (p=0.85). CONCLUSION INH chemoprophylaxis was well tolerated in patients using anti-TNF-α agent and a DMARD. It seems not to be a strong risk factor for hepatotoxicity. However, comorbidities and other drugs used may be additional factors in the elevation of transaminases.
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Affiliation(s)
- Döndü Üsküdar Cansu
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Sabri Güncan
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - N Şule Yaşar Bilge
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Timuçin Kaşifoğlu
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Cengiz Korkmaz
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
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Murdaca G, Spanò F, Contatore M, Guastalla A, Magnani O, Puppo F. Efficacy and safety of etanercept in chronic immune-mediated disease. Expert Opin Drug Saf 2014; 13:649-61. [DOI: 10.1517/14740338.2014.899579] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Iannone F, La Montagna G, Bagnato G, Gremese E, Giardina A, Lapadula G. Safety of Etanercept and Methotrexate in Patients with Rheumatoid Arthritis and Hepatitis C Virus Infection: A Multicenter Randomized Clinical Trial. J Rheumatol 2014; 41:286-92. [DOI: 10.3899/jrheum.130658] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective.To evaluate the safety and efficacy of therapy with etanercept and methotrexate (MTX) in patients with active rheumatoid arthritis (RA) and mild hepatitis C virus (HCV) infection.Methods.In this prospective open study, 29 patients with active RA were randomly assigned to receive therapy with MTX alone, etanercept alone, or a combination of MTX and etanercept, and monitored up to 54 weeks. The primary endpoint was safety; secondary aims were efficacy as defined by the 44-joint Disease Activity Score (DAS44) and health assessment questionnaire (HAQ). Serum liver enzymes and HCV viral load were serially measured.Results.In the whole cohort, aspartate aminotransferase (AST) serum levels were (mean ± SD) 35 ± 3 at entry, 39 ± 5, 41 ± 7, and 38 ± 4 at 14, 30, and 54 weeks, respectively; alanine aminotransferase (ALT) serum levels were 43 ± 5 at entry, 47 ± 5, 53 ± 9, and 50 ± 6 at 14, 30, and 54 weeks, respectively. HCV viral load was 5.6 ± 0.5 at entry, 5.9 ± 0.6, 5.7 ± 0.3, and 5.6 ± 0.6 at 14, 30, and 54 weeks, respectively. AST and ALT did not significantly change in all 3 arms of treatment, nor did HCV viral load. A significant reduction of DAS44 (p < 0.01) and HAQ (p < 0.04) was detected at 54 weeks compared to baseline. No patient discontinued the therapy because of worsening of liver disease.Conclusion.This study showed that patients with RA and chronic HCV and mild hepatitis may be successfully treated with etanercept and MTX without increasing the risk of hepatotoxicity and HCV replication.ClinicalTrials.govIdentifierNCT01543594.
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Single-dose infliximab in hepatitis C genotype 1 treatment-naive patients with high serum tumour necrosis factor-alpha does not influence the efficacy of pegylated interferon alpha-2b/ribavirin therapy. Can J Gastroenterol Hepatol 2014; 28:35-40. [PMID: 24212915 PMCID: PMC4071902 DOI: 10.1155/2014/367131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Serum tumour necrosis factor-alpha (TNF-α) levels correlate negatively with hepatitis C virus (HCV) antiviral response. OBJECTIVES To test the hypothesis that a single infliximab induction dose would positively influence on-treatment virological response and sustained virological response (SVR). METHODS The present study was a phase IIIB, randomized, prospective, open-label pilot trial conducted at eight Canadian sites. Treatment-naive HCV genotype 1-infected patients 18 to 65 years of age with high serum TNF-α values (>300 pg⁄mL) were randomly assigned to receive a single pretreatment induction infliximab infusion (5 mg⁄kg) seven days before antiviral therapy (arm A) or no pretreatment (arm B). All patients received pegylated interferon α2b (1.5 μg⁄kg⁄week) plus weight-based ribavirin (800 mg⁄day to 1400 mg⁄day) for up to 48 weeks. RESULTS Eighty-five patients (arm A [n=41], arm B [n=44]; 70% male) received pegylated interferon α2b. The mean age (48.1 years), race (81% white) and METAVIR fibrosis stage (F0-2 = 79%, F3-4 = 21%) were similar between groups. Infliximab was well tolerated without attributable severe adverse events; 56.5% completed the study (arm A [n=21], arm B [n=27]). Most discontinuations were due to virological failure at weeks 12 (n=20 [23.5%]) and 24 (n=7 [8.2%]) and did not differ according to group. Numerically lower proportions of infliximab recipients achieved rapid virological response (19.5% versus 36.4%), complete early virological response (43.9% versus 59.1%) and SVR (34.1% versus 52.3%). However, between-group differences did not reach statistical significance. No differences in adverse event profile or laboratory measures were noted. CONCLUSION A single infliximab dose before pegylated-interferon α2b and ribavirin therapy did not result in greater viral decline during the first 12 weeks of HCV therapy or improved SVR.
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Allen AM, Kim WR, Larson J, Loftus EV. Efficacy and safety of treatment of hepatitis C in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2013; 11:1655-60.e1. [PMID: 23891915 PMCID: PMC3846435 DOI: 10.1016/j.cgh.2013.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 06/24/2013] [Accepted: 07/02/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is uncertainty about the efficacy and safety of treatment for hepatitis C virus (HCV) infection in patients with inflammatory bowel disease (IBD). IBD can become exacerbated during treatment with interferon (IFN), and serious adverse events, such as pancytopenia or hepatotoxicity, can be compounded by drug interactions. We investigated the risk of exacerbation of IBD during HCV therapy and the rate of adverse effects of concomitant therapy for HCV and IBD. We also evaluated the efficacy of HCV treatment in the IBD population. METHODS We conducted a retrospective review of all patients who underwent IFN-based treatment for HCV at the Mayo Clinic in Rochester, Minnesota from 2001 to 2012. Exacerbation of IBD was evaluated by clinical, endoscopic, and histologic parameters during antiviral therapy and the ensuing 12 months. Hematologic toxicity was assessed by levels of all 3 cell lineages at baseline and during therapy. Efficacy of antiviral treatment was assessed by serum levels of HCV RNA until 24 weeks after completion of therapy. We also conducted a detailed MEDLINE database search and reviewed the literature on this topic. RESULTS We identified 15 subjects with concomitant IBD (8 with ulcerative colitis and 7 with Crohn's disease). Only 1 patient experienced exacerbation of the disease during therapy; symptoms were controlled with mesalamine enemas. Another patient developed a flare shortly after completing antiviral therapy; symptoms returned spontaneously to baseline 2 weeks later. All subjects experienced an anticipated degree of pancytopenia while on IFN-based therapy. The rate of sustained virologic response was 67%. A concise review of available literature regarding the safety and efficacy of HCV treatment in IBD patients is also presented; although limited, the published data appear to support the safety of treatment with IFN in patients whose IBD is under control. CONCLUSIONS In conjunction with data from the literature, our findings indicate that the efficacy and safety of HCV therapy with IFN and ribavirin for patients with IBD are comparable to those of subjects without IBD.
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Affiliation(s)
- Alina M. Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Joseph Larson
- Division of Biostatistics and Informatics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Edward V. Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, U.S.A
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Pompili M, Biolato M, Miele L, Grieco A. Tumor necrosis factor-α inhibitors and chronic hepatitis C: A comprehensive literature review. World J Gastroenterol 2013; 19:7867-7873. [PMID: 24307780 PMCID: PMC3848134 DOI: 10.3748/wjg.v19.i44.7867] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 10/31/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
Tumor necrosis factor-α (TNF-α) inhibitors are known to increase reactivation of concurrent chronic hepatitis B, but their impact on the hepatitis C virus (HCV) is controversial. Some conditions of immunosuppression, such as liver transplantation, typically cause an increase in the rate of HCV evolution. Inhibition of TNF-α, a cytokine involved in the apoptotic signaling pathway of hepatocytes infected by HCV, could potentially increase viral replication. Currently available clinical data appear to contradict this hypothesis. A review of medical literature revealed that a total of 216 patients with HCV were exposed to one or more treatments with TNF-α inhibitors, with a median observation time of 1.2 years and 260 cumulative patient-years of exposure. Only three cases of drug withdrawal due to suspected HCV liver disease recrudescence were reported. Treatment with TNF-α inhibitors in patients with HCV infection appears to be safe in the short term, but there are insufficient data to assess their long-term safety. Universal screening for HCV before beginning treatment with TNF-α inhibitors is currently controversial. The presence of HCV is not a contraindication to therapy with TNF-α inhibitors, with the exception of cirrhotic patients. In cases of cirrhosis, the benefit/risk ratio should be evaluated at the individual level. Prior to treatment with TNF-α inhibitors, patients with HCV should be referred to a hepatologist to determine the necessity of hepatic disease assessment, using liver biopsy or non-invasive methods, and the potential indication for antiviral therapy. In patients with HCV infection who are treated with TNF-α inhibitors, liver function monitoring every three months is advised.
