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Huang X, Huang X, Lin S, Luo S, Dong L, Lin D, Huang Y, Xie C, Nian D, Xu X, Weng X. Prophylaxis for Pneumocystis carinii pneumonia in non-Hodgkin's lymphoma undergoing R-CHOP21 in China: a meta-analysis and cost-effectiveness analysis. BMJ Open 2023; 13:e068943. [PMID: 36972963 PMCID: PMC10069585 DOI: 10.1136/bmjopen-2022-068943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 03/08/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE Rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone, once every 3 weeks (R-CHOP21) is commonly used in non-Hodgkin's lymphoma (NHL), but accompanied by Pneumocystis carinii pneumonia (PCP) as a fatal treatment complication. This study aims to estimate the specific effectiveness and cost-effectiveness of PCP prophylaxis in NHL undergoing R-CHOP21. DESIGN A two-part decision analytical model was developed. Prevention effects were determined by systemic review of PubMed, Embase, Cochrane Library and Web of Science from inception to December 2022. Studies reporting results of PCP prophylaxis were included. Enrolled studies were quality assessed with Newcastle-Ottawa Scale. Costs were derived from the Chinese official websites, and clinical outcomes and utilities were obtained from published literature. Uncertainty was evaluated through deterministic and probabilistic sensitivity analyses (DSA and PSA). Willingness-to-pay (WTP) threshold was set as US$31 315.23/quality-adjusted life year (QALY) (threefold the 2021 per capita Chinese gross domestic product). SETTING Chinese healthcare system perspective. PARTICIPANTS NHL receiving R-CHOP21. INTERVENTIONS PCP prophylaxis versus no prophylaxis. MAIN OUTCOME MEASURES Prevention effects were pooled as relative risk (RR) with 95% CI. QALYs and incremental cost-effectiveness ratio (ICER) were calculated. RESULTS A total of four retrospective cohort studies with 1796 participants were included. PCP risk was inversely associated with prophylaxis in NHL receiving R-CHOP21 (RR 0.17; 95% CI 0.04 to 0.67; p=0.01). Compared with no prophylaxis, PCP prophylaxis would incur an additional cost of US$527.61, and 0.57 QALYs gained, which yielded an ICER of US$929.25/QALY. DSA indicated that model results were most sensitive to the risk of PCP and preventive effectiveness. In PSA, the probability that prophylaxis was cost-effective at the WTP threshold was 100%. CONCLUSION Prophylaxis for PCP in NHL receiving R-CHOP21 is highly effective from retrospective studies, and routine chemoprophylaxis against PCP is overwhelmingly cost-effective from Chinese healthcare system perspective. Large sample size and prospective controlled studies are warranted.
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Affiliation(s)
- Xiaojia Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoting Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shen Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shaohong Luo
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liangliang Dong
- Department of Pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Dong Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yaping Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Chen Xie
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dongni Nian
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiongwei Xu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiuhua Weng
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Alsayed AR, Al-Dulaimi A, Alkhatib M, Al Maqbali M, Al-Najjar MAA, Al-Rshaidat MMD. A comprehensive clinical guide for Pneumocystis jirovecii pneumonia: a missing therapeutic target in HIV-uninfected patients. Expert Rev Respir Med 2022; 16:1167-1190. [PMID: 36440485 DOI: 10.1080/17476348.2022.2152332] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is an opportunistic, human-specific fungus that causes Pneumocystis pneumonia (PCP). PCP symptoms are nonspecific. A patient with P. jirovecii and another lung infection faces a diagnostic challenge. It may be difficult to determine which of these agents is responsible for the clinical symptoms, preventing effective treatment. Diagnostic and treatment efforts have been made more difficult by the rising frequency with which coronavirus 2019 (COVID-19) and PCP co-occur. AREAS COVERED Herein, we provide a comprehensive review of clinical and pharmacological recommendations along with a literature review of PCP in immunocompromised patients focusing on HIV-uninfected patients. EXPERT OPINION PCP may be masked by identifying co-existing pathogens that are not necessarily responsible for the observed infection. Patients with severe form COVID-19 should be examined for underlying immunodeficiency, and co-infections must be considered as co-infection with P. jirovecii may worsen COVID-19's severity and fatality. PCP should be investigated in patients with PCP risk factors who come with pneumonia and suggestive radiographic symptoms but have not previously received PCP prophylaxis. PCP prophylaxis should be explored in individuals with various conditions that impair the immune system, depending on their PCP risk.
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Affiliation(s)
- Ahmad R Alsayed
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Abdullah Al-Dulaimi
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Mohammad Alkhatib
- Department of Experimental Medicine, University of Rome "Tor Vergata", Roma, Italy
| | - Mohammed Al Maqbali
- Department of Nursing Midwifery and Health, Northumbria University, Newcastle-Upon-Tyne, UK
| | - Mohammad A A Al-Najjar
- Department of Pharmaceutical Sciences and Pharmaceutics, Applied Science Private University, Amman, Kingdom of Jordan
| | - Mamoon M D Al-Rshaidat
- Laboratory for Molecular and Microbial Ecology (LaMME), Department of Biological Sciences, School of Sciences, The University of Jordan, Amman, Jordan
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Belov BS, Egorova ON, Tarasova GM, Muravieva NV. Infections and systemic vasculitis. MODERN RHEUMATOLOGY JOURNAL 2022. [DOI: 10.14412/1996-7012-2022-5-75-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Infections and systemic vasculitis (SV) are characterized by mutual influence, which increases the risk of occurrence, aggravates the course and outcome of the disease. The review considers the issues related to both the trigger role of infections in the development of SV and comorbid infections (CI) that complicate the course of the disease. Recognition of the infectious etiology of SV is of great importance, since it requires a comprehensive examination and, if necessary, early and complete etiotropic treatment. Since SV per se and the use of both induction and maintenance immunosuppressive therapy are significant risk factors for secondary CIs, special attention should be paid to the prevention of the latter, including vaccination, primarily against influenza and pneumococcal infections.
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Affiliation(s)
- B. S. Belov
- V.A. Nasonova Research Institute of Rheumatology
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Rúa-Figueroa Fernández de Larrinoa Í, Carreira PE, Brito García N, Díaz Del Campo Fontecha P, Pego Reigosa JM, Gómez Puerta JA, Ortega-Castro R, Tejera Segura B, Aguado García JM, Torre-Cisneros J, Valencia-Martín JL, Pereda CA, Nishishinya-Aquino MB, Otón Sánchez MT, Silva Fernández L, Maese Manzano J, Chamizo Carmona E, Correyero Plaza M. Recommendations for prevention of infection in systemic autoimmune rheumatic diseases. REUMATOLOGIA CLINICA 2022; 18:317-330. [PMID: 34607782 DOI: 10.1016/j.reumae.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). METHODS Clinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. RESULTS Five questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. CONCLUSIONS There is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.
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Affiliation(s)
| | - Patricia E Carreira
- Servicio de Reumatología, Hospital Universitario 12 de octubre, Madrid, Spain
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | | | - José María Pego Reigosa
- Servicio de Reumatología, Complexo Hospitalario Universitario de Vigo, Grupo IRIDIS-VIGO (Investigation in Rheumatology and Immune-Mediated Diseases), Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | | | - Rafaela Ortega-Castro
- Unidad de Gestión Clínica de Reumatologia, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre. Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense Madrid, Madrid, Spain
| | - Julián Torre-Cisneros
- Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica (IMIBIC), Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, Córdoba, Spain
| | - José L Valencia-Martín
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Intapiboon P, Siripaitoon B. Thai Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Outcomes and Risk Factors for Mortality. J Clin Rheumatol 2021; 27:e378-e384. [PMID: 32568951 DOI: 10.1097/rhu.0000000000001456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) have an increased risk of premature death. Different subtypes, predictors, and ethnicities may affect the overall survival. However, the overall survival of Thai AAV patients has not been reported. We examined the mortality and prognosis of these patients. METHODS This medical record review study included adult AAV patients, admitted to Songklanagarind Hospital from 2007 to 2017. Antineutrophil cytoplasmic antibody-associated vasculitis was diagnosed according to the 1990 American College of Rheumatology criteria or 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Follow-up data were collected until June 2018. Prognostic factors and overall survival were analyzed. RESULTS Among 57 AAV patients, mean (SD) age was 49.3 (16.1) years. Microscopic polyangiitis was the predominant diagnosis (42%). Kidneys (67%) and lungs (65%) were the 2 most affected organs. Initial Birmingham Vasculitis Activity Score (BVAS) greater than 20 was found in 61% of patients. Corticosteroids were the main drugs, and 58% received cyclophosphamide during the induction phase. Overall mean survival time was 38.8 (42.2) months. Patient survival was 91% and 82% at 1 and 6 months, respectively. One-year and 5-year survival rates were 78% and 63%, respectively. Univariate analysis showed that initial BVAS of greater than 20, neutrophil-to-lymphocyte ratio greater than 5.8, and need for invasive ventilator were significant predictors of mortality. Initial BVAS of greater than 20 was the only predictor of death in multivariate analyses (odds ratio, 4.22; 95% confidence interval, 1.01-17.63; p = 0.048). CONCLUSIONS The mortality rate of Thai AAV patients is high and strongly related to high disease activity. An early recognition and referral system are warranted to improve outcomes.
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Affiliation(s)
- Porntip Intapiboon
- From the Allergy and Rheumatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
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Rúa-Figueroa Fernández de Larrinoa Í, Carreira PE, Brito García N, Díaz Del Campo Fontecha P, Pego Reigosa JM, Gómez Puerta JA, Ortega-Castro R, Tejera Segura B, Aguado García JM, Torre-Cisneros J, Valencia-Martín JL, Pereda CA, Nishishinya-Aquino MB, Otón Sánchez MT, Silva Fernández L, Maese Manzano J, Chamizo Carmona E, Correyero Plaza M. Recommendations for prevention of infection in systemic autoimmune rheumatic diseases. REUMATOLOGIA CLINICA 2021; 18:S1699-258X(21)00124-8. [PMID: 34176767 DOI: 10.1016/j.reuma.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). METHODS Clinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. RESULTS Five questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. CONCLUSIONS There is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.
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Affiliation(s)
| | - Patricia E Carreira
- Servicio de Reumatología, Hospital Universitario 12 de octubre, Madrid, España
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, España.
| | | | - José María Pego Reigosa
- Servicio de Reumatología, Complexo Hospitalario Universitario de Vigo, Grupo IRIDIS-VIGO (Investigation in Rheumatology and Immune-Mediated Diseases), Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España
| | - José Alfredo Gómez Puerta
- Servicio de Reumatología, Complexo Hospitalario Universitario de Vigo, Grupo IRIDIS-VIGO (Investigation in Rheumatology and Immune-Mediated Diseases), Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España; Servicio de Reumatología, Hospital Clínic de Barcelona, Barcelona, España
| | - Rafaela Ortega-Castro
- Unidad de Gestión Clínica de Reumatologia, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, España
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, España
| | - Julián Torre-Cisneros
- Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica (IMIBIC), Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, Córdoba, España
| | - José L Valencia-Martín
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, Madrid, España
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Is cotrimoxazole prophylaxis against Pneumocystis jirovecii pneumonia needed in patients with systemic autoimmune rheumatic diseases requiring immunosuppressive therapies? Rheumatol Int 2021; 41:1419-1427. [PMID: 33656582 DOI: 10.1007/s00296-021-04808-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
The incidence of Pneumocystis jirovecii pneumonia (PJP) has increased over recent years in patients with systemic autoimmune rheumatic diseases (SARD). PJP prognosis is poor in those receiving immunosuppressive therapy and glucocorticoids in particular. Despite the effectiveness of cotrimoxazole against PJP, the risk of adverse effects remains significant, and no consensus has emerged regarding the need for PJP prophylaxis in SARD patients undergoing immunosuppressor therapies.Objective: To evaluate the efficacy and safety of cotrimoxazole prophylaxis against PJP in SARD adult patients receiving immunosuppressive therapies. Methods: We performed a systematic review, consulting MEDLINE, EMBASE, and Cochrane Library databases up to April 2020. Outcomes covered prevention of PJP, other infections, morbidity, mortality, and safety. The information obtained was summarized with a narrative review and results were tabulated. Of the 318 identified references, 8 were included. Two were randomized controlled trials and six observational studies. The quality of studies was moderate or low. Despite disparities in the cotrimoxazole prophylaxis regimens described, results were consistent in terms of efficacy, particularly with glucocorticoid doses > 20 mg/day. However, cotrimoxazole 400 mg/80 mg/day, prescribed three times/ week, or 200 mg/40 mg/day or in dose escalation, exhibited similar positive performances. Conversely, cotrimoxazole 400 mg/80 mg/day showed higher incidences of withdrawals and adverse effects. Cotrimoxazole prophylaxis against PJP exhibited efficacy in SARD, mainly in patients taking glucocorticoids ≥ 20 mg/day. All cotrimoxazole regimens exposed seemed equally efficacious, although, higher quality trials are needed. Adverse effects were observed 2 months after initiation, particularly with the 400 mg/80 mg/day regimen. Conversely, escalation dosing or 200 mg/40 mg/day regimens appeared better tolerated.
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Peterson K, Berrigan L, Popovic K, Wiebe C, Sun S, Ho J. Lifelong, universal Pneumocystis jirovecii pneumonia prophylaxis: Patient uptake and adherence after kidney transplant. Transpl Infect Dis 2020; 23:e13509. [PMID: 33171008 DOI: 10.1111/tid.13509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/14/2020] [Accepted: 10/11/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is a significant cause of morbidity and mortality in transplant patients yet little is known about their adherence to prophylaxis. The goal of this study was to evaluate patient uptake and long-term adherence after implementing universal, lifelong PJP prophylaxis. MATERIALS AND METHODS This retrospective cohort study evaluated an adult kidney transplant program 18-months after initiating trimethoprim-sulfamethoxazole (TMP-SMX) 80/400 mg thrice-weekly following a cluster of PJP cases. The protocol incorporated multi-modal patient education and drug tolerability strategies to improve adherence, including a modified re-challenge strategy for TMP-SMX intolerance. Adherence was independently confirmed by the transplant pharmacist and nurse for each patient, with an a priori target ≥ 75% population on prophylaxis. RESULTS Initial uptake was high with 237/250 (94.8%) patients starting prophylaxis. Long-term maintenance was high with 192/237 (81.0%) patients remaining on prophylaxis at 18-months. Of the remaining 45 patients who initiated prophylaxis, 36/237 (15.2%) were non-adherent and 9/237 (3.8%) discontinued prophylaxis by 18-months. Reasons for non-adherence included gastrointestinal upset, fear of drug reactions and cost; but the majority of reasons were not delineated by the patients (31/36, 86.1%). There was a statistically significant increase in serum creatinine 3.3 µmol/L (0.3-6.3 µmol/L 95% CI) and potassium 0.08 mmol/L (0.03-0.15 mmol/L 95% CI) in those prescribed TMP-SMX with only 3/237 (1.3%) patients discontinuing TMP-SMX for an increase in creatinine. CONCLUSION High rates of patient uptake (94.8%) and long-term adherence (81.0%) were observed after implementing universal lifelong PJP prophylaxis. This may be due in part to the in-depth patient education and drug tolerability strategies employed.
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Affiliation(s)
| | - Liam Berrigan
- Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | | | - Christopher Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Immunology, University of Manitoba, Winnipeg, MB, Canada.,Shared Health Services Manitoba, Winnipeg, MB, Canada
| | - Siyao Sun
- Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
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Hasan MR, Sakibuzzaman M, Tabassum T, Moosa SA. A Case of Granulomatosis with Polyangiitis (Wegener's Granulomatosis) Presenting with Rapidly Progressive Glomerulonephritis. Cureus 2019; 11:e5896. [PMID: 31772866 PMCID: PMC6839754 DOI: 10.7759/cureus.5896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA, Wegener’s granulomatosis) presenting as rapidly progressive glomerulonephritis is not uncommon. The recognition of multisystem disease involving joints, kidney, and lung is critical for diagnosing Wegener's vasculitis. Here, we report a case study of a 52-year-old Bangladeshi man presented with a history of progressively worsening fever, recurrent cough, and hemoptysis. He developed renal failure within a month which was successfully treated with high-dose steroids, cyclophosphamide, and trimethoprim-sulfamethoxazole (TMP-SMX). Rapidly progressive glomerulonephritis can be a fulminant manifestation of GPA, in which case an immediate and aggressive treatment with pulse steroids, high-dose cyclophosphamide and TMP-SMX can be lifesaving.
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Affiliation(s)
| | - Md Sakibuzzaman
- Internal Medicine, Sir Salimullah Medical College, Dhaka, BGD
| | - Tahsin Tabassum
- Virology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Syed Ahmad Moosa
- Family Medicine, Woodhaven Medical Professional Corporation, Queens Village, USA
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Petta I, Peene I, Elewaut D, Vereecke L, De Bosscher K. Risks and benefits of corticosteroids in arthritic diseases in the clinic. Biochem Pharmacol 2019; 165:112-125. [PMID: 30978323 DOI: 10.1016/j.bcp.2019.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
Glucocorticoids (GCs) constitute a first line treatment for many autoimmune and inflammatory diseases. Due to their potent anti-inflammatory and immunosuppressive actions, GCs are added frequently to disease modifying antirheumatic drugs (DMARDs) in various arthritic diseases, such as rheumatoid arthritis. However, their prolonged administration or administration at high doses is associated with adverse effects that may be (quality of) life-threatening, including osteoporosis, metabolic, gastrointestinal and cardiovascular side effects. In this review, we summarize the clinical and pharmacological effects of GCs in different arthritic diseases, while documenting the current research efforts towards the identification of novel and more efficient GCs with reduced side effects.
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Affiliation(s)
- Ioanna Petta
- Department of Rheumatology, Faculty of Medicine and Health Sciences, Host-Microbiota Interaction Lab (HMI) and Laboratory for Molecular Immunology and Inflammation, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; VIB Center for Inflammation Research (IRC), Ghent University, Technologiepark 71 - Zwijnaarde, 9052 Ghent, Belgium; Ghent Gut Inflