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Chen HH, Wu CL, Chao WC. Analysis of the impact of maternal sepsis on pregnancy outcomes: a population-based retrospective study. BMC Pregnancy Childbirth 2024; 24:518. [PMID: 39090584 PMCID: PMC11295718 DOI: 10.1186/s12884-024-06607-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 05/26/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND To investigate the association between maternal sepsis during pregnancy and poor pregnancy outcome and to identify risk factors for poor birth outcomes and adverse perinatal events. METHODS We linked the Taiwan Birth Cohort Study (TBCS) database and the Taiwanese National Health Insurance Database (NHID) to conduct this population-based study. We analysed the data of pregnant women who met the criteria for sepsis-3 during pregnancy between 2005 and 2017 as the maternal sepsis cases and selected pregnant women without infection as the non-sepsis comparison cohort. Sepsis during pregnancy and fulfilled the sepsis-3 definition proposed in 2016. The primary outcome included low birth weight (LBW, < 2500 g) and preterm birth (< 34 weeks), and the secondary outcome was the occurrence of adverse perinatal events. RESULTS We enrolled 2,732 women who met the criteria for sepsis-3 during pregnancy and 196,333 non-sepsis controls. We found that the development of maternal sepsis was highly associated with unfavourable pregnancy outcomes, including LBW (adjOR 9.51, 95% CI 8.73-10.36), preterm birth < 34 weeks (adjOR 11.69, 95%CI 10.64-12.84), and the adverse perinatal events (adjOR 3.09, 95% CI 2.83-3.36). We also identified that socio-economically disadvantaged status was slightly associated with an increased risk for low birth weight and preterm birth. CONCLUSION We found that the development of maternal sepsis was highly associated with LBW, preterm birth and adverse perinatal events. Our findings highlight the prolonged impact of maternal sepsis on pregnancy outcomes and indicate the need for vigilance among pregnant women with sepsis.
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Affiliation(s)
- Hsin-Hua Chen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Big Data Center, Chung Hsing University, Taichung, Taiwan
- Department of post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Chieh-Liang Wu
- Department of post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Cheng Chao
- Big Data Center, Chung Hsing University, Taichung, Taiwan.
- Department of post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
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Sen R, Riofrio M, Singh JA. A narrative review of the comparative safety of disease-modifying anti-rheumatic drugs used for the treatment of rheumatoid arthritis. Expert Opin Drug Saf 2024; 23:687-714. [PMID: 38695151 DOI: 10.1080/14740338.2024.2348575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/24/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Disease-modifying anti-rheumatic drugs (DMARDs) have improved the outcomes of patients with rheumatoid arthritis (RA). DMARDs are classified into three categories: conventional synthetic DMARDs, biological DMARDs (including biosimilars), and targeted synthetic DMARDs. DMARDs, by way of their effect on the immune system, are associated with increased risk of adverse events, including infections, malignancies, cardiovascular disease, gastrointestinal perforations, and other less common events. AREAS COVERED In this narrative literature review performed with searches of the PubMed database from 1 January 2010 through 1 January 2023, we compare the risk of safety events between DMARDs using data from both randomized clinical trials and observational studies. EXPERT OPINION DMARD use in RA is associated with higher rates of serious infections, tuberculosis reactivation, opportunistic infections, and possibly malignancies. Specific biologic DMARDs and higher doses are associated with elevated risks of various adverse events (gastrointestinal perforations, thromboembolism, serious infection). Shared decision-making is paramount when choosing a treatment regimen for patients based on their own comorbidities. JAKi are the newest class of medications used for RA with robust safety data provided in clinical trials. However, more real-world evidence and phase-IV pharmacovigilance data are needed to better understand comparative safety profile of DMARDs in RA.