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Rojas-Feria M, Castro M, Suárez E, Ampuero J, Romero-Gómez M. Hepatobiliary manifestations in inflammatory bowel disease: The gut, the drugs and the liver. World J Gastroenterol 2013; 19:7327-7340. [PMID: 24259964 PMCID: PMC3831215 DOI: 10.3748/wjg.v19.i42.7327] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/07/2013] [Accepted: 09/29/2013] [Indexed: 02/06/2023] Open
Abstract
Abnormal liver biochemical tests are present in up to 30% of patients with inflammatory bowel disease (IBD), and therefore become a diagnostic challenge. Liver and biliary tract diseases are common extraintestinal manifestations for both Crohn’s disease and ulcerative colitis (UC), and typically do not correlate with intestinal activity. Primary sclerosing cholangitis (PSC) is the most common hepatobiliary manifestation of IBD, and is more prevalent in UC. Approximately 5% of patients with UC develop PSC, with the prevalence reaching up to 90%. Cholangiocarcinoma and colon cancer risks are increased in these patients. Less common disorders include autoimmune hepatitis/PSC overlap syndrome, IgG4-associated cholangiopathy, primary biliary cirrhosis, hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis, liver abscess, and non-alcoholic fatty liver disease. Hepatitis B reactivation during immunosuppressive therapy is a major concern, with screening and vaccination being recommended in serologically negative cases for patients with IBD. Reactivation prophylaxis with entecavir or tenofovir for 6 to 12 mo after the end of immunosuppressive therapy is mandatory in patients showing as hepatitis B surface antigen (HBsAg) positive, independently from viral load. HBsAg negative and anti-HBc positive patients, with or without anti-HBs, should be closely monitored, measuring alanine aminotransferase and hepatitis B virus DNA within 12 mo after the end of therapy, and should be treated if the viral load increases. On the other hand, immunosuppressive therapy does not seem to promote reactivation of hepatitis C, and hepatitis C antiviral treatment does not influence IBD natural history either. Most of the drugs used for IBD treatment may induce hepatotoxicity, although the incidence of serious adverse events is low. Abnormalities in liver biochemical tests associated with aminosalicylates are uncommon and are usually not clinically relevant. Methotrexate-related hepatotoxicity has been described in 14% of patients with IBD, in a dose-dependent manner. Liver biopsy is not routinely recommended. Biologics-related hepatotoxicity is rare, but has been shown most frequently in patients treated with infliximab. Thiopurines have been associated with veno-occlusive disease, regenerative nodular hyperplasia, and liver peliosis. Routine liver biochemical tests are recommended, especially during the first month of treatment. All these conditions should be considered in IBD patients with clinical or biochemical features suggestive of hepatobiliary involvement. Diagnosis and management of these disorders usually involve hepatologists and gastroenterologists due to its complexity.
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Khairy M, El-Raziky M, El-Akel W, Abdelbary MS, Khatab H, El-Kholy B, Esmat G, Mabrouk M. Serum autoantibodies positivity prevalence in patients with chronic HCV and impact on pegylated interferon and ribavirin treatment response. Liver Int 2013; 33:1504-9. [PMID: 23763380 DOI: 10.1111/liv.12227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 05/01/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Prevalence of serum autoantibodies in chronic hepatitis C (HCV) patients is higher than that in the general population. Interferon may induce autoimmune manifestations in patients treated with peg-interferon and ribavirin. Effect of autoantibody seropositivity and treatment response are limited and controversial. To detect the prevalence of serum autoantibodies in patients with chronic HCV and impact on histopathology and treatment response. METHODS Retrospective study including 3673 Egyptian chronic HCV naïve patients enrolled in the Egyptian national programme for HCV treatment with pegylated interferon and ribavirin in the years 2007-2010. Antinuclear antibody (ANA) was determined by ELISA considered positive with a titre ≥ 1:40 by indirect immunofluorescence. ANA-positive patients pre treatment workup including serum aminotransferases, thyroid profile and liver biopsy, follow-up during treatment and sustained virological response (SVR) were assessed compared to ANA-negative patients. RESULTS Serum ANA was positive in 1.6% of the studied patients. There were no statistically significant differences concerning the demographic, biochemical and histopathological data in ANA positive and negative patients. SVR was comparable between ANA-positive and ANA-negative patients (67.8% and 61.3% respectively). Follow-up treatment; ANA-positive patients' did not experience statistically significant haematological complications, flare-up of serum transaminases, thyroid dysfunction. No systemic autoimmune disorders developed during follow-up. CONCLUSIONS ANA positivity is not a factor in chronic HCV disease progression and does not affect the treatment response. Pegylated interferon and ribavirin therapy is safe and effective in autoantibodies-positive chronic HCV patients with no need for further follow-up or worry during the treatment in absence of systemic autoimmune disorders.
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Affiliation(s)
- Marwa Khairy
- Endemic Medicine and Hepatology Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
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Abstract
INTRODUCTION Biologic agents have transformed clinical outcomes in rheumatoid arthritis, and there are now several immune-modulating therapies available. Tumour necrosis factor-α (TNF-α) inhibitors were the first biologic drug class licensed for the treatment of rheumatoid arthritis. Etanercept is a fusion protein composed of two TNF receptors bound to the constant portion (Fc) of human immunoglobulin G (IgG). AREAS COVERED This article will consider the pharmacological properties of etanercept and the clinical efficacy data presented in clinical trials. Its safety in clinical practice will be reviewed. EXPERT OPINION There is overwhelming evidence to support the use of etanercept in rheumatoid arthritis. Trial data demonstrate etanercept's efficacy in reducing structural damage, improving clinical outcomes and inducing remission. Optimal response to therapy is seen when used in combination with methotrexate and when initiated early. Etanercept is an attractive therapeutic option given the excellent safety profile, reduced immunogenicity and ease of administration.
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Affiliation(s)
- Laura Hunt
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital , Chapeltown Road, LS7 4SA, Leeds , UK
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Navarro R, Vilarrasa E, Herranz P, Puig L, Bordas X, Carrascosa JM, Taberner R, Ferrán M, García-Bustinduy M, Romero-Maté A, Pedragosa R, García-Diez A, Daudén E. Safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and chronic viral hepatitis B or C: a retrospective, multicentre study in a clinical setting. Br J Dermatol 2013; 168:609-16. [PMID: 22985451 DOI: 10.1111/bjd.12045] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Both the safety and efficacy of biologic therapy may be affected in the presence of highly prevalent chronic viral hepatitis. OBJECTIVE To evaluate the safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and concomitant chronic viral hepatitis. METHODS This was a retrospective, multicentre study. Twenty-five patients with psoriasis and concurrent hepatitis C virus (HCV) (20 patients) or hepatitis B virus (HBV) (five patients) infection who had received at least one biologic agent (etanercept, 21 treatments; adalimumab, four; ustekinumab, four; infliximab, two) were included. Clinical, imaging and laboratory data were recorded. RESULTS In the case of HCV infection, the majority of the patients did not exhibit increases in their viral load or serum liver tests. Aspartate aminotransferase, alanine aminotransferase and gamma glutamyl transpeptidase were doubled from the baseline measurement in only one patient treated with etanercept. Two other cases exhibited viral load increases during the follow-up period. In total, 18 of the 26 treatments achieved a 75% improvement in their Psoriasis Area and Severity Index (PASI 75) score during the follow-up period. Two patients treated with etanercept were diagnosed with hepatocellular carcinoma. In the case of HBV infection, all of the patients were being treated with antiviral therapy, and none presented significant variations in viral load or serum liver enzymes. All patients achieved a PASI 75 during follow-up. CONCLUSIONS Biologic therapy was effective and safe for the majority of our patients with HCV and HBV infection, although there may be a risk of reactivation or aggravation. We describe the first cases to receive ustekinumab. The use of biologics should be limited to those cases in which the risk-benefit ratio is justified.
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Affiliation(s)
- R Navarro
- Department of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain.
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Liver abnormalities in the immunosuppressed. Best Pract Res Clin Gastroenterol 2013; 27:597-618. [PMID: 24090945 DOI: 10.1016/j.bpg.2013.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 06/21/2013] [Indexed: 01/31/2023]
Abstract
The immunosuppressed state may arise due to medical illness or drug therapy, which can result in a diverse array of liver derangements. This article discusses the commonly-encountered immunosuppressed conditions and the associated specific liver diseases. Due to the frequency of blood-borne viral disease globally, viral hepatitis (hepatitis B and C) during chemotherapy, transplantation and the increasingly utilised biological therapies for autoimmune disorders is discussed. An overview of human immunodeficiency virus co-infection with hepatitis B and C is provided. This article aims to highlight the variety of liver diseases which can occur in clinically relevant, particularly iatrogenic, immunosuppressed conditions, and summarise learning and practice points for clinicians. Recognition and prevention of viral liver disease is crucial and early involvement of experts prior to administration of immunosuppressive therapy is advised.
