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Sen R, Riofrio M, Singh JA. A narrative review of the comparative safety of disease-modifying anti-rheumatic drugs used for the treatment of rheumatoid arthritis. Expert Opin Drug Saf 2024; 23:687-714. [PMID: 38695151 DOI: 10.1080/14740338.2024.2348575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/24/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Disease-modifying anti-rheumatic drugs (DMARDs) have improved the outcomes of patients with rheumatoid arthritis (RA). DMARDs are classified into three categories: conventional synthetic DMARDs, biological DMARDs (including biosimilars), and targeted synthetic DMARDs. DMARDs, by way of their effect on the immune system, are associated with increased risk of adverse events, including infections, malignancies, cardiovascular disease, gastrointestinal perforations, and other less common events. AREAS COVERED In this narrative literature review performed with searches of the PubMed database from 1 January 2010 through 1 January 2023, we compare the risk of safety events between DMARDs using data from both randomized clinical trials and observational studies. EXPERT OPINION DMARD use in RA is associated with higher rates of serious infections, tuberculosis reactivation, opportunistic infections, and possibly malignancies. Specific biologic DMARDs and higher doses are associated with elevated risks of various adverse events (gastrointestinal perforations, thromboembolism, serious infection). Shared decision-making is paramount when choosing a treatment regimen for patients based on their own comorbidities. JAKi are the newest class of medications used for RA with robust safety data provided in clinical trials. However, more real-world evidence and phase-IV pharmacovigilance data are needed to better understand comparative safety profile of DMARDs in RA.
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Affiliation(s)
- Rouhin Sen
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
| | - Maria Riofrio
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
| | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
- Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA
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Bredemeier M, Duarte ÂL, Pinheiro MM, Kahlow BS, Macieira JC, Ranza R, Miranda JR, Valim V, de Castro GR, Bértolo MB, Sauma MF, Fernandes V, Ribeiro AC, Teodoro RB, Brenol CV, Carvalho HM, Studart SA, Pinheiro GR, da Rocha LF, de Lima HD, Pereira IA, Gazzeta MO, Kakehasi AM, Louzada P, Hayata AL, Lupo CM, da Silveira IG, Kowalski SC, Titton DC, Chakr RM, Ranzolin A, Xavier RM, Laurindo IM. The effect of antimalarials on the safety and persistence of treatment with biologic agents or Janus kinase inhibitors in rheumatoid arthritis. Rheumatology (Oxford) 2024; 63:456-465. [PMID: 37216912 DOI: 10.1093/rheumatology/kead232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/27/2023] [Accepted: 05/10/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVES To test the association of use of antimalarials with the overall safety of treatment in RA patients receiving one or multiple courses of biologic (b)DMARDs or a Janus kinase inhibitor (JAKi). METHODS BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or JAKi. The present analysis includes RA patients recruited from January 2009 to October 2019, followed up over one or multiple (up to six) courses of treatment (latest date, 19 November 2019). The primary outcome was the incidence of serious adverse events (SAEs). Total and system-specific adverse events (AEs) and treatment interruption served as secondary outcomes. Negative binomial regression with generalized estimating equations (to estimate multivariate incidence rate ratios, mIRR) and frailty Cox proportional hazards models were used for statistical analyses. RESULTS The number of patients enrolled was 1316 (2335 treatment courses, 6711 patient-years [PY]; 1254.5 PY on antimalarials). The overall incidence of SAEs was 9.2/100 PY. Antimalarials were associated with reduced risk of SAEs (mIRR: 0.49; 95% CI: 0.36, 0.68; P < 0.001), total AEs (0.68; 95% CI: 0.56, 0.81; P < 0.001), serious infections (0.53; 95% CI: 0.34, 0.84; P = 0.007) and total hepatic AEs (0.21; 95% CI: 0.05, 0.85; P = 0.028). Antimalarials were also related to better survival of treatment course (P = 0.003). There was no significant increase in the risk of cardiovascular AEs. CONCLUSION Among RA patients on treatment with bDMARDs or JAKi, concomitant use of antimalarials was associated with reduced the incidence of serious and total AEs and with longer treatment course survival.