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Affiliation(s)
- Rouhin Sen
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
| | - Maria Riofrio
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
| | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
- Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA
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3
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Chen HH, Wu PY, Lin CH, Wu CL, Chao WC. Factors associated with mental illness in patients with rheumatoid arthritis initiating b/ts DMARDs: A population-based study. Int J Rheum Dis 2024; 27:e14992. [PMID: 38061767 DOI: 10.1111/1756-185x.14992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 01/31/2024]
Abstract
AIM Mental health is an essential issue in patients with rheumatoid arthritis (RA) but remains unclear among those receiving biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). We aim to assess the incidence and factors associated with mental illness among patients with RA who underwent b/tsDMARD therapy. METHOD We used Taiwan's National Health Insurance Research Database for the period 2001-2020 to identify patients with RA receiving b/tsDMARDs. The primary outcome was newly developed mental illness, including anxiety and mood disorders. We performed a Cox regression analysis to determine factors associated with mental illness and presented as hazard ratios (HR) with 95% confidence interval (CI). RESULTS We enrolled 10 852 patients, with 7854 patients receiving tumor necrosis factors inhibitors (TNFi), 1693 patients receiving non-TNFi bDMARDs, and 1305 patients treated with tsDMARD. We found that 13.62% of enrolled patients developed mental illness, with an incidence rate of 4054 per 100 000 person-year. Those receiving tocilizumab (aHR 0.64, 95% CI: 0.51-0.82), abatacept (aHR 0.69, 95% CI: 0.55-0.86), or tsDMARDs (aHR 0.58, 95% CI: 0.47-0.73) had a lower risk of mental illness compared with those receiving TNFi. We also found that old age, low income, diabetes mellitus, use of cyclosporine, and use of steroids were associated with incident mental illness. CONCLUSION This population-based study investigated the incidence and factors associated with mental illness among patients with RA receiving b/tsDMARDs. Our findings highlight the need for vigilance with respect to the possibility of mental illness in patients with RA.
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Affiliation(s)
- Hsin-Hua Chen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, Chung Hsing University, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Big Data Center, Chung Hsing University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Peng-Yen Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ching-Heng Lin
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Healthcare Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chieh-Liang Wu
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Cheng Chao
- Big Data Center, Chung Hsing University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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Sepriano A, Kerschbaumer A, Bergstra SA, Smolen JS, van der Heijde D, Caporali R, Edwards CJ, Verschueren P, de Souza S, Pope J, Takeuchi T, Hyrich K, Winthrop KL, Aletaha D, Stamm T, Schoones JW, Landewé RBM. Safety of synthetic and biological DMARDs: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2023; 82:107-118. [PMID: 36376026 DOI: 10.1136/ard-2022-223357] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To perform a systematic literature review (SLR) concerning the safety of synthetic(s) and biological (b) disease-modifying antirheumatic drugs (DMARDs) to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA). METHODS SLR of observational studies comparing safety outcomes of any DMARD with another intervention in RA. A comparator group was required for inclusion. For treatments yet without, or limited, registry data, randomised controlled trials (RCTs) were used. RESULTS Fifty-nine observational studies addressed the safety of DMARDs. Two studies (unclear risk of bias (RoB)) showed an increased risk of serious infections with bDMARDs compared with conventional synthetic (cs)DMARDs. Herpes zoster infections occurred more with JAKi than csDMARDs (adjusted HR (aHR): 3.66) and bDMARDs (aHR: 1.9-2.3) (four studies, two low RoB). The risk of malignancies was similar across bDMARDs (five studies) and with tofacitinib compared with bDMARDs (one study, low RoB). The risk of major adverse cardiovascular events (MACE) was similar with bDMARDs and tofacitinib (two studies, one low RoB). Thirty studies reported safety from RCTs, with one, designed to evaluate safety, showing that malignancies (HR (95% CI): 1.48 (1.04 to 2.09)) and MACE (HR (95% CI): 1.33 (0.91 to 1.94)) occurred numerically more frequently with tofacitinib (5 mg and 10 mg doses combined) than with TNFi in patients with cardiovascular risk factors. In this study, the risk of venous thromboembolism (VTE) was higher with tofacitinib 10 mg than with TNFi. CONCLUSION The safety profile of bDMARDs was further demonstrated. Whether the difference in incidence of malignancies, MACE and VTE between tofacitinib and TNFi applies to other JAKi needs further evaluation.
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Affiliation(s)
- Alexandre Sepriano
- CHRC Campus Nova Medical School, Lisboa, Portugal .,Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Wien, Austria
| | | | - Josef S Smolen
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Wien, Austria.,2nd Department of Medicine, Hietzing Hospital, Wien, Austria
| | | | - Roberto Caporali
- Department of Clinical Sciences and Community Health, ASS G. Pini, University of Milan, Milano, Italy.,Department of Rheumatology, ASST PINI-CTO, Milan, Italy
| | - Christopher J Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick Verschueren
- Rheumatology, KU Leuven University Hospitals, Leuven, Belgium.,Engineering Research Centre, Lueven, Belgium
| | - Savia de Souza
- Patient Research Partner Network, European Alliance of Associations for Rheumatology, Zurich, Switzerland
| | - Janet Pope
- Medicine, Division of Rheumatology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan.,Saitama Medical University, Iruma-gun, Japan
| | - Kimme Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Kevin L Winthrop
- School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Wien, Austria
| | - Tanja Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Wien, Austria.,Institute for Arthritis and Rehabilitation, Ludwig Boltzmann, Vienna, Austria
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
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Yen CY, Yu SJ, Chen YM, Lai KL, Wu YD, Liao EC, Hsieh CL. Mechanisms of Tumor Necrosis Factor-Alpha Inhibitor-Induced Systemic Lupus Erythematosus. Front Med (Lausanne) 2022; 9:870724. [PMID: 35733860 PMCID: PMC9208548 DOI: 10.3389/fmed.2022.870724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Systemic lupus erythematosus induced by biologics mainly results from tumor necrosis factor-alpha remains unclear. The objectives of the study were to investigate the mechanisms of tumor necrosis factor-alpha inhibitor-induced systemic lupus erythematosus. Peripheral blood mononuclear cells obtained from thirteen psoriasis patients were cultured and treated with the following: untreated control, Streptococcus pyogenes with or without different biologics. The supernatants were collected for cytokines assay. Analysis of cytokine expression revealed that IL-2 and IL-10 levels decreased only in the TNF-α inhibitor-treated groups but not in the groups treated with biologics involving IL-17, IL-12/IL-23 or IL-23 inhibitor mechanisms (p < 0.001, p < 0.05). The IFN-γ/IL-13 ratio increased significantly in patients with SLE inducing biologics to S. pyogenes induction only compared with non-SLE inducing biologics to S. pyogenes induction only (p = 0.001). IL-2 and IL-10 depletion and a shift to the Th-1 pathway in the innate response are the correlated mechanism for tumor necrosis factor-alpha inhibitor-induced systemic lupus erythematosus.
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Affiliation(s)
- Chung-Yang Yen
- Department of Dermatology, Taichung Veterans General Hospital, Taichung City, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sheng-Jie Yu
- Department of Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Yi-Ming Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City, Taiwan
| | - Yi-Da Wu
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City, Taiwan
| | - En-Chih Liao
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Ching-Liang Hsieh
- Chinese Medicine Research Center, China Medical University, Taichung City, Taiwan
- Department of Chinese Medicine, China Medical University Hospital, Taichung City, Taiwan
- *Correspondence: Ching-Liang Hsieh
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Bellan M, Scotti L, Ferrante D, Calzaducca E, Manfredi GF, Sainaghi PP, Barone-Adesi F. Risk of Severe Infection among Rheumatoid Arthritis Patients on Biological DMARDs: A Population-Based Cohort Study. J Clin Med 2022; 11:jcm11112955. [PMID: 35683344 PMCID: PMC9181346 DOI: 10.3390/jcm11112955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/14/2022] [Accepted: 05/22/2022] [Indexed: 12/15/2022] Open
Abstract
Biological disease-modifying anti-rheumatic drugs (bDMARDs) are widely used for the management of rheumatoid arthritis, although their benefits are counterweight by an increased risk of infections. In the present study, we used administrative data to compare the risk of severe infections among different classes of bDMARDs. A retrospective cohort study was conducted using Administrative Health Databases of the Piedmont Region, Italy. Relevant data were obtained from: (1) the inhabitants registry, (2) hospital discharge records, and (3) the co-payment exemption registry and (4) drug claims registry. Fine and Gray competing risk models were fitted to evaluate the association between the use of different types of bDMARDs and occurrence of severe infection accounting for treatment interruption as competing risk. A total of 1780 new users of bDMARDs were identified. Among them, 50 hospitalizations for infection occurred during the study period. The use of Tocilizumab was associated with an increased risk of infection, compared to tumor necrosis factor (TNF) inhibitor drugs (sub-distribution hazard ratios-sHR: 2.510; 95% CI: 1.279–4.926), whereas no difference in the risk of severe infection was found for abatacept (sHR: 0.584; 95% CI: 0.234–1.457). bDMARDs treatment is generally safe in clinical practice with slight but important differences among classes. The increased risk of infection associated with tocilizumab use should be taken into account when balancing the risk and benefits of starting a treatment with this drug.
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Affiliation(s)
- Mattia Bellan
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
- Center for Translational Research on Autoimmune and Allergic Diseases (CAAD), Università del Piemonte Orientale (UPO), 28100 Novara, Italy
| | - Lorenza Scotti
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
| | - Daniela Ferrante
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
| | - Elisa Calzaducca
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
| | - Giulia Francesca Manfredi
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
| | - Pier Paolo Sainaghi
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
- Center for Translational Research on Autoimmune and Allergic Diseases (CAAD), Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- Correspondence: ; Tel.: +39-0321-3737512
| | - Francesco Barone-Adesi
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
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