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Cito A, Fornaro M, Carenza A, Anelli MG, Scioscia C, Iannone F, Lopalco G. Turning the Tide against Herpes Zoster in Rheumatoid Arthritis Patients Treated with JAK Inhibitors. J Clin Med 2024; 13:4423. [PMID: 39124690 PMCID: PMC11313145 DOI: 10.3390/jcm13154423] [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: 06/18/2024] [Revised: 07/26/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024] Open
Abstract
Objectives: This study aimed to evaluate the incidence of Herpes Zoster (HZ) in patients with rheumatoid arthritis (RA) treated with Janus kinase inhibitors (JAKi), and to predict potential risk factors for HZ development. Methods: We retrospectively analysed medical records from RA patients at our rheumatology unit who met the 2010 ACR/EULAR criteria for RA and were receiving JAKi. The incidence and course of HZ were assessed through chart review and supplementary phone interviews. Results: A total of 198 JAKi-treated patients were monitored for an average of 18.5 months. Nine subjects experienced HZ, resulting in an incidence of 2.95 per 100 patient-years. No demographic or treatment-related differences were found among patients who developed HZ and those who did not. Disease duration (OR: 1.06, 95% CI: 1.01-1.12), time on JAKi treatment (OR: 1.04, 95% CI: 1.009-1.073), higher disease activity at JAKi initiation (OR: 4.16, 95% CI: 1.07-16.17), and at 3-month follow-up (OR: 6.0, 95% CI: 1.35-26.60) were identified as predictors of HZ occurrence. Thirty-six patients received vaccination against HZ, and none reported adverse reactions or flare-ups during a mean follow-up of 9.6 months. Conclusions: The incidence of HZ aligns with published data, suggesting that disease and treatment duration, as well as disease activity, are significant predictors of HZ in RA patients on JAKi therapy. Vaccination against HZ proved to be safe and effective, underscoring its potential protective value in this patient population.
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Affiliation(s)
| | | | | | | | | | | | - Giuseppe Lopalco
- Rheumatology Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari Aldo Moro, 70121 Bari, Italy; (A.C.); (M.F.); (A.C.); (M.G.A.); (C.S.); (F.I.)
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de Almeida ALB, Guimarães MFBR, da Costa Pinto MR, Pereira LR, Reis APMG, Bonfiglioli KR, Louzada-Junior P, Giorgi RDN, de Castro GRW, Radominski SC, Brenol CV, Pugliesi A, da Mota LMH, da Rocha Castelar-Pinheiro G. Predictors of serious infections in rheumatoid arthritis-a prospective Brazilian cohort. Adv Rheumatol 2024; 64:23. [PMID: 38553751 DOI: 10.1186/s42358-024-00363-1] [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: 07/17/2023] [Accepted: 03/19/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Infections increase mortality and morbidity and often limit immunosuppressive treatment in rheumatoid arthritis patients. OBJECTIVE To analyze the occurrence of serious infections and the associated factors in a cohort of rheumatoid arthritis patients under real-life conditions. METHODS We analyzed data from the REAL, a prospective observational study, that evaluated Brazilian RA patients, with clinical and laboratory data collected over a year. Univariate and multivariate analyses were performed from the adjustment of the logistic regression model Generalized Estimating Equations (GEE), with the primary outcome being the occurrence of serious infection, defined as need for hospitalization or use of intravenous antibiotics for its treatment. RESULTS 841 patients were included with an average follow-up time of 11.2 months (SD 2.4). Eighty-nine serious infections occurred, corresponding to 13 infections per 100 patient-years. Pulmonary fibrosis, chronic kidney disease (CKD) and central nervous system disease increased the chances of serious infection by 3.2 times (95% CI: 1.5-6.9), 3.6 times (95% CI: 1.2-10.4) and 2.4 times (95% CI: 1.2-5.0), respectively. The use of corticosteroids in moderate doses increased the chances by 5.4 times (95% CI: 2.3-12.4), and for each increase of 1 unit in the health assessment questionnaire (HAQ), the chance increased 60% (95% CI: 20-120%). CONCLUSION The use of corticosteroids at moderate doses increased the risk of serious infection in RA patients. Reduced functionality assessed by the HAQ and comorbidities were other important factors associated with serious infection in this cohort.
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Affiliation(s)
| | | | | | - Leticia Rocha Pereira
- Departamento de Reumatologia, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Karina Rossi Bonfiglioli
- Departamento de Reumatologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | | | - Claiton Viegas Brenol
- Departamento de Reumatologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alisson Pugliesi
- Departamento de Reumatologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Yun H, Chen L, Roy JA, Greenberg J, Harrold LR, George MD, Curtis JR. Rheumatoid Arthritis Disease Activity and Hospitalized Infection in a Large US Registry. Arthritis Care Res (Hoboken) 2023; 75:1639-1647. [PMID: 35866713 PMCID: PMC10277216 DOI: 10.1002/acr.24984] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 05/30/2022] [Accepted: 07/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The association between disease activity and infection risk among patients with rheumatoid arthritis (RA) is not clear, and it is challenging to determine because of confounding due to the effects of RA treatments and comorbidities. METHODS Using patients with RA in the CorEvitas registry with Medicare coverage in 2006-2019, we identified eligible patients who had at least 1 visit with moderate disease activity based on the Clinical Disease Activity Index (CDAI; CDAI >10 and ≤22). Follow-up started at the subsequent CorEvitas visit. Hospitalized infection during follow-up was assessed in linked Medicare data. We calculated the incidence rate of hospitalized infection for patients in remission, and low and moderate disease activity, and estimated the effect of time-varying CDAI on hospitalized infection by controlling for baseline and time-dependent confounders using marginal structural models (MSMs). RESULTS A total of 3,254 patients with RA were eligible for analysis, among which 529 hospitalized infections were identified during follow-up. The crude incidence of hospitalized infection was 3.8 per 100 person-years for patients in remission, 6.6 for low disease activity, and 8.0 for moderate disease activity. Using MSMs and compared with being in remission, the hazard ratio of hospitalized infection associated with low disease activity was 1.60 (95% confidence interval [95% CI] 1.13-2.28) and with moderate disease activity was 1.83 (95% CI 1.30-2.64). CONCLUSION The risk of hospitalized infection was higher for patients with RA in low or moderate disease activity than for those in remission after accounting for the interplay of disease activity, RA treatments, treatment switching, and other potential confounders.
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Affiliation(s)
- Huifeng Yun
- University of Alabama at Birmingham, Department of Epidemiology
| | - Lang Chen
- University of Alabama at Birmingham, Division of Immunology and Rheumatology
| | - Jason A Roy
- Rutgers University, Department of Biostatistics and Epidemiology
| | | | - Leslie R. Harrold
- CorEvitas LLC
- University of Massachusetts Medical School, Department of Medicine
| | | | - Jeffrey R Curtis
- University of Alabama at Birmingham, Division of Immunology and Rheumatology
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Chebbi P, Shobha V, Rao VK, Haridas V, Janardana R, Pinto B, Kumar S, Patil A, Tekkatte R, Salanke M, Mahendranath KM. Occurrence and outcome of COVID-19 in AIRD patients on concomitant treatment with Tofacitinib- results from KRA COVID COHORT (KRACC) subset. BMC Rheumatol 2023; 7:22. [PMID: 37496101 PMCID: PMC10369741 DOI: 10.1186/s41927-023-00345-8] [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: 06/18/2022] [Accepted: 07/10/2023] [Indexed: 07/28/2023] Open
Abstract
INTRODUCTION We assessed the risk factors and outcome of COVID-19 in patients with autoimmune rheumatic diseases(AIRD) who contracted infection while on background treatment with tofacitinib. METHODS This is a non-interventional, cross-sectional, questionnaire based telephonic study which included consecutive AIRD patients on tofacitinib co-treatment. Data related to the AIRD subset, disease modifying anti rheumatic drugs(DMARDs) including glucocorticoids and comorbidities, was collected from 7 rheumatology centers across Karnataka during the second wave of COVID-19 pandemic. The information about COVID-19 occurrence and COVID-19 vaccination was recorded. RESULTS During the study period (Jun-July 2021), 335 AIRD patients (80.6% female) on treatment with tofacitinib were included. The mean duration of tofacitinib use was 3.4+/-3.1months. Thirty-six(10.75%) patients developed COVID-19. Diabetes mellitus (p = 0.04 (OR 2.60 (1.13-5.99)) was identified as a risk factor for COVID-19 in our cohort. Almost half of our cohort was COVID-19 vaccinated with at least one dose, with resultant decline in incidence of COVID-19(OR 0.15 (0.06-0.39) among the vaccinated. Recovery amongst COVID-19 infection group was 91.2%. CONCLUSIONS The subset of AIRD patients who were on treatment with tofacitinib were found to have a higher rate of COVID-19 infection as compared to our KRACC cohort. Pre-existing comorbidity of diabetes mellitus was the significant risk factor in our cohort. This subset of the KRACC cohort shows RA patients had a lesser infection and PsA patients had a higher infection.
