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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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Respiratory infections associated with anti-TNFα agents. Med Mal Infect 2017; 47:375-381. [DOI: 10.1016/j.medmal.2017.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 05/10/2017] [Indexed: 12/17/2022]
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Iwama T, Sakatani A, Fujiya M, Tanaka K, Fujibayashi S, Nomura Y, Ueno N, Kashima S, Gotoh T, Sasajima J, Moriichi K, Ikuta K. Increased dosage of infliximab is a potential cause of Pneumocystis carinii pneumonia. Gut Pathog 2016; 8:2. [PMID: 26839596 PMCID: PMC4736477 DOI: 10.1186/s13099-016-0086-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 01/18/2016] [Indexed: 12/02/2022] Open
Abstract
Methods Pneumocystis carinii pneumonia occasionally appears in immunodeficient patients. While several reports have shown that Pneumocystis carinii pneumonia occurred in the early phase of starting infliximab treatment in patients with Crohn’s disease (CD), the present case suggests for the first time that an increased dosage of infliximab may also lead to pneumonia. Results A 51-year-old male had been taking 5 mg of infliximab for the treatment of CD for 10 years with no adverse events. Beginning in September 2013, the dose of infliximab had to be increased to 10 mg/kg because his status worsened. Thereafter, he complained of a fever and cough, and a CT scan revealed ground-glass opacities in the lower lobes of the bilateral lung with a crazy-paving pattern. Bronchoscopy detected swelling of the tracheal mucosa with obvious dilations of the vessels. A polymerase chain reaction using a bronchoalveolar lavage fluid sample detected specific sequences for Pneumocystis jirovecii; thus he was diagnosed with Pneumocystis carinii (jirovecii) pneumonia. After discontinuing infliximab and starting antibiotic treatment, his symptoms and CT findings were dramatically improved. Conclusions The administration of an increased dosage of infliximab can cause Pneumocystis carinii pneumonia in CD patients.
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Affiliation(s)
- Takuya Iwama
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Aki Sakatani
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Mikihiro Fujiya
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Kazuyuki Tanaka
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Shugo Fujibayashi
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Yoshiki Nomura
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Nobuhiro Ueno
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Shin Kashima
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Takuma Gotoh
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Junpei Sasajima
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Kentaro Moriichi
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
| | - Katsuya Ikuta
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510 Japan
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Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: Risks and Prophylaxis Recommendations. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:29-40. [PMID: 26396551 PMCID: PMC4562607 DOI: 10.4137/ccrpm.s23286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 01/05/2023]
Abstract
Pneumocystis jirovecii infection causes fulminant interstitial pneumonia (Pneumocystis pneumonia, PCP) in patients with rheumatoid arthritis (RA) who are receiving biological and/or nonbiological antirheumatic drugs. Recently, we encountered a PCP outbreak among RA outpatients at our institution. Hospital-acquired, person-to-person transmission appears to be the most likely mode of this cluster of P. jirovecii infection. Carriage of P. jirovecii seems a time-limited phenomenon in immunocompetent hosts, but in RA patients receiving antirheumatic therapy, clearance of this organism from the lungs is delayed. Carriers among RA patients can serve as sources and reservoirs of P. jirovecii infection for other susceptible patients in outpatient facilities. Development of PCP is a matter of time in such carriers. Considering the poor survival rates of PCP cases, prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy. Once a new case of PCP occurs, we should take prompt action not only to treat the PCP patient but also to prevent other patients from becoming new carriers of P. jirovecii. Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, Social Insurance Omuta Tenryo Hospital, Fukuoka, Japan
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Murdaca G, Spanò F, Contatore M, Guastalla A, Penza E, Magnani O, Puppo F. Infection risk associated with anti-TNF-α agents: a review. Expert Opin Drug Saf 2015; 14:571-82. [PMID: 25630559 DOI: 10.1517/14740338.2015.1009036] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION TNF-α is a pro-inflammatory cytokine known to a have a key role in the pathogenesis of chronic immune-mediated diseases. TNF-α inhibitors can be administered either as monotherapy or in combination with other anti-inflammatory or disease-modifying anti-rheumatic drugs (DMARDs) to treat chronic immune-mediated diseases. AREAS COVERED Patients receiving TNF-α inhibitors are at high risk of infections. Based on our experience, in this paper, we discuss the risk of infections associated with the administration of TNF-α inhibitors and the strategies for mitigating against the development of these serious adverse events. EXPERT OPINION Infliximab more so than etanercept appears to be responsible for the increased risk of infections. Re-activation of latent tuberculosis (LTB) infection and the overall risk of opportunistic infections should be considered before beginning TNF-α inhibitor therapy. A careful medical history, Mantoux test and chest-x-ray should always be performed before prescribing TNF-α inhibitors. Particular attention should be paid to risk factors for Pneumocystis jirovecii infection. Hepatitis B and C virological follow-up should be considered during TNF-α inhibitor treatment. Finally, patients who are at high risk of herpes zoster (HZ) reactivation would benefit from a second vaccination in adulthood when receiving TNF-α inhibitors.
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Affiliation(s)
- Giuseppe Murdaca
- University of Genova, Department of Internal Medicine, Clinical Immunology Unit , Viale Benedetto XV, n. 6, 16132 Genova , Italy +39 0103537924 ; +39 0105556950 ;
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Mori S. A relationship between pharmacokinetics (PK) and the efficacy of infliximab for patients with rheumatoid arthritis: characterization of infliximab-resistant cases and PK-based modified therapy. Mod Rheumatol 2014. [DOI: 10.3109/s10165-006-0544-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Yoshida Y, Takahashi Y, Minemura N, Ueda Y, Yamashita H, Kaneko H, Mimori A. Prognosis of pneumocystis pneumonia complicated in patients with rheumatoid arthritis (RA) and non-RA rheumatic diseases. Mod Rheumatol 2014. [DOI: 10.3109/s10165-011-0523-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mori S, Cho I, Ichiyasu H, Sugimoto M. Asymptomatic carriage ofPneumocystis jiroveciin elderly patients with rheumatoid arthritis in Japan: a possible association between colonization and development ofPneumocystis jirovecipneumonia during low-dose MTX therapy. Mod Rheumatol 2014. [DOI: 10.3109/s10165-008-0037-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Fritzsche C, Riebold D, Munk-Hartig AK, Klammt S, Neeck G, Reisinger EC. High prevalence ofPneumocystis jiroveciicolonization among patients with autoimmune inflammatory diseases and corticosteroid therapy. Scand J Rheumatol 2012; 41:208-13. [DOI: 10.3109/03009742.2011.630328] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Serologic responses to pneumocystis proteins in HIV patients with and without Pneumocystis jirovecii pneumonia. J Acquir Immune Defic Syndr 2011; 57:190-6. [PMID: 21372726 DOI: 10.1097/qai.0b013e3182167516] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Immune responses to Pneumocystis jirovecii are not well understood in HIV infection, but antibody responses to proteins may be useful as a marker of Pneumocystis risk or presence of Pneumocystis pneumonia (PcP). DESIGN Retrospective analysis of a prospective cohort. METHODS Enzyme-linked immunosorbent assays of antibodies to recombinant Pneumocystis proteins of major surface glycoprotein fragments (MsgC1, C3, C8, and C9) and of antibody titers to recombinant kexin protein (KEX1) were performed on 3 sequential serum samples up to 18 months before and 3 samples after first AIDS-defining illness from Multicenter AIDS Cohort Study participants and compared between those who had PcP or a non-PcP AIDS-defining illness. RESULTS Fifty-four participants had PcP and 47 had a non-PcP AIDS-defining illness. IgG levels to MsgC fragments were similar between groups before first AIDS-defining illness, but the PcP group had higher levels of IgG to MsgC9 (median units/mL 50.2 vs. 22.2, P = 0.047) post-illness. Participants with PcP were more likely to have an increase in MsgC3 [odds ratio (OR): 3.9, P = 0.02], MsgC8 (OR: 5.5, P = 0.001), and MsgC9 (OR: 4.0, P = 0.007). The PcP group was more likely to have low KEX1 IgG before development of PcP (OR: 3.6, P = 0.048) independent of CD4 cell count and to have an increase in high IgG titers to KEX1 after PcP. CONCLUSIONS HIV-infected individuals develop immune responses to both Msg and kexin proteins after PcP. Low KEX1 IgG titers may be a novel marker of future PcP risk before CD4 cell count has declined below 200 cells per microliter.
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Lee JC, Bell DC, Guinness RM, Ahmad T. Pneumocystis jiroveci pneumonia and pneumomediastinum in an anti-TNFα naive patient with ulcerative colitis. World J Gastroenterol 2009; 15:1897-900. [PMID: 19370790 PMCID: PMC2670420 DOI: 10.3748/wjg.15.1897] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We report the case of a 21-year-old man who was noted to have pneumomediastinum during an admission for an acute flare of ulcerative colitis. At that time, he was on maintenance treatment with azathioprine at a dose of 1.25 mg/kg per day, and had not received supplementary steroids for 9 mo. He had never received anti-tumor necrosis factor (TNF)α therapy. Shortly after apparently effective treatment with intravenous steroids and an increased dose of azathioprine, he developed worsening colitic and new respiratory symptoms, and was diagnosed with Pneumocystis jiroveci (carinii) pneumonia (PCP). Pneumomediastinum is rare in immunocompetent hosts, but is a recognized complication of PCP in human immunodeficiency virus (HIV) patients, although our patient’s HIV test was negative. Treatment of PCP with co-trimoxazole resulted in resolution of both respiratory and gastrointestinal symptoms, without the need to increase the steroid dose. There is increasing vigilance for opportunistic infections in patients with inflammatory bowel disease following the advent of anti-TNFα therapy. This case emphasizes the importance of considering the possibility of such infections in all patients with inflammatory bowel disease, irrespective of the immunosuppressants they receive, and highlights the potential of steroid-responsive opportunistic infections to mimic worsening colitic symptoms in patients with ulcerative colitis.
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Komano Y, Harigai M, Koike R, Sugiyama H, Ogawa J, Saito K, Sekiguchi N, Inoo M, Onishi I, Ohashi H, Amamoto F, Miyata M, Ohtsubo H, Hiramatsu K, Iwamoto M, Minota S, Matsuoka N, Kageyama G, Imaizumi K, Tokuda H, Okochi Y, Kudo K, Tanaka Y, Takeuchi T, Miyasaka N. Pneumocystis jirovecipneumonia in patients with rheumatoid arthritis treated with infliximab: A retrospective review and case-control study of 21 patients. ACTA ACUST UNITED AC 2009; 61:305-12. [DOI: 10.1002/art.24283] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Mori S, Cho I, Ichiyasu H, Sugimoto M. Asymptomatic carriage of Pneumocystis jiroveci in elderly patients with rheumatoid arthritis in Japan: a possible association between colonization and development of Pneumocystis jiroveci pneumonia during low-dose MTX therapy. Mod Rheumatol 2008; 18:240-6. [PMID: 18306977 DOI: 10.1007/s10165-008-0037-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 11/26/2007] [Indexed: 12/01/2022]
Abstract
Low-dose methotrexate (MTX) has been used effectively for rheumatoid arthritis (RA) because of its favorable risk-benefit ratio. One of the recent concerns arising from this therapy is a possible increase in the rate of opportunistic infections, particularly Pneumocystis jiroveci pneumonia (PCP). In this study, we report two cases of PCP occurring during low-dose methotrexate therapy for RA and review 13 additional cases from the literature on Japanese patients with RA. The average age of these patients was 67.7 years, and most were over the age of 60. MTX-associated PCP appears to occur more frequently in elderly individuals in Japan. To identify individuals with a high risk of PCP, we performed a polymerase chain reaction on specimens from induced sputum or bronchoalveolar lavage fluids from 55 patients with RA. At that point in time, they showed no evidence of PCP development. We found six patients (10.9%) having asymptomatic carriage of P. jiroveci. The mean age of the P. jiroveci-positive patients was 74.7 years, which was significantly older than the P. jiroveci-negative patients (mean age 63.6 years). Of the RA patients over the age of 65, 18.8% (6 cases out of 32) were carriers of P. jiroveci. There were no significant differences in RA duration or counts of white blood cells or lymphocytes between the positive and negative groups. Notably, we encountered a case of PCP occurring in an asymptomatic carrier of P. jiroveci during low-dose MTX therapy for RA. This case appeared to be a reactivation of latent infection. By careful follow-up on the carriers of P. jiroveci, we succeeded in promptly diagnosing PCP, and we employed the appropriate therapeutic strategies for this possibly life-threatening complication.
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Affiliation(s)
- Shunsuke Mori
- Clinical Research Center for Rheumatic Disease and Department of Rheumatology, Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto, Japan.
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Lahiff C, Khiaron OB, Nolan N, Chadwick GA. Pneumocystis carinii pneumonia in a patient on etanercept for psoriatic arthritis. Ir J Med Sci 2007; 176:309-11. [PMID: 17906888 DOI: 10.1007/s11845-007-0087-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Accepted: 09/10/2007] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pneumocystis carinii pneumonia (PCP) is a rare form of pneumonia associated with immune-suppression. It is common in patients with AIDS and with a CD4 count of less than 200 cells/mm(3). We report a case of PCP secondary to immune-suppression in a 41-year-old man with psoriatic arthritis being treated with the immune-modulatory agent etanercept. METHODS Diagnosis of PCP was made histologically using tissue obtained via transbronchial biopsy. RESULTS There was a good response to standard treatment with high-dose co-trimoxazole. CONCLUSION This report highlights a recognised but previously unreported complication of etanercept.
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Affiliation(s)
- C Lahiff
- Department of Medicine, St. Columcilles Hospital, Loughlinstown, Co. Dublin, Ireland.
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Mori S. A relationship between pharmacokinetics (PK) and the efficacy of infliximab for patients with rheumatoid arthritis: characterization of infliximab-resistant cases and PK-based modified therapy. Mod Rheumatol 2007; 17:83-91. [PMID: 17437161 DOI: 10.1007/s10165-006-0544-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Accepted: 11/01/2006] [Indexed: 12/29/2022]
Abstract
Infliximab, a chimeric anti-tumor necrosis factor alpha (TNF-alpha) monoclonal antibody, has been recognized as significantly improving the course of rheumatoid arthritis (RA); however, a subset of patients shows poor responses. To understand the mechanism underlying such unresponsiveness, I examined the clinical pharmacokinetics (PK) of infliximab, using time-serum concentration profiles obtained from 21 RA patients who had received infliximab therapy in combination with methotrexate (MTX). At week 14 of therapy, 15 cases achieved good or moderate responses in the European League Against Rheumatism (EULAR) criteria, and 3 cases resulted in nonresponders. The others discontinued therapy because of severe adverse effects or aggravation of disease activities. The means of distribution volume and elimination half-life (t (1/2)) during the first 2 weeks were 0.05 l/kg and 9.5 days, respectively. Through 14 weeks, most good and moderate responders maintained serum concentrations of more than 1 microg/ml, even immediately before the next infusions. Only 3 cases among good or moderate responders showed undetectable levels of trough serum concentration at week 14. In contrast, the PK profiles of all nonresponders except one showed rapid clearance during therapy. These data support the idea that the rapid clearance of infliximab is the main cause of poor therapeutic responses. I also found that the t (1/2) during the first 2 weeks is inversely correlated to the disease activity scores for 28 joints at the start of treatment, suggesting that TNF-alpha levels may determine the disease activity of RA. For patients who showed a rapid clearance of infliximab, the increased use of prednisone or MTX was beneficial to achieve sufficient clinical responses. The addition of tacrolimus was effective to improve the clinical outcomes of nonresponders. Thus PK data apparently offer guidance when modified treatment for infliximab-resistant RA patients is being considered.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, National Kumamoto Saishunsou Hospital, 2659 Suya, Kohshi 861-1196, Japan.
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