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Khoo JK, Barnes H, Key S, Glaspole IN, Östör AJ. Pulmonary adverse events of small molecule JAK inhibitors in autoimmune disease: systematic review and meta-analysis. Rheumatology (Oxford) 2020; 59:2217-2225. [DOI: 10.1093/rheumatology/keaa117] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/30/2022] Open
Abstract
Abstract
Objectives
Small molecule tyrosine kinase inhibitors [smTKI, comprising mostly of Janus kinase (JAK) and to a lesser extent, spleen tyrosine kinase (SyK) inhibitors] modulate the cytokine receptor-mediated intracellular signal cascade, and are an effective treatment for autoimmune diseases and malignancies. As smTKI are novel, long-term safety is uncertain. Due to increasing use, characterization of their true adverse event profile is critical.
Methods
We performed a systematic review and meta-analysis of all published trial data on the pulmonary and serious adverse effects of smTKIs in autoimmune disease. EMBASE, MEDLINE, CENTRAL and Pneumotox databases were searched up to April 2019 for randomized controlled trials, observational studies and post marketing surveillance, comparing any smTKI with placebo or another therapy, or as monotherapy at different doses. Primary outcomes comprised of any respiratory complications including upper and lower respiratory tract infections (URTI, LRTI), influenza, pneumonia, opportunistic respiratory infections, drug-induced interstitial lung disease, pulmonary embolism and lung neoplasm.
Results
We identified 4667 citations for screening, and selected 319 studies for full text review. Seventy-nine studies were analysed, including 47 randomized controlled trials, 25 observational studies and seven post-marketing surveillance studies, comprising 159 652 participants. There were significantly increased risks of URTI [risk difference (RD) 0.03; 95% CI: 0.01, 0.05; P = 0.00; 36 studies, 14 724 participants], LRTI (RD 0.01; 95% CI: 0.00, 0.02; P = 0.02; 24 studies, 12 302 participants), influenza (RD 0.01; 95% CI: 0.00, 0.01; P = 0.04; 22 studies, 10 684 participants), and pneumonia (RD 0.00; 95% CI: 0.00, 0.01; P = 0.02; 33 studies, 15 511 participants). No increased risk was found for other respiratory complications, including pulmonary embolism.
Conclusion
SmTKI increases the risk of non-opportunistic respiratory infections compared with placebo. The risk of any serious pulmonary adverse events is low.
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Affiliation(s)
- Jun K Khoo
- Department of Respiratory Medicine, Alfred Hospital
| | | | - Seraphina Key
- Central Clinical School, Monash University, Melbourne
| | - Ian N Glaspole
- Department of Respiratory Medicine, Alfred Hospital
- Central Clinical School, Monash University, Melbourne
| | - Andrew J Östör
- Central Clinical School, Monash University, Melbourne
- Cabrini Medical Centre, Melbourne Rheumatology Group, Malvern, Victoria, Australia
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Grigoropoulos I, Thomas K, Christoforou P, Fanidi I, Papavdi M, Kyriakou F, Deutsch M, Pirounaki M, Vassilopoulos D. Pneumocystis Jirovecii Pneumonia after Initiation of Tofacitinib Therapy in Rheumatoid Arthritis: Case-Based Review. Mediterr J Rheumatol 2019; 30:167-170. [PMID: 32185360 PMCID: PMC7045858 DOI: 10.31138/mjr.30.3.167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/30/2022] Open
Abstract
The use of biologic and targeted synthetic disease-modifying anti-rheumatic drugs (tsDMARDs) in rheumatic diseases is constantly increasing during the last decade. Tofacitinib is a new oral Janus Kinase (JAK) inhibitor, approved for rheumatoid arthritis (RA), psoriatic arthritis and ulcerative colitis. Safety data of tofacitinib derived from randomized controlled trials and long-term extension studies has demonstrated a moderate increase in the risk for common serious infections. We describe a case of Pneumocystis jirovecii pneumonia (PJP) in a woman on tofacitinib therapy for RA. Although tofacitinib use has been associated with the development of opportunistic infections, PJP has been rarely reported. PJP should be included in the differential diagnosis of patients with autoimmune disorders under newer oral JAK inhibitors therapy who present with fever, hypoxia and pulmonary infiltrates.
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Affiliation(s)
- Ioannis Grigoropoulos
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Thomas
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Christoforou
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Iliana Fanidi
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Maria Papavdi
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Fani Kyriakou
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Melanie Deutsch
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Maria Pirounaki
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Vassilopoulos
- 2 Department of Medicine and Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
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