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Affiliation(s)
- Pramod Chebbi
- Department of Rheumatology, SDMCMSH, SDM University Dharwad, Dharwad, India
| | - Vineeta Shobha
- Department of Clinical Immunology and Rheumatology, St.John's Medical college Hospital, Sarjapur Road, Bengaluru, 560034, India.
| | - Vijay K Rao
- Department of Rheumatology, Manipal Hospital, Bengaluru, India
| | | | - Ramya Janardana
- Department of Clinical Immunology and Rheumatology, St.John's Medical college Hospital, Sarjapur Road, Bengaluru, 560034, India
| | - Benzeeta Pinto
- Department of Clinical Immunology and Rheumatology, St.John's Medical college Hospital, Sarjapur Road, Bengaluru, 560034, India
| | - Sharath Kumar
- OPTIMA Rheumatology & Arthritis clinic, Bengaluru, India
| | - Abhishek Patil
- Department of Rheumatology, Manipal Hospital, Bengaluru, India
| | | | - Manasa Salanke
- ChanRe Rheumatology and Immunology Centre, Bangalore, India
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Dieperink SS, Mehnert F, Nørgaard M, Oestergaard LB, Benfield T, Petersen A, Torp-Pedersen C, Glintborg B, Hetland ML. Antirheumatic treatment, disease activity and risk of Staphylococcus aureus bacteraemia in rheumatoid arthritis: a nationwide nested case-control study. RMD Open 2022; 8:rmdopen-2022-002636. [PMID: 36517186 PMCID: PMC9756197 DOI: 10.1136/rmdopen-2022-002636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To assess how biological disease-modifying antirheumatic drugs (bDMARDs), glucocorticoids and disease activity affect risk of Staphylococcus aureus bacteraemia (SAB) in patients with rheumatoid arthritis (RA). METHODS In a nationwide cohort of patients with RA from the DANBIO registry, we conducted a nested case-control study including first-time microbiologically verified SAB cases from 2010 to 2018 and incidence density matched controls (1:4 by sex, age). We interlinked Danish registries and identified antirheumatic treatments, RA-specific clinical characteristics, comorbidities and socioeconomic status. The relative risk of SAB was assessed by adjusted ORs with 95% CIs and number needed to harm (NNH) reflected the absolute risk. RESULTS Among 30 479 patients, we identified 180 SAB cases (incidence rate: 106.7/100 000 person-years) and matched 720 controls (57% women, median age 73 years, IQR: 65-80). Risk of SAB was increased in current (OR 1.8 (95% CI 1.1 to 3.2)) and former bDMARD users (OR 2.5 (95% CI 0.9 to 7.0)), and in current users of oral glucocorticoids ≤7.5 prednisolone-equivalent mg/day (OR 2.2 (95% CI 1.3 to 4.0) and >7.5 mg/day (OR 9.5 (95% CI 3.9 to 22.7)) (non-use as reference). ORs for moderate/high disease activity compared with remission were 1.6 (95% CI 0.8 to 3.3)/1.5 (95% CI 0.6 to 4.3). Risk was increased in patients with longstanding RA (>10 years vs ≤3 years, OR=2.4 (95% CI 1.1 to 5.3)). The NNH was 1172(95% CI 426 to 9374) for current use of bDMARDs and 110(95% CI 43 to 323) for glucocorticoids >7.5 mg/day. CONCLUSION We identified a dose-dependent increased risk of SAB in patients with RA currently using oral glucocorticoids. Daily use of >7.5 mg appeared to be a clinically relevant risk factor, whereas the absolute risk was low for bDMARDs. No clear impact of disease activity was found.
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Affiliation(s)
- Sabine Sparre Dieperink
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Louise Bruun Oestergaard
- Cardiovascular Research Center, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Thomas Benfield
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Andreas Petersen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bente Glintborg
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Center for Arthritis Research (COPECARE) and the DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Merete Lund Hetland
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Center for Arthritis Research (COPECARE) and the DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
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Dieperink SS, Glintborg B, Oestergaard LB, Nørgaard M, Benfield T, Mehnert F, Petersen A, Torp-Pedersen C, Hetland ML. Risk of Staphylococcus aureus bacteraemia in patients with rheumatoid arthritis and the effect of orthopaedic implants on the risk: a nationwide observational cohort study. Scand J Rheumatol 2022; 52:250-258. [PMID: 35442139 DOI: 10.1080/03009742.2022.2049057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE It remains disputed how much the risk of Staphylococcus aureus bacteraemia (SAB) is increased in patients with rheumatoid arthritis (RA), and the extent to which orthopaedic implants explain the risk. We assessed SAB incidence rates (IRs) and incidence rate ratios (IRRs), comparing RA patients with a general population cohort (GPC) and individuals with versus without orthopaedic implants. METHOD Danish residents aged ≥ 18 years without prior RA or SAB (=GPC) were followed up for RA and microbiologically verified SAB events (1996-2017). IRRs were calculated by age- and sex-stratified Poisson regression adjusted for age, comorbidities, calendar year, and socioeconomic status. RESULTS The GPC comprised 5 398 690 individuals. We identified 33 567 incident RA patients (=RA cohort) (median follow-up 7.3 years, IQR 3.6-12.3). We observed 25 023 SAB events (n = 224 in the RA cohort). IRs per 100 000 person-years were 81.0 (RA cohort) and 29.9 (GPC). IRs increased with age. Adjusted IRRs in 18-59-year-old RA patients were 2.6 (95% confidence interval 1.8-3.7) for women and 1.8 (1.1-3.1) for men, compared with same sex and age group GPC. IRRs declined with age. Compared with the GPC without implants, IRRs for RA patients with implants ranged from 1.9 (1.3-2.8) (women ≥ 70 years) to 5.3 (2.2-12.8) (18-59-year-old men). CONCLUSION In this nationwide registry-based cohort study RA was a risk factor for SAB, and orthopaedic implants further increased the risk. Clinicians should be aware of potential SAB in patients with RA and orthopaedic implants.
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Affiliation(s)
- S S Dieperink
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B Glintborg
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - L B Oestergaard
- Cardiovascular Research Center, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - M Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - T Benfield
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - F Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - A Petersen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - C Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - M L Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
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Rheumatoid arthritis-related interstitial lung disease (RA-ILD): a possible association between disease activity and prognosis. Clin Rheumatol 2022; 41:1741-1747. [PMID: 35112192 DOI: 10.1007/s10067-021-06040-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 11/26/2021] [Accepted: 12/16/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES We hypothesized that RA disease activity might be associated with the survival of RA-ILD patients. To evaluate this possibility, we analyzed data on disease activity during follow-up in an RA-ILD cohort and compared disease activity between surviving patients and those who died during follow-up. METHODS RA-ILD patients referred for medical evaluation and treatment at a single center, with CDAI scores during all follow up were included. We estimated the HR of the mean of the CDAI score during follow-up with survival. Also, we compared the survival function of patients with high disease activity (CDAI scores ≥ 22) during all follow-up with those with moderate and low disease activity. RESULTS Thirty-seven patients were included. The mean of the CDAI score during follow-up was higher in death patients (median 30.8 ± 18.5 Vs. 16.8 ± 11.3), and a single unit increase in the mean of the CDAI score was associated with non-survival, HR:1.07 (95% CI: 1.02 -1.12). Patients with high disease activity during all follow-up (CDAI scores > 22) had lower survival function in comparison with moderate and low disease activity (P = 0.042). CONCLUSION The results of the study suggest that higher RA disease activity is associated with a worse prognosis of RA-ILD patients. The hypothesis that high disease activity is associated with worse survival in RA-ILD patients must be evaluated in more extensive cohort studies and clinical trials. KEY POINTS • RA-ILD patients with high disease activity during follow-up had a worse prognosis than those with moderate or low disease activity. • The study results suggest the hypothesis that patients with RA-ILD must be treated with a treat to target strategy, with the aim of remission or low RA disease activity.
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Bykerk VP, Blauvelt A, Curtis JR, Gaujoux-Viala C, Kvien TK, Winthrop K, Tilt N, Popova C, Mariette X, Haraoui B. Associations Between Safety of Certolizumab Pegol, Disease Activity, and Patient Characteristics, Including Corticosteroid Use and Body Mass Index. ACR Open Rheumatol 2021; 3:501-511. [PMID: 34196507 PMCID: PMC8363853 DOI: 10.1002/acr2.11259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/17/2021] [Indexed: 12/19/2022] Open
Abstract
Objective To investigate the impact of baseline and time‐varying factors on the risk of serious adverse events (SAEs) in patients during long‐term certolizumab pegol (CZP) treatment. Methods Safety data were pooled across 34 CZP clinical trials in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), and plaque psoriasis (PSO). Cox proportional hazards modeling was used to investigate the association of baseline patient characteristics with risk of serious infectious events (SIEs), malignancies, and major adverse cardiac events (MACEs). Cox modeling for recurrent events assessed the impact of time‐varying body mass index (BMI), systemic corticosteroid (CS) use, and disease activity on SIE risk in RA and SAE risk in PSO. Results Data were pooled from 8747 CZP‐treated patients across indications. Cox models reported a 44% increase in SIE risk associated with a baseline BMI of 35 kg/m2 or more versus a baseline BMI of 18.5 kg/m2 to less than 25 kg/m2. Baseline systemic CS use, age of 65 years or more, and disease duration of 10 years or longer also increased SIE risk. Older age was the only identified risk factor for malignancies. The risk of MACEs increased 107% for BMI of 35 kg/m2 or more versus BMI of 18.5 kg/m2 to less than 25 kg/m2 and increased 51% for men versus women. Higher disease activity, older age, systemic CS use, BMI of 35 kg/m2 or more, and baseline comorbidities were SIE risk factors in RA. Age and systemic CS use were risk factors for SAEs in PSO. Conclusion Age, BMI, systemic CS use, and disease activity were identified as SIE risk factors in CZP‐treated patients. Risk of malignancies was greater in older patients, whereas obesity and male sex were MACE risk factors.
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Affiliation(s)
| | | | | | - Cécile Gaujoux-Viala
- Nîmes University Hospital, Nîmes, France, and Institut Desbrest d'Epidemiologie et de Sante Publique, IDESP UMR UA11 INSERM, University Montpellier, Montpellier, France
| | | | | | | | | | | | - Boulos Haraoui
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebéc, Canada
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Riley TR, George MD. Risk for infections with glucocorticoids and DMARDs in patients with rheumatoid arthritis. RMD Open 2021; 7:e001235. [PMID: 33597206 PMCID: PMC7893655 DOI: 10.1136/rmdopen-2020-001235] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 12/15/2022] Open
Abstract
Immunomodulatory therapy for rheumatoid arthritis (RA) carries risk for infectious complications. Understanding the risks of different therapeutic options is essential for making treatment decisions and appropriately monitoring patients. This review examines data on the risks for serious infections and other key infections of interest for the major classes of agents in use for RA: glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), biologics and Janus kinase (JAK) inhibitors. Conventional synthetic DMARDs have an excellent safety profile with recent data available supporting the relative safety of methotrexate. Tumour necrosis factor (TNF) inhibitors are associated with an increase in the risk of serious infections. Risk with other biological agents and with JAK inhibitors varies somewhat but overall appears similar to that of TNF inhibitors, with JAK inhibitors also associated with a greater risk of herpes zoster. Glucocorticoids have a dose-dependent effect on serious infection risk-at higher doses risk of infection with glucocorticoids is substantially greater than with other immunomodulatory therapies, and even low-dose therapy carries a risk of infection that appears to be similar to that of biological therapies.
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Affiliation(s)
- Thomas R Riley
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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George MD, Baker JF, Winthrop K, Hsu JY, Wu Q, Chen L, Xie F, Yun H, Curtis JR. Risk for Serious Infection With Low-Dose Glucocorticoids in Patients With Rheumatoid Arthritis : A Cohort Study. Ann Intern Med 2020; 173:870-878. [PMID: 32956604 PMCID: PMC8073808 DOI: 10.7326/m20-1594] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Low-dose glucocorticoids are frequently used for the management of rheumatoid arthritis (RA) and other chronic conditions, but the safety of long-term use remains uncertain. OBJECTIVE To quantify the risk for hospitalized infection with long-term use of low-dose glucocorticoids in patients with RA receiving stable disease-modifying antirheumatic drug (DMARD) therapy. DESIGN Retrospective cohort study. SETTING Medicare claims data and Optum's deidentified Clinformatics Data Mart database from 2006 to 2015. PATIENTS Adults with RA receiving a stable DMARD regimen for more than 6 months. MEASUREMENTS Associations between glucocorticoid dose (none, ≤5 mg/d, >5 to 10 mg/d, and >10 mg/d) and hospitalized infection were evaluated using inverse probability-weighted analyses, with 1-year cumulative incidence predicted from weighted models. RESULTS 247 297 observations were identified among 172 041 patients in Medicare and 58 279 observations among 44 118 patients in Optum. After 6 months of stable DMARD use, 47.1% of Medicare patients and 39.5% of Optum patients were receiving glucocorticoids. The 1-year cumulative incidence of hospitalized infection in Medicare patients not receiving glucocorticoids was 8.6% versus 11.0% (95% CI, 10.6% to 11.5%) for glucocorticoid dose of 5 mg or less per day, 14.4% (CI, 13.8% to 15.1%) for greater than 5 to 10 mg/d, and 17.7% (CI, 16.5% to 19.1%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). The 1-year cumulative incidence of hospitalized infection in Optum patients not receiving glucocorticoids was 4.0% versus 5.2% (CI, 4.7% to 5.8%) for glucocorticoid dose of 5 mg or less per day, 8.1% (CI, 7.0% to 9.3%) for greater than 5 to 10 mg/d, and 10.6% (CI, 8.5% to 13.2%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). LIMITATION Potential for residual confounding and misclassification of glucocorticoid dose. CONCLUSION In patients with RA receiving stable DMARD therapy, glucocorticoids were associated with a dose-dependent increase in the risk for serious infection, with small but significant risks even at doses of 5 mg or less per day. Clinicians should balance the benefits of low-dose glucocorticoids with this potential risk. PRIMARY FUNDING SOURCE National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Michael D George
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Joshua F Baker
- University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania (J.F.B.)
| | - Kevin Winthrop
- Oregon Health & Science University, Portland, Oregon (K.W.)
| | - Jesse Y Hsu
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Qufei Wu
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Fenglong Xie
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Huifeng Yun
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
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Chung HY, Tam LS, Chan SCW, Cheung JPY, Wong PY, Ciang CO, Ng HY, Law MY, Lai TL, Wong CH. Risk of community-acquired pneumonia requiring hospitalization in patients with spondyloarthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20962618. [PMID: 33133244 PMCID: PMC7576917 DOI: 10.1177/1759720x20962618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022] Open
Abstract
AIMS To compare the risk of community-acquired pneumonia (CAP) requiring hospitalization in spondyloarthritis (SpA) and non-specific back pain (NSBP), and to identify the risk factors for CAP in SpA. METHODS A total of 2984 patients with SpA from 11 rheumatology centers and 2526 patients with NSBP from orthopedic units were reviewed from the centralized electronic database in Hong Kong. Incidence of CAP requiring hospitalization and demographic data including age, gender, smoking and drinking status, use of sulfasalazine, individual biological-disease modifying anti-rheumatic drugs (DMARDs) used, micro-organisms, other immunosuppressants or immunosuppressive states, use of steroid for more than ½ year, and co-morbidities were identified. Risks of CAP in SpA were compared with those in NSBP using propensity score regression method. Multivariate Cox regression model was used to identify the risk factors in SpA. RESULTS CAP requiring hospitalization was found in 183 patients with SpA and 138 patients with NSBP. Increased risk for CAP was found in the following groups with SpA: all subgroups (hazard ratio (HR) 2.14, p < 0.001), without use of DMARDs (HR 2.64, p < 0.001), without psoriasis and not taking DMARDs (HR 2.38, p < 0.001). Infliximab (HR2.55, p = 0.04), smoking (HR 1.68, p = 0.003), comorbid psoriasis (HR 1.67, p = 0.003), and use of steroid for more than ½ year (HR 1.94, p = 0.003) were found to associate with CAP after adjustments for traditional risk factors. CONCLUSION Risk of CAP is increased in patients with SpA. Our data favor universal influenza and pneumococcal vaccination programs in the population. Rheumatologists should also advise smoking cessation and avoid long term steroid therapy.
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Affiliation(s)
- Ho Yin Chung
- Division of Rheumatology and Clinical Immunology, the University of Hong Kong, 102, Pokfulam Road, Hong Kong, China
| | - Lai Shan Tam
- Department of Medicine & Therapeutics, the Prince of Wales Hospital, the Chinese University of Hong Kong
| | - Shirley Chiu Wai Chan
- Division of Rheumatology and Clinical Immunology, the University of Hong Kong, Hong Kong
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, the University of Hong Kong, Hong Kong
| | - Pui Yan Wong
- Department of Rheumatology, Tseung Kwan O Hospital, Hong Kong
| | - Chu Oi Ciang
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Hoi Yan Ng
- Division of Rheumatology, Caritas Medical Center, Hong Kong
| | - Mei Yan Law
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Tin Lok Lai
- Department of Rheumatology, Tseung Kwan O Hospital, Hong Kong
| | - Ching Han Wong
- Department of Medicine & Therapeutics, the Prince of Wales Hospital, the Chinese University of Hong Kong
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12
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Rheumatoid arthritis patients on persistent moderate disease activity on biologics have adverse 5-year outcome compared to persistent low-remission status and represent a heterogeneous group. Arthritis Res Ther 2020; 22:226. [PMID: 32993800 PMCID: PMC7523072 DOI: 10.1186/s13075-020-02313-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background The long-term outcome of rheumatoid arthritis (RA) patients who in clinical practice exhibit persistent moderate disease activity (pMDA) despite treatment with biologics has not been adequately studied. Herein, we analyzed the 5-year outcome of the pMDA group and assessed for within-group heterogeneity. Methods We included longitudinally monitored RA patients from the Hellenic Registry of Biologic Therapies with persistent (cumulative time ≥ 50% of a 5-year period) moderate (pMDA, 3.2 < DAS28 ≤ 5.1) or remission/low (pRLDA, DAS28 ≤ 3.2) disease activity. The former was further classified into persistent lower-moderate (plMDA, DAS28 < 4.2) and higher-moderate (phMDA, DAS28 ≥ 4.2) subgroups. Five-year trajectories of functionality (HAQ) were the primary outcome in comparing pRLDA versus pMDA and assessing heterogeneity within the pMDA subgroups through multivariable mixed-effect regression. We further compared serious adverse events (SAEs) occurrence between the two groups. Results We identified 295 patients with pMDA and 90 patients with pRLDA, the former group comprising of plMDA (n = 133, 45%) and phMDA (n = 162, 55%). pMDA was associated with worse 5-year functionality trajectory than pRLDA (+ 0.27 HAQ units, CI 95% + 0.22 to + 0.33; p < 0.0001), while the phMDA subgroup had worse 5-year functionality than plMDA (+ 0.26 HAQ units, CI 95% 0.18 to 0.36; p < 0.0001). Importantly, higher persistent disease activity was associated with more SAEs [pRLDA: 0.2 ± 0.48 vs pMDA: 0.5 ± 0.96, p = 0.006; plMDA: 0.32 ± 0.6 vs phMDA: 0.64 ± 1.16, p = 0.038]. Male gender (p = 0.017), lower baseline DAS28 (p < 0.001), HAQ improvement > 0.22 (p = 0.029), and lower average DAS28 during the first trimester since treatment initiation (p = 0.001) independently predicted grouping into pRLDA. Conclusions In clinical practice, RA patients with pMDA while on bDMARDs have adverse long-term outcomes compared to lower disease activity status, while heterogeneity exists within the pMDA group in terms of 5-year functionality and SAEs. Targeted studies to better characterize pMDA subgroups are needed, in order to assist clinicians in tailoring treatments.
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13
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Performance of the RABBIT infection risk score in an Argentinian rheumatoid arthritis cohort. Clin Rheumatol 2020; 40:513-519. [PMID: 32986234 DOI: 10.1007/s10067-020-05425-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
Patients with rheumatic autoimmune diseases have a higher risk of infections compared with age-and sex-matched controls. In Latin America, there are no validated tools to assess the risk of serious infection. The objectives were to estimate the incidence of serious infections in a cohort of rheumatoid arthritis (RA) patients followed for 12 months and to validate the RABBIT risk score for serious infections. Patients with RA were included and followed for 12 months. Baseline sociodemographic data, comorbidities, RA characteristics, and vaccination status were recorded. The baseline RABBIT risk score was calculated. Serious infections were documented, describing site and time since enrollment. Six hundred five patients were included (13 centers). The incidence of serious infection was 5% (95% CI 3-7). The most frequent sites were respiratory and urinary (90%). Performance of RABBIT risk score: patients with no infection during follow-up had a median score of 1.2 (IQR 0.8-2.1) and patients with infection 5.1 (IQR 2.15-12.6) p 0.00001. ROC curve analysis: AUC 0.86 (95% CI 0.8-0.94), best cut-off 2.85 (sensibility 75%, specificity 85%). The incidence of serious infections was 5% during the follow-up. The RABBIT score performed excellently in our patients. Key Points • The RABBIT risk score for serious infections showed an excellent performance in a population different (Latin America) from the original one included in the German registry. • This may assist rheumatologists in selecting drugs for patients according to the individual risk of infection, in a fast and simple way.
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14
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George MD, Baker JF, Wallace B, Chen L, Wu Q, Xie F, Yun H, Curtis JR. Variability in Glucocorticoid Prescribing for Rheumatoid Arthritis and the Influence of Provider Preference on Long-Term Use of Glucocorticoids. Arthritis Care Res (Hoboken) 2020; 73:1597-1605. [PMID: 32702188 DOI: 10.1002/acr.24382] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Glucocorticoids are recommended for short-term use in rheumatoid arthritis (RA), but many patients continue receiving long-term therapy. We evaluated the variability in glucocorticoid prescribing across rheumatologists to inform interventions to limit long-term glucocorticoid use to the lowest dose necessary. METHODS Two cohorts were created using Medicare data from 2006 to 2015. Using cohort 1 (RA patients receiving disease-modifying antirheumatic drugs [DMARDs]), we calculated each rheumatologist's "provider preference" for glucocorticoids (frequency of use compared to other providers), using the ratio of observed to expected number of patients receiving glucocorticoids to account for case mix. In cohort 2 (RA patients receiving stable DMARD therapy), we evaluated whether provider preference for glucocorticoids could independently predict use of ≥5 mg/day of glucocorticoids 6-9 months after initiation of DMARD therapy. RESULTS Using cohort 1 (1,272,644 yearly observations; 385,597 patients), we calculated provider preference among 6,875 rheumatologists (28,936 yearly observations). Provider preference was highly variable, with physicians at the lowest and upper quartiles prescribing glucocorticoids 33% less often to 31% more often (25th and 75th percentiles, respectively) than expected. In cohort 2 (155,539 patients receiving stable DMARD therapy), provider preference was strongly associated with glucocorticoid use ≥5 mg/day at 6-9 months, with a predicted probability of use of 22% (95% confidence interval [95% CI] 21.7-22.7) versus 11% (95% CI 10.2-10.9) for a patient seeing a provider in the highest versus lowest quintile of preference. CONCLUSION Glucocorticoid prescribing for RA varies greatly among rheumatologists, and provider preference is one of the strongest predictors of a patient's long-term glucocorticoid use. These findings raise quality of care concerns and highlight the need for stronger evidence to guide RA treatment.
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Affiliation(s)
| | - Joshua F Baker
- University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | | | | | - Qufei Wu
- University of Pennsylvania, Philadelphia
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15
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Harrold LR, Griffith J, Zueger P, Litman HJ, Gershenson B, Islam SS, Barr CJ, Guo D, Fay J, Greenberg JD. Longterm, Real-world Safety of Adalimumab in Rheumatoid Arthritis: Analysis of a Prospective US-based Registry. J Rheumatol 2020; 47:959-967. [PMID: 31371657 DOI: 10.3899/jrheum.190260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess longterm safety in a US cohort of patients with rheumatoid arthritis (RA) treated with adalimumab (ADA) in real-world clinical care settings. METHODS This observational study analyzed the longterm incidence of safety outcomes among patients with RA initiating ADA, using data from the Corrona RA registry. Patients were adults (≥ 18 yrs) who initiated ADA treatment between January 2008 and June 2017, and who had at least 1 followup visit. RESULTS In total, 2798 ADA initiators were available for analysis, with a mean age of 54.5 years, 77% female, and mean disease duration of 8.3 years. Nearly half (48%) were biologic-naive, and 9% were using prednisone ≥ 10 mg at ADA initiation. The incidence rates per 100 person-years for serious infections, congestive heart failure requiring hospitalization, malignancy (excluding nonmelanoma skin cancer), and all-cause mortality were 1.86, 0.15, 0.64, and 0.33, respectively. The incidence of serious infections was higher in the first year of therapy (3.44, 95% CI 2.45-4.84) than in subsequent years, while other measured adverse effects did not vary substantially by duration of exposure. The median time to ADA discontinuation was 11 months, while the median time to first serious infection among those experiencing a serious infection event was 12 months. CONCLUSION Analysis of longterm data from this prospective real-world registry demonstrated a safety profile consistent with previous studies in patients with RA. This analysis did not identify any new safety signals associated with ADA treatment and provides guidance for physicians prescribing ADA for extended periods.
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Affiliation(s)
- Leslie R Harrold
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA.
| | - Jenny Griffith
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Patrick Zueger
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Heather J Litman
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Bernice Gershenson
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Syed S Islam
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Christine J Barr
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Dianlin Guo
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Jonathan Fay
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
| | - Jeffrey D Greenberg
- From the University of Massachusetts Medical School, Worcester; Corrona LLC, Waltham, Massachusetts; AbbVie, North Chicago, Illinois; New York University School of Medicine, New York, New York, USA
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Furer V, Zisman D, Kaufman I, Arad U, Berman M, Sarbagil-Maman H, Elias M, Hadad A, Paran D, Drori Y, Friedman N, Mandelboim M, Elkayam O. Immunogenicity and safety of vaccination against seasonal influenza vaccine in patients with psoriatic arthritis treated with secukinumab. Vaccine 2020; 38:847-851. [DOI: 10.1016/j.vaccine.2019.10.081] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 10/21/2019] [Accepted: 10/27/2019] [Indexed: 01/03/2023]
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17
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Dieperink SS, Glintborg B, Oestergaard LB, Nørgaard M, Benfield T, Mehnert F, Petersen A, Hetland ML. Risk factors for Staphylococcus aureus bacteremia in patients with rheumatoid arthritis and incidence compared with the general population: protocol for a Danish nationwide observational cohort study. BMJ Open 2019; 9:e030999. [PMID: 31481566 PMCID: PMC6731901 DOI: 10.1136/bmjopen-2019-030999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Staphylococcus aureus bacteremia (SAB) is an invasive infection with high mortality and morbidity. Rheumatoid arthritis (RA) is associated with increased risk of infections due to the disease per se and the use of antirheumatic treatments. Few minor studies have previously investigated risk of SAB in patients with RA and indicated increased risk compared with the general population. This nationwide observational study aims to investigate incidence of and risk factors for SAB in adult patients with RA compared with the general population. The effect of disease characteristics (eg, joint erosions, disease duration and activity), different antirheumatic treatments and smoking on SAB risk will be evaluated. METHODS AND ANALYSIS All adults (>18 years of age) alive and living in Denmark in 1996-2017 will be identified in The Danish Civil Registration System. Incident patients with RA are identified in the Danish National Patient Registry (DNPR) and the nationwide rheumatology registry, DANBIO, in which information on, for example, antirheumatic treatments, disease characteristics and smoking is collected prospectively in routine care. Information on comorbidities, invasive procedures and prescribed drugs are identified in the DNPR and in The Register of Medicinal Product Statistics. Socioeconomic status is evaluated in national registers on income and education. Incident cases of first-time SAB are identified in The Danish National SAB Database. All registers are linked on an individual level by unique civil registration numbers. Incidence rates and incidence rate ratios will be analysed using Poisson regression models and the impact of possible risk factors will be evaluated. ETHICS AND DISSEMINATION All data will be handled in accordance with the General Data Protection Regulation (EU) 2016/679. No ethical approval is necessary in Denmark when handling registry data only. The results will be presented in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology initiative in international peer-reviewed journals and at medical conferences. TRIAL REGISTRATION NUMBER NCT03908086.
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Affiliation(s)
- Sabine Sparre Dieperink
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Bente Glintborg
- The DANBIO registry and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | | | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Benfield
- Department of Clinical Medicine, University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Infectious Diseases, Hvidovre Hospital, Hvidovre, Denmark
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Andreas Petersen
- Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Merete Lund Hetland
- The DANBIO registry and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
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18
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Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, Breedveld FC, D'Amelio R, Dougados M, Kapetanovic MC, van Laar JM, de Thurah A, Landewé RBM, Molto A, Müller-Ladner U, Schreiber K, Smolar L, Walker J, Warnatz K, Wulffraat NM, Elkayam O. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2019; 79:39-52. [DOI: 10.1136/annrheumdis-2019-215882] [Citation(s) in RCA: 357] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 12/16/2022]
Abstract
To update the European League Against Rheumatism (EULAR) recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) published in 2011. Four systematic literature reviews were performed regarding the incidence/prevalence of vaccine-preventable infections among patients with AIIRD; efficacy, immunogenicity and safety of vaccines; effect of anti-rheumatic drugs on the response to vaccines; effect of vaccination of household of AIIRDs patients. Subsequently, recommendations were formulated based on the evidence and expert opinion. The updated recommendations comprise six overarching principles and nine recommendations. The former address the need for an annual vaccination status assessment, shared decision-making and timing of vaccination, favouring vaccination during quiescent disease, preferably prior to the initiation of immunosuppression. Non-live vaccines can be safely provided to AIIRD patients regardless of underlying therapy, whereas live-attenuated vaccines may be considered with caution. Influenza and pneumococcal vaccination should be strongly considered for the majority of patients with AIIRD. Tetanus toxoid and human papilloma virus vaccination should be provided to AIIRD patients as recommended for the general population. Hepatitis A, hepatitis B and herpes zoster vaccination should be administered to AIIRD patients at risk. Immunocompetent household members of patients with AIIRD should receive vaccines according to national guidelines, except for the oral poliomyelitis vaccine. Live-attenuated vaccines should be avoided during the first 6 months of life in newborns of mothers treated with biologics during the second half of pregnancy. These 2019 EULAR recommendations provide an up-to-date guidance on the management of vaccinations in patients with AIIRD.
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Ribeiro R, Batista F, Seguro Paula F, Delgado Alves J. Changes in Iron Metabolism Induced by Anti-Interleukin-6 Receptor Monoclonal Antibody are Associated with an Increased Risk of Infection. Pharmaceuticals (Basel) 2019; 12:ph12030100. [PMID: 31261772 PMCID: PMC6789697 DOI: 10.3390/ph12030100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 06/20/2019] [Accepted: 06/25/2019] [Indexed: 01/13/2023] Open
Abstract
(1) Background: Treatment of patients with rheumatoid arthritis (RA) with an anti-IL-6 receptor (anti-IL-6R) monoclonal antibody (tocilizumab) has been found to influence iron metabolism. The objective of the present study was to ascertain whether changes in iron metabolism induced by anti-IL-6R biologic therapy were independently associated with an increased infection risk. (2) Methods: A prospective longitudinal study of patients with RA treated with tocilizumab was conducted. RA patients treated with an antitumor necrosis factor α monoclonal antibody were also included as a control group. The primary outcome was occurrence of infection during the first 24 months of biologic therapy. (3) Results: A total of 15 patients were included, with a mean age of 51.0 ± 4,1 and 73.3% (n = 11) female. A multivariate survival regression model, adjusted for confounding factors, was fitted for each of the iron metabolism variables. Hazard ratios for being above the median of each parameter was considered. Transferrin saturation above the median value (>32.1%) was associated with a higher infection risk (HR 4.3; 95%CI 1.0–19.69; p = 0.05). Similarly, although non-significantly, higher serum iron was strongly associated with infection occurrence. (4) Conclusions: This study identified a probable association between infection risk and higher serum iron and transferrin saturation in patients with RA on anti-IL-6R biologic therapy. We suggest that both these parameters should be considered relevant contributing factors for infection occurrence in patients on anti-IL-6R therapy.
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Affiliation(s)
- Renata Ribeiro
- Immune Response and Vascular Disease-CEDOC, Chronic Diseases Research Center, NOVA Medical School, 1150-082 Lisbon, Portugal.
- Systemic Immune-mediated Diseases Unit (UDIMS), Department of Medicine IV, Hospital Professor Doutor Fernando Fonseca, 2720-276 Amadora, Portugal.
| | - Frederico Batista
- Immune Response and Vascular Disease-CEDOC, Chronic Diseases Research Center, NOVA Medical School, 1150-082 Lisbon, Portugal
- Systemic Immune-mediated Diseases Unit (UDIMS), Department of Medicine IV, Hospital Professor Doutor Fernando Fonseca, 2720-276 Amadora, Portugal
| | - Filipe Seguro Paula
- Immune Response and Vascular Disease-CEDOC, Chronic Diseases Research Center, NOVA Medical School, 1150-082 Lisbon, Portugal
- Systemic Immune-mediated Diseases Unit (UDIMS), Department of Medicine IV, Hospital Professor Doutor Fernando Fonseca, 2720-276 Amadora, Portugal
| | - José Delgado Alves
- Immune Response and Vascular Disease-CEDOC, Chronic Diseases Research Center, NOVA Medical School, 1150-082 Lisbon, Portugal
- Systemic Immune-mediated Diseases Unit (UDIMS), Department of Medicine IV, Hospital Professor Doutor Fernando Fonseca, 2720-276 Amadora, Portugal
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20
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Mehta B, Pedro S, Ozen G, Kalil A, Wolfe F, Mikuls T, Michaud K. Serious infection risk in rheumatoid arthritis compared with non-inflammatory rheumatic and musculoskeletal diseases: a US national cohort study. RMD Open 2019; 5:e000935. [PMID: 31245055 PMCID: PMC6560658 DOI: 10.1136/rmdopen-2019-000935] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/23/2019] [Accepted: 05/15/2019] [Indexed: 11/04/2022] Open
Abstract
Objectives To identify serious infection (SI) risk by aetiology and site in patients with rheumatoid arthritis (RA) compared with those with non-inflammatory rheumatic and musculoskeletal diseases (NIRMD). Methods Patients participating in FORWARD from 2001 to 2016 were assessed for SIs; defined by infections requiring hospitalisation, intravenous antibiotics or followed by death. SIs were categorised by aetiology and site. SI risk was assessed through Cox proportional hazards models. Best models were selected using machine learning Least Absolute Shrinkage and Selection Operator (LASSO) methodology. Results Among 20 361 patients with RA and 6176 patients with NIRMD, 1600 and 276 first SIs were identified, respectively. Incidence of SIs was higher in RA compared with NIRMD (IRR = 1.5; 95% CI 1.2 to 1.5). The risk persisted after adjusting using the LASSO model (HR 1.7; 95% CI 1.5 to 1.8), but attenuated when additionally adjusted for glucocorticoid use (HR 1.3; 95% CI 1.2 to 1.5). SI risk was significantly higher in RA versus NIRMD for bacterial infections as well as for respiratory, skin, bone, joint, bloodstream infections and sepsis irrespective of glucocorticoid use. Compared with NIRMD, SI risk was significantly increased in patients with RA who were in moderate and high disease activity but was similar to those in low disease activity/remission (p trend < 0.001). Conclusions The risk of all SIs, particularly bacterial, respiratory, bloodstream, sepsis, skin, bone and joint infections are significantly increased in patients with RA compared with patients with NIRMD. This infection risk appears to be greatest in those with higher RA disease activity.
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Affiliation(s)
- Bella Mehta
- Department of Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Sofia Pedro
- Forward, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA
| | - Gulsen Ozen
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andre Kalil
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Frederick Wolfe
- Forward, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA
| | - Ted Mikuls
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kaleb Michaud
- Forward, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA.,Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Kasai S, Sakai R, Koike R, Kohsaka H, Miyasaka N, Harigai M. Higher risk of hospitalized infection, cardiovascular disease, and fracture in patients with rheumatoid arthritis determined using the Japanese health insurance database. Mod Rheumatol 2018; 29:788-794. [DOI: 10.1080/14397595.2018.1519889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Shoko Kasai
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryoko Sakai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Department of Rheumatology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Ryuji Koike
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Masayoshi Harigai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Department of Rheumatology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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Concomitant use of intravenous methylprednisolone to increase retention rate of abatacept in rheumatoid arthritis. Rheumatol Int 2018; 38:1825-1831. [DOI: 10.1007/s00296-018-4115-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 07/24/2018] [Indexed: 11/27/2022]
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23
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JACOBS JOHANNESW, PEREIRA DA SILVA JOSÉA. Glucocorticoids Are Always Under Suspicion — Is the Perception of Their Risks Unbiased? J Rheumatol 2018; 45:293-296. [DOI: 10.3899/jrheum.171331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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24
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Goodman SM, Bass AR. Perioperative medical management for patients with RA, SPA, and SLE undergoing total hip and total knee replacement: a narrative review. BMC Rheumatol 2018; 2:2. [PMID: 30886953 PMCID: PMC6390575 DOI: 10.1186/s41927-018-0008-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022] Open
Abstract
Total hip (THA) and total knee arthroplasty (TKA) are widely used, successful procedures for symptomatic end stage arthritis of the hips or knees, but patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and spondyloarthritis (SPA) including ankylosing spondylitis (AS) and psoriatic arthritis (PSA) are at higher risk for adverse events after surgery. Utilization rates of THA and TKA remain high for patients with RA, and rates of arthroplasty have increased for patients with SLE and SPA. However, complications such as infection are increased for patients with SLE, RA, and SPA, most of whom are receiving potent immunosuppressant medications and glucocorticoids at the time of surgery. Patients with SLE and AS are also at increased risk for perioperative cardiac and venous thromboembolism (VTE), while RA patients do not have an increase in perioperative cardiac or VTE risk, despite an overall increase in VTE and cardiac disease. This narrative review will discuss the areas of heightened risk for patients with RA, SLE, and SPA, and the perioperative management strategies currently used to minimize the risks.
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Affiliation(s)
- Susan M. Goodman
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
| | - Anne R. Bass
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
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25
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Harrold LR, Litman HJ, Saunders KC, Dandreo KJ, Gershenson B, Greenberg JD, Low R, Stark J, Suruki R, Jaganathan S, Kremer JM, Yassine M. One-year risk of serious infection in patients treated with certolizumab pegol as compared with other TNF inhibitors in a real-world setting: data from a national U.S. rheumatoid arthritis registry. Arthritis Res Ther 2018; 20:2. [PMID: 29329557 PMCID: PMC5795286 DOI: 10.1186/s13075-017-1496-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 12/08/2017] [Indexed: 02/05/2023] Open
Abstract
Background Registry studies provide a valuable source of comparative safety data for tumor necrosis factor inhibitors (TNFi) used in rheumatoid arthritis (RA), but they are subject to channeling bias. Comparing safety outcomes without accounting for channeling bias can lead to inaccurate comparisons between TNFi prescribed at different stages of the disease. In the present study, we examined the incidence of serious infection and other adverse events during certolizumab pegol (CZP) use vs other TNFi in a U.S. RA cohort before and after using a methodological approach to minimize channeling bias. Methods Patients with RA enrolled in the Corrona registry, aged ≥ 18 years, initiating CZP or other TNFi (etanercept, adalimumab, golimumab, or infliximab) after May 1, 2009 (n = 6215 initiations), were followed for ≤ 12 months. A propensity score (PS) model was used to control for baseline characteristics associated with the probability of receiving CZP vs other TNFi. Incidence rate ratios (IRRs) of serious infectious events (SIEs), malignancies, and cardiovascular events (CVEs) in the CZP group vs other TNFi group were calculated with 95% CIs, before and after PS matching. Results Patients were more likely to initiate CZP later in the course of therapy than those initiating other TNFi. CZP initiators (n = 975) were older and had longer disease duration, more active disease, and greater disability than other TNFi initiators (n = 5240). After PS matching, there were no clinically important differences between CZP (n = 952) and other TNFi (n = 952). Before PS matching, CZP was associated with a greater incidence of SIEs (IRR 1.53 [95% CI 1.13, 2.05]). The risk of SIEs was not different between groups after PS matching (IRR 1.26 [95% CI 0.84, 1.90]). The 95% CI of the IRRs for malignancies or CVEs included unity, regardless of PS matching, suggesting no difference in risk between CZP and other TNFi. Conclusions After using PS matching to minimize channeling bias and compare patients with a similar likelihood of receiving CZP or other TNFi, the 1-year risk of SIEs, malignancies, and CVEs was not distinguishable between the two groups. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1496-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leslie R Harrold
- University of Massachusetts Medical School, Worcester, MA, USA. .,Pharmacoepidemiology and Outcomes Research, Corrona, 352 Turnpike Road, Suite 325, Southborough, MA, 01772, USA.
| | - Heather J Litman
- Pharmacoepidemiology and Outcomes Research, Corrona, 352 Turnpike Road, Suite 325, Southborough, MA, 01772, USA
| | - Katherine C Saunders
- Pharmacoepidemiology and Outcomes Research, Corrona, 352 Turnpike Road, Suite 325, Southborough, MA, 01772, USA
| | - Kimberly J Dandreo
- Pharmacoepidemiology and Outcomes Research, Corrona, 352 Turnpike Road, Suite 325, Southborough, MA, 01772, USA
| | - Bernice Gershenson
- University of Massachusetts Medical School, Worcester, MA, USA.,Pharmacoepidemiology and Outcomes Research, Corrona, 352 Turnpike Road, Suite 325, Southborough, MA, 01772, USA
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26
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Yamanaka H, Askling J, Berglind N, Franzen S, Frisell T, Garwood C, Greenberg JD, Ho M, Holmqvist M, Novelli Horne L, Inoue E, Michaud K, Pappas DA, Reed G, Symmons D, Tanaka E, Tran TN, Verstappen SMM, Wesby-van Swaay E, Nyberg F. Infection rates in patients from five rheumatoid arthritis (RA) registries: contextualising an RA clinical trial programme. RMD Open 2017; 3:e000498. [PMID: 29081988 PMCID: PMC5652583 DOI: 10.1136/rmdopen-2017-000498] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 09/07/2017] [Accepted: 09/21/2017] [Indexed: 11/29/2022] Open
Abstract
Objective Patients with rheumatoid arthritis (RA) have an increased risk of serious infections. Comparing infection rates across RA populations is complicated by differences in background infection risk, population composition and study methodology. We measured infection rates from five RA registries globally, with the aim to contextualise infection rates from an RA clinical trials population. Methods We used data from Consortium of Rheumatology Research of North America (CORRONA) (USA), Swedish Rheumatology Quality of Care Register (Sweden), Norfolk Arthritis Register (UK), CORRONA International (multiple countries) and Institute of Rheumatology Rheumatoid Arthritis (Japan) and an RA clinical trial programme (fostamatinib). Within each registry, we analysed a main cohort of all patients with RA from January 2000 to last available data. Infection definitions were harmonised across registries. Sensitivity analyses to address potential confounding explored subcohorts defined by disease activity, treatment change and/or prior comorbidities and restriction by calendar time or follow-up. Rates of infections were estimated and standardised to the trial population for age/sex and, in one sensitivity analysis also, for Health Assessment Questionnaire (HAQ) score. Results Overall, age/sex-standardised rates of hospitalised infection were quite consistent across registries (range 1.14–1.62 per 100 patient-years). Higher and more consistent rates across registries and with the trial programme overall were seen when adding standardisation for HAQ score (registry range 1.86–2.18, trials rate 2.92) or restricting to a treatment initiation subcohort followed for 18 months (registry range 0.99–2.84, trials rate 2.74). Conclusion This prospective, coordinated analysis of RA registries provided incidence rate estimates for infection events to contextualise infection rates from an RA clinical trial programme and demonstrated relative comparability of hospitalised infection rates across registries.
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Affiliation(s)
- Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Johan Askling
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Berglind
- Biometric & Information Sciences, Global Medicines Development, AstraZeneca R&D, Mölndal, Sweden
| | - Stefan Franzen
- Biometric & Information Sciences, Global Medicines Development, AstraZeneca R&D, Mölndal, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Christopher Garwood
- Arthritis Research UK Centre for Epidemiology, The University of Manchester, Manchester, UK
| | - Jeffrey D Greenberg
- NYU School of Medicine, New York City, New York, USA.,Corrona LLC, Southborough, Massachusetts, USA
| | - Meilien Ho
- Clinical, Global Medicines Development, AstraZeneca R&D, Alderley Park, Macclesfield, UK
| | - Marie Holmqvist
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Laura Novelli Horne
- Medical Evidence & Observational Research Centre, Global Medical Affairs, AstraZeneca, Wilmington, Delaware, USA
| | - Eisuke Inoue
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, Nebraska, USA.,National Data Bank for Rheumatic Diseases, Wichita, Kansas, USA
| | - Dimitrios A Pappas
- Corrona LLC, Southborough, Massachusetts, USA.,The College of Physicians and Surgeons, Columbia University, New York City, New York, USA
| | - George Reed
- Corrona LLC, Southborough, Massachusetts, USA.,University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Deborah Symmons
- Arthritis Research UK Centre for Epidemiology, The University of Manchester, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Eiichi Tanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Epidemiology, The University of Manchester, Manchester, UK
| | | | - Fredrik Nyberg
- Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Medical Evidence & Observational Research Centre, Global Medical Affairs, AstraZeneca R&D, Mölndal, Sweden
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27
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Morel J, Constantin A, Baron G, Dernis E, Flipo RM, Rist S, Combe B, Gottenberg JE, Schaeverbeke T, Soubrier M, Vittecoq O, Dougados M, Saraux A, Mariette X, Ravaud P, Sibilia J. Risk factors of serious infections in patients with rheumatoid arthritis treated with tocilizumab in the French Registry REGATE. Rheumatology (Oxford) 2017; 56:1746-1754. [DOI: 10.1093/rheumatology/kex238] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Indexed: 12/13/2022] Open
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28
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Mori S, Yoshitama T, Hidaka T, Sakai F, Hasegawa M, Hashiba Y, Suematsu E, Tatsukawa H, Mizokami A, Yoshizawa S, Hirakata N, Ueki Y. Comparative risk of hospitalized infection between biological agents in rheumatoid arthritis patients: A multicenter retrospective cohort study in Japan. PLoS One 2017; 12:e0179179. [PMID: 28594905 PMCID: PMC5464634 DOI: 10.1371/journal.pone.0179179] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/24/2017] [Indexed: 12/20/2022] Open
Abstract
Objective Knowing the risk of hospitalized infection associated with individual biological agents is an important factor in selecting the best treatment option for patients with rheumatoid arthritis (RA). This study examined the comparative risk of hospitalized infection between biological agents in a routine care setting. Methods We used data for all RA patients who had first begun biological therapy at rheumatology divisions of participating community hospitals in Japan between January 2009 and December 2014. New treatment episodes with etanercept, infliximab, adalimumab, abatacept, or tocilizumab were included. Patients were allowed to contribute multiple treatment episodes with different biological agents. Incidence rates (IRs) of hospitalized infection during the first year of follow-up were examined. Cox regression analysis was used to calculate hazard ratios (HRs) for overall hospitalized infection and for pulmonary hospitalized infection, adjusting for possible confounders. Results A total of 1596 new treatment episodes were identified. The incidence of overall hospitalized infection during the first year was 86 with 1239 person-years (PYs), yielding a crude IR of 6.9 per 100 PYs (95% confidence interval [CI], 5.6–8.6). After correction for confounders, no significant difference in risk of hospitalized infection was observed between treatment groups: adjusted HRs (95% CI) were 1.54 (0.78–3.04) for infliximab, 1.72 (0.88–3.34) for adalimumab, 1.11 (0.55–2.21) for abatacept, and 1.02 (0.55–1.87) for tocilizumab compared with etanercept. Patient-specific factors such as age, RA functional class, body mass index (BMI), prednisolone use, and chronic lung disease contributed more to the risk of hospitalized infection than specific biological agents. The incidence of pulmonary hospitalized infection was 50 and a crude IR of 4.0 per 100 PYs (95% CI, 3.1–5.3). After adjustment for confounders, adalimumab had a significantly higher HR for pulmonary hospitalized infection compared with tocilizumab: an adjusted HR (95% CI) was 4.43 (1.72–11.37) for adalimumab. BMI, prednisolone use, diabetes mellitus, and chronic lung disease were also significant factors associated with the risk of pulmonary hospitalized infection. Conclusions The magnitude of the risk of overall hospitalized infection was not determined by the type of biological agents, and patient-specific risk factors had more impact on the risk of hospitalized infection. For pulmonary hospitalized infections, the use of adalimumab was significantly associated with a greater risk of this complication than tocilizumab use.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization (NHO) Kumamoto Saishunsou National Hospital, Kohshi, Kumamoto, Japan
- * E-mail:
| | - Tamami Yoshitama
- Yoshitama Clinic for Rheumatic Diseases, Kirishima, Kagoshima, Japan
| | - Toshihiko Hidaka
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Mizue Hasegawa
- Department of Respiratory Medicine, Tokyo Women’s Medical University Yachiyo Medical Center, Yachiyo, Chiba
| | - Yayoi Hashiba
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - Eiichi Suematsu
- Department of Internal Medicine and Rheumatology, Clinical Research Institute, NHO Kyushu Medical Center, Fukuoka, Japan
| | | | - Akinari Mizokami
- Department of Rheumatology, Japan Community Healthcare Organization (JCHO) Isahaya General Hospital, Isahaya, Nagasaki, Japan
| | - Shigeru Yoshizawa
- Department of Rheumatology, NHO Fukuoka National Hospital, Fukuoka, Japan
| | - Naoyuki Hirakata
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
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29
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Barrett O, Abramovich E, Dreiher J, Novack V, Abu-Shakra M. Short- and long-term mortality due to sepsis in patients with rheumatoid arthritis. Rheumatol Int 2017; 37:1021-1026. [PMID: 28286904 DOI: 10.1007/s00296-017-3694-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/02/2017] [Indexed: 11/28/2022]
Abstract
Severe infections and sepsis are common among patients with rheumatoid arthritis (RA) and are associated with increased morbidity and mortality risks. To determine whether RA is an independent risk factor for short- and long-term mortality in patients admitted to an Intensive Care Unit (ICU) with sepsis. A retrospective age- and sex-matched cohort study, based on data of the SEPSIS-ISR Registry, an ongoing study that collects data on all patients admitted with the diagnosis of sepsis to the ICUs of 7 large hospitals during the period 2002-2012. The primary outcomes of the study were the 30-day and 3-years survival rates. A total of 124 RA patients and 248 non-RA patients (mean age 71 years; 64.5% female) were included. Primary site of infection as well as pathogens distributions were similar between the two groups. Severe sepsis and septic shock were diagnosed in 92% vs. 84% (p = 0.03) and 50% versus 39% (p = 0.06) of the RA patients and non-RA, respectively. 30-day survival rates were similar between groups, whereas 3-year survival rate in 30-day survivors was significantly lower among RA patients (34.9%) compared to non-RA patients (55.7%) (p = 0.01). In multivariate Cox proportional hazards regression, RA was found to be a significant independent risk factor for 3-year mortality in 30-day survivors (hazard ratio 1.63 95% confidence interval 1.03-1.63; p = 0.04). RA is an independent risk factor for 3-year mortality, but not short-term mortality following ICU admission with sepsis.
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Affiliation(s)
- Orit Barrett
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ella Abramovich
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | | | - Victor Novack
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Mahmoud Abu-Shakra
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. .,Rheumatic Diseases Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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30
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Osterman MT, Sandborn WJ, Colombel JF, Peyrin-Biroulet L, Robinson AM, Zhou Q, Lewis JD. Crohn's Disease Activity and Concomitant Immunosuppressants Affect the Risk of Serious and Opportunistic Infections in Patients Treated With Adalimumab. Am J Gastroenterol 2016; 111:1806-1815. [PMID: 27670599 DOI: 10.1038/ajg.2016.433] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 08/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Anti-tumor necrosis factor (TNF) drugs are commonly used to treat moderate-to-severe Crohn's disease (CD). Both the activity of CD and the concomitant immunosuppressants (corticosteroids and immunomodulators) used with anti-TNF drugs could increase the risk of infection. We determined the relative risk of serious and opportunistic infections associated with increasing disease activity and concomitant immunomodulators and corticosteroids in patients with CD treated with adalimumab. METHODS This pooled analysis identified incident treatment-emergent serious and opportunistic infections among patients with CD in clinical trials of adalimumab. Disease activity was assessed with the Crohn's Disease Activity Index (CDAI). RESULTS The analysis included 2,266 patients treated with adalimumab with median age 35 years. Higher disease activity was associated with significantly increased risks of both serious and opportunistic infections at 1 year, with each 100-point increase in CDAI associated with a >30% increased risk of each type of infection. Concomitant use of immunomodulators was associated with a significant >3-fold decreased risk of serious infection (hazard ratio (HR) 0.29 (0.08-0.98), P=0.045) by 1 year. Concomitant use of corticosteroids was associated with a significantly increased risk of serious infection by day 120 (HR 2.40 (1.33-4.35), P=0.004). Concomitant use of either category of immmunosuppressant was associated with numerically higher rates of opportunistic infection, 40% of which were due to herpes zoster, compared with adalimumab monotherapy. CONCLUSIONS Higher disease activity in CD is associated with significantly increased risks of both serious and opportunistic infections. In addition to corticosteroid-sparing strategies, consideration should be given to expanding herpes zoster vaccination guidelines to include younger patients.
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Affiliation(s)
- Mark T Osterman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | | | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | | | - Qian Zhou
- AbbVie Inc., North Chicago, Illinois, USA
| | - James D Lewis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Murota A, Kaneko Y, Yamaoka K, Takeuchi T. Safety of Biologic Agents in Elderly Patients with Rheumatoid Arthritis. J Rheumatol 2016; 43:1984-1988. [PMID: 27585685 DOI: 10.3899/jrheum.160012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To clarify the safety of biologics in elderly patients with rheumatoid arthritis. METHODS Biologics were analyzed for safety in relation to age in 309 patients. RESULTS Young (< 65 yrs old, n = 174), elderly (65-74 yrs old, n = 86), and older elderly patients (≥ 75 yrs old, n = 49) were enrolled. Although the incidence of adverse events causing treatment withdrawal was significantly higher in elderly and old elderly compared with young patients, no difference was found between elderly and older elderly patients. Pulmonary complications were independent risk factors. CONCLUSION Old patients require special attention, although the safety of biologics in those ≥ 75 years old and 65-74 was comparable.
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Affiliation(s)
- Atsuko Murota
- From the Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,A. Murota, MD, PhD, Postdoctoral Fellow, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; Y. Kaneko, MD, PhD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; K. Yamaoka, MD, PhD, Associate Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; T. Takeuchi, MD, PhD, Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine
| | - Yuko Kaneko
- From the Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,A. Murota, MD, PhD, Postdoctoral Fellow, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; Y. Kaneko, MD, PhD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; K. Yamaoka, MD, PhD, Associate Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; T. Takeuchi, MD, PhD, Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine
| | - Kunihiro Yamaoka
- From the Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,A. Murota, MD, PhD, Postdoctoral Fellow, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; Y. Kaneko, MD, PhD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; K. Yamaoka, MD, PhD, Associate Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; T. Takeuchi, MD, PhD, Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine
| | - Tsutomu Takeuchi
- From the Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan. .,A. Murota, MD, PhD, Postdoctoral Fellow, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; Y. Kaneko, MD, PhD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; K. Yamaoka, MD, PhD, Associate Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine; T. Takeuchi, MD, PhD, Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine.
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Safety of biologic DMARDs in RA patients in real life: A systematic literature review and meta-analyses of biologic registers. Joint Bone Spine 2016; 84:133-140. [PMID: 27341745 DOI: 10.1016/j.jbspin.2016.02.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 02/03/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVES In daily practice, safety in rheumatoid arthritis (RA) patients receiving biological treatment is an important issue. Unlike randomized controlled trials, biologic registers provide long-term real life safety data. To identify all biologic registers worldwide, to extract and analyze data regarding safety in RA patients under biologics. METHOD Systematic review was performed independently by 2 rheumatologists using PUBMED, COCHRANE Library and EMBASE databases, up to December 2014. Worldwide biologic registers and related publications were identified. Data on safety issues in RA patients were extracted for meta-analyses. Random-effect meta-analyses were performed to estimate risk ratios (RRs) of mortality, cardiovascular events, cancer, including lymphoma and melanoma and serious infections between (1) biological and non-biological DMARD (cDMARD), (2) between biologics when data were available. RESULTS Forty-three biological registers were identified worldwide and 27 publications were included for safety meta-analyses on anti-TNFs. Compared to cDMARD, mortality and cardiovascular events were significantly decreased in patients treated with anti-TNFs: RR=0.60 [95% CI 0.38-0.94] and RR=0.62 [0.44-0.88], respectively. Anti-TNFs did not increase the risk of solid cancer in patients without or with prior malignancy (RR=0.84 [0.60-1.18] and RR=0.77 [0.29-2.03], respectively), lymphoma (RR=0.90 [0.62-1.31]) and melanoma (RR=1.17 [0.86-1.59]). As expected, serious infections were significantly increased during anti-TNF treatment (RR=1.48 [1.18-1.85]) compared to cDMARD. No significant difference was found between soluble receptor to TNF and monoclonal antibodies (RR=0.55 [0.22-1.35]). CONCLUSIONS By reducing dramatically chronic inflammation in RA patients, anti-TNFs decrease mortality, cardiovascular events without increase significantly the risk of cancer, compared to cDMARDs.
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Brocq O, Acquacalda E, Berthier F, Albert C, Bolla G, Millasseau E, Destombe C, Azulay J, Asquier C, Florent A, Le Seaux S, Euller-Ziegler L. Influenza and pneumococcal vaccine coverage in 584 patients taking biological therapy for chronic inflammatory joint: A retrospective study. Joint Bone Spine 2015; 83:155-9. [PMID: 26725745 DOI: 10.1016/j.jbspin.2015.11.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate influenza and pneumococcal vaccine coverage in patients taking biological therapy for chronic inflammatory joint disease and to identify factors associated with the decision to administer these two vaccines. METHODS Retrospective cross-sectional questionnaire study of a cohort of 584 patients taking biological therapy for chronic inflammatory joint disease (rheumatoid arthritis or spondyloarthritis). We studied the influenza and pneumococcal vaccine coverage rates, information about these vaccines given to patients by the primary-care physician and rheumatologist, and reasons for not administering the vaccines. RESULTS Overall vaccine coverage rates were 44% for influenza and 62% for pneumococcus. Factors associated with being vaccinated were patient age, previous influenza vaccination, and patient information. Concern about adverse effects and absence of patient information by the primary-care physician and rheumatologist were associated with very low coverage rates. CONCLUSION This study showed insufficient vaccine coverage rates, particularly against influenza, in a population at high risk because of exposure to biological therapy. Patient information by healthcare professionals about influenza and pneumococcal vaccination has a major impact and should be renewed as often as possible.
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Affiliation(s)
- Olivier Brocq
- Rhumatologie, centre hospitalier Princesse Grâce, boulevard Pasteur, 98000 Monaco, Monaco.
| | - Emilie Acquacalda
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
| | | | - Christine Albert
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
| | - Gilles Bolla
- Service de rhumatologie, centre hospitalier de Cannes, 06400 Cannes, France
| | - Elodie Millasseau
- Service de rhumatologie, centre hospitalier Fréjus-Saint-Raphaël, 83800 Saint-Raphaël, France
| | - Claire Destombe
- Service de rhumatologie, centre hospitalier Fréjus-Saint-Raphaël, 83800 Saint-Raphaël, France
| | - Johanna Azulay
- Service de rhumatologie, centre hospitalier de Cannes, 06400 Cannes, France
| | - Caroline Asquier
- Service de rhumatologie, centre hospitalier de Cannes, 06400 Cannes, France
| | - Amélie Florent
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
| | - Sylvie Le Seaux
- Service de rhumatologie, centre hospitalier Fréjus-Saint-Raphaël, 83800 Saint-Raphaël, France
| | - Liana Euller-Ziegler
- Service de rhumatologie, hôpital Archet 1, université de Nice, 06200 Nice, France
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Abstract
PURPOSE OF REVIEW The management of inflammatory arthritis has been revolutionized by the use of biologic therapy. However, an important safety issue has been identified with regard to the risk of serious and opportunistic infections with biologic therapy. This review aims to summarize the most recent data available in the field. RECENT FINDINGS The risk of infection in inflammatory arthritis is partly determined by the nature of the underlying disease, comorbidities and other immunosuppressive treatments, in particular glucocorticoids. Data are conflicting with regard to the absolute risk of infection with biologic agents, as a result of differing study methodologies, classification of outcomes and patient populations. There appear to be some differences in risk of infection between biologic agents, which relate to their varying modes of action. SUMMARY Long-term observational data about the risk of infection and biologic therapy continue to emerge, although there are inherent limitations with this type of data. The process of determining the risk of infection for an individual patient should incorporate a range of factors, which may contribute to the infection risk.
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Fitzgerald P, Siddle HJ, Backhouse MR, Nelson EA. Prevalence and microbiological characteristics of clinically infected foot-ulcers in patients with rheumatoid arthritis: a retrospective exploratory study. J Foot Ankle Res 2015; 8:38. [PMID: 26279683 PMCID: PMC4537588 DOI: 10.1186/s13047-015-0099-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 08/06/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The prevalence of foot ulcers in patients with rheumatoid arthritis (RA) has been reported at almost 10 %. These foot ulcers often occur at multiple sites and are reoccurring, with the potential risk of infection increased due to RA diagnosis and disease modifying medications. The objective of this study was to estimate the prevalence of clinical infection in foot-ulcers of patients with RA; describe the microbiological characteristics and investigate risk factors. METHODS Retrospective clinical data was collected for all patients attending a rheumatology foot ulcer clinic between 1st May 2012 and 1st May 2013: wound swab data was collected from those with clinical infection. RESULTS Twenty-eight patients with RA and foot-ulcers were identified; eight of these patients had clinical infection and wound swabs taken (29 %). Of these eight patients there were equal men and women, with median age 74 years, and average disease duration 22 years. Cardiovascular disease/peripheral-vascular disease (CVD/PVD) were reported in six patients, diabetes in two patients. Six patients were treated with disease-modifying anti-rheumatic drugs (DMARDs); three were on biologic medications and two on steroids. Five wound swabs cultured skin flora, one staphylococcus aureus, one had no growth after culture; and one was rejected due to labelling error. CONCLUSION Almost a third of people with RA and foot ulcers attending clinic over one year had clinical infection, however microbiological analysis failed to isolate pathogens in six of seven wound swabs. This may be due to inaccurate diagnosis of ulcer infection or to issues with sampling, collection, transport, analysis or reporting. There was insufficient data to relate risk of clinical infection with risk factors. Further research is required to identify the most appropriate techniques for infection diagnosis, wound sampling and processing. TRIAL REGISTRATION Ethical approval was obtained from University of Leeds, Faculty of Medicine and Health (Reference number: SHREC/RP/349).
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Affiliation(s)
| | - Heidi J. Siddle
- />Foot Health Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- />Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Michael R. Backhouse
- />Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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36
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Goodman SM. Optimizing Perioperative Outcomes for Older Patients with Rheumatoid Arthritis Undergoing Arthroplasty: Emphasis on Medication Management. Drugs Aging 2015; 32:361-9. [DOI: 10.1007/s40266-015-0262-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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37
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Kapetanovic MC. Further evidence for influenza and pneumococcal vaccination in patients treated with disease modifying antirheumatic drugs and anti-tumor necrosis factor agents. J Rheumatol 2014; 41:626-8. [PMID: 24692602 DOI: 10.3899/jrheum.140063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Meliha C Kapetanovic
- Institution of Medical Sciences, Department of Rheumatology, Skånes Universitetssjukhus, Lund, SE-221 85, Sweden
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