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Lin MV, Blonski W, Buchner AM, Reddy KR, Lichtenstein GR. The influence of anti-TNF therapy on the course of chronic hepatitis C virus infection in patients with inflammatory bowel disease. Dig Dis Sci 2013. [PMID: 23179145 DOI: 10.1007/s10620-012-2457-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Ming Valerie Lin
- Division of Digestive Disease, University of Cincinnati, Cincinnati, OH, USA
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Ali T, Kaitha S, Mahmood S, Ftesi A, Stone J, Bronze MS. Clinical use of anti-TNF therapy and increased risk of infections. Drug Healthc Patient Saf 2013; 5:79-99. [PMID: 23569399 PMCID: PMC3615849 DOI: 10.2147/dhps.s28801] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Biologics such as antitumor necrosis factor (anti-TNF) drugs have emerged as important agents in the treatment of many chronic inflammatory diseases, especially in cases refractory to conventional treatment modalities. However, opportunistic infections have become a major safety concern in patients on anti-TNF therapy, and physicians who utilize these agents must understand the increased risks of infection. A literature review of the published data on the risk of bacterial, viral, fungal, and parasitic infections associated with anti-TNF therapy was performed and the clinical presentation, diagnostic tests, management, and prevention of opportunistic infections in patients receiving anti-TNF therapy were reviewed. Awareness of the therapeutic potential and associated adverse events is necessary for maximizing therapeutic benefits while minimizing adverse effects from anti-TNF treatments. Patients should be adequately vaccinated when possible and closely monitored for early signs of infection. When serious infections occur, withdrawal of anti-TNF therapy may be necessary until the infection has been identified and properly treated.
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Affiliation(s)
- Tauseef Ali
- OU Physicians Center for Inflammatory Bowel Disease, University of Oklahoma Health Sciences Center
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Sindhu Kaitha
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Sultan Mahmood
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Abdul Ftesi
- Integris Baptist Hospital, Oklahoma City, Oklahoma, USA
| | - Jordan Stone
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Michael S Bronze
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
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Bartalesi F, Salomoni E, Cavallo A, Corti G, Pimpinelli N, Bartoloni A, Taliani G. Chronic hepatitis C virus hepatitis and psoriasis: no longer a contraindication to interferon use in the era of biological agents? ACTA ACUST UNITED AC 2012; 45:320-3. [PMID: 23113733 DOI: 10.3109/00365548.2012.720026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We describe a patient with severe psoriasis and hepatitis C simultaneously treated with pegylated interferon alpha (peg-IFNα) plus ribavirin and etanercept, whose skin lesions improved and who reached a sustained virological response. This case suggests that refractory psoriasis can today no longer be considered as a contraindication for combined hepatitis C virus treatment.
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Affiliation(s)
- Filippo Bartalesi
- SOD Malattie Infettive e Tropicali, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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van Denderen JC, Blom GJ, van der Horst-Bruinsma IE, Dijkmans BAC, Nurmohamed MT. Elevated liver enzymes in patients with ankylosing spondylitis treated with etanercept. Clin Rheumatol 2012; 31:1677-82. [PMID: 22941219 DOI: 10.1007/s10067-012-2072-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 06/25/2012] [Accepted: 08/16/2012] [Indexed: 01/17/2023]
Abstract
TNF-alpha blocking agents are very effective in patients with ankylosing spondylitis (AS), but several cases of liver problems have been published. We systematically studied the frequency of this potential side effect in our AS patients treated with etanercept. Consecutive AS patients treated with etanercept for at least 3 months were included. Liver disease was defined as elevated liver enzymes more than 1.5 times the upper normal limit (UNL) and was categorised as probably, possibly, probably not or not related to etanercept treatment. Patients with and without raised liver enzymes were compared for prognostic factors. A total of 105 patients were included. Fifteen patients had elevated liver enzymes more than once. In nine cases, the liver disease was probably (five) or possibly (four) related to etanercept treatment. The liver enzyme elevations were serious (>3× UNL) in six cases and resulted in permanent cessation of etanercept in two cases. The nine patients with liver disease were compared with patients without elevated liver enzymes. No differences were found in age or use of alcohol; however, in patients with liver disease, a higher body mass index and a trend for a higher atherogenic index were observed. Hepatic steatosis was observed in five of six patients with elevated liver enzymes. Elevated serum aminotransferases, probably or possibly related to etanercept treatment, were observed in 9 % of the AS patients. An increased risk for the elevation of liver enzymes was found in patients with a higher body mass index. We recommend regular testing of liver enzymes in patients treated with etanercept.