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Affiliation(s)
- Markus Bredemeier
- Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Ângela L Duarte
- Hospital das Clinicas da Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Marcelo M Pinheiro
- Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Bárbara S Kahlow
- Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brazil
| | - José C Macieira
- Hospital Universitário da Universidade Federal de Sergipe, Aracajú, SE, Brazil
| | - Roberto Ranza
- Hospital das Clínicas da Universidade Federal de Uberlândia, Uberlândia, MG, Brazil
| | | | - Valéria Valim
- Hospital Universitário Cassiano Antônio de Moraes, Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | | | - Manoel B Bértolo
- Hospital das Clínicas da Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | | | - Ana C Ribeiro
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Reginaldo B Teodoro
- Hospital de Clínicas da Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil
| | - Claiton V Brenol
- Universidade Federal do Rio Grande do Sul/Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | | | - Geraldo R Pinheiro
- Universidade Estadual do Rio de Janeiro/Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brazil
| | - Laurindo F da Rocha
- Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil
| | - Hugo D de Lima
- Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil
| | - Ivânio A Pereira
- Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Morgana O Gazzeta
- Santa Casa de Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Adriana M Kakehasi
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Paulo Louzada
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Cristiano M Lupo
- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Inês G da Silveira
- Faculdade de Medicina da Pontifícia Universidade Católica do Rio Grande do Sul/Hospital São Lucas, Porto Alegre, RS, Brazil
| | - Sergio C Kowalski
- Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - David C Titton
- Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Rafael M Chakr
- Universidade Federal do Rio Grande do Sul/Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Aline Ranzolin
- Hospital das Clinicas da Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Ricardo M Xavier
- Universidade Federal do Rio Grande do Sul/Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ieda M Laurindo
- Faculdade de Medicina da Universidade Nove de Julho, São Paulo, SP, Brazil
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Fiehn C, Leipe J, Weseloh C, Bergner R, Krüger K. Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search. Z Rheumatol 2024; 83:8-19. [PMID: 37831190 DOI: 10.1007/s00393-023-01417-3] [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] [Accepted: 08/14/2023] [Indexed: 10/14/2023]
Abstract
Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective product information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.
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Affiliation(s)
- C Fiehn
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany.
- Tätigkeitsschwerpunkt klinische Immunologie, Rheumatologie Baden-Baden, Beethovenstr. 2, 76530, Baden-Baden, Germany.
| | - J Leipe
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- V. Medizinische Klinik, Universitätsmedizin Mannheim, Mannheim, Germany
| | - C Weseloh
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
| | - R Bergner
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Medizinische Klinik A, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - K Krüger
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Rheumatologisches Praxiszentrum St. Bonifatius, Munich, Germany
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[Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search]. Z Rheumatol 2023; 82:151-162. [PMID: 36633662 DOI: 10.1007/s00393-022-01308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 01/13/2023]
Abstract
Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective specialist subject information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.
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Tsakas JJ, Liew DFL, Adams CL, Hill CL, Proudman S, Whittle S, Buchbinder R, Robinson PC. Attitudes and practices in the laboratory monitoring of conventional synthetic disease modifying anti-rheumatic drugs by rheumatologists and rheumatology trainees. BMC Rheumatol 2022; 6:59. [PMID: 36244979 PMCID: PMC9575262 DOI: 10.1186/s41927-022-00290-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
There is scant research about laboratory monitoring in people taking conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) for rheumatic disease. Our objective was to conduct a scoping study to assess the range of current attitudes and the variation in practice of laboratory monitoring of csDMARDs by rheumatologists and trainees.
Methods
Australian and overseas rheumatologists or trainees were invited through newsletter, Twitter and personal e-mail, to complete an anonymous online survey between 1 February and 22 March 2021. Questions focused on laboratory tests requested by csDMARD prescribed, frequency/pattern of monitoring, influence of additional factors and combination therapy, actions in response to abnormal tests, and attitudes to monitoring frequencies. Results were presented descriptively and analysed using linear and logistic regression.
Results
There were 221 valid responses. Most respondents were from Australia (n = 53, 35%) followed by the US (n = 39, 26%), with a slight preponderance of women (n = 84, 56%), ≥ 11 years in rheumatology practice (n = 83, 56%) and in mostly public practice (n = 79, 53%). Respondents had a wide variation in the frequency and scheduling of tests. In general, respondents reported increasing monitoring frequency if patients had numerous comorbidities or if both methotrexate and leflunomide were being taken concurrently. There was a wide variety of responses to abnormal monitoring results and 27 (40%) considered that in general, monitoring tests are performed too frequently.
Conclusions
The results demonstrated a wide variation in the frequency of testing, factors that should influence this, and what responses to abnormal test results are appropriate, indicates a likely lack of evidence and the need to define the risks, benefits and costs of different csDMARD monitoring regimens.
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