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Affiliation(s)
- J C van Denderen
- Jan van Breemen Research Institute/Reade, Amsterdam, The Netherlands.
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Joseph AM. Treatment of rheumatoid arthritis in patients with concomitant chronic hepatitis C infection. Ther Adv Musculoskelet Dis 2012; 4:35-40. [PMID: 22870493 DOI: 10.1177/1759720x11424459] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Hepatitis C virus (HCV) infection is present in 1.8% of the general US population and its prevalence worldwide is estimated at 2-3%. HCV infected patients with concomitant rheumatoid arthritis (RA) pose a particular challenge to the rheumatologist because of the risks of treatment with disease-modifying medications in patients with chronic liver infection. In this paper the difficulties of diagnosing RA in HCV patients and the safety of RA treatment in patients with both conditions are discussed.
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Papp KA, DeKoven J, Parsons L, Pirzada S, Robern M, Robertson L, Tan JK. Biologic Therapy in Psoriasis: Perspectives on Associated Risks and Patient Management. J Cutan Med Surg 2012; 16:153-68. [DOI: 10.1177/120347541201600305] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Previous publications have described practical considerations for initiating biologic therapy in psoriasis patients. However, most publications have focused on anti–tumor necrosis factor (TNF) therapy. Objective: To create an evidence-based, practical tool that provides guidance on patient management for all biologics currently approved in Canada and the United States. Methods: Psoriasis publications regarding safety issues in the initiation or monitoring of adalimumab, alefacept, etanercept, infliximab, or ustekinumab therapy were identified through a PubMed search. Phase III trials and open-label extensions (regardless of indication) and relevant guidelines from Health Canada were used to compile this review. Results: Although these biologic agents have demonstrated efficacy in patients with psoriasis and are generally considered safe and well tolerated, rare but serious safety issues (ie, demyelination, infection, tuberculosis, malignancy, lymphoma, cardiovascular outcomes, hepatitis, pregnancy, surgery, and vaccination) have been observed. Attention to specific aspects of patient management (ie, prescreening requirements, symptoms to watch for, appropriate treatment, and referrals) is required to mitigate risk. Conclusion: Much of the evidence regarding the long-term safety of these agents has been based on experience in other patient populations. However, it does serve to guide us in understanding the risks that may impact the management of psoriasis patients.
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Affiliation(s)
| | | | - Laurie Parsons
- University of Calgary Foothills Medical Centre, Calgary, AB
| | - Syed Pirzada
- Family Dermatology Clinic, Wedgwood Medical Centre, St John's, NL
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Girolomoni G, Altomare G, Ayala F, Berardesca E, Calzavara-Pinton P, Chimenti S, Peserico A, Puglisi Guerra A, Vena GA. Safety of anti-TNFα agents in the treatment of psoriasis and psoriatic arthritis. Immunopharmacol Immunotoxicol 2012; 34:548-60. [DOI: 10.3109/08923973.2011.653646] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Viganò M, Degasperi E, Aghemo A, Lampertico P, Colombo M. Anti-TNF drugs in patients with hepatitis B or C virus infection: safety and clinical management. Expert Opin Biol Ther 2011; 12:193-207. [DOI: 10.1517/14712598.2012.646986] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Prignano F, Ricceri F, Pescitelli L, Bonciani D, Lotti T. Etanercept therapy in a hepatitis B virus (HBV)-positive psoriatic patient developing a monoclonal gammopathy of undetermined significance. Int J Dermatol 2011; 50:999-1001. [DOI: 10.1111/j.1365-4632.2010.04676.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
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
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Affiliation(s)
- Kim A Papp
- University of Western Ontario, and K Papp Clinical Research Waterloo, ON, Canada
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Brunasso AMG, Puntoni M, Gulia A, Massone C. Safety of anti-tumour necrosis factor agents in patients with chronic hepatitis C infection: a systematic review. Rheumatology (Oxford) 2011; 50:1700-11. [PMID: 21690185 DOI: 10.1093/rheumatology/ker190] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Alexandra M G Brunasso
- Department of Environmental Dermatology and Venereology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz, Austria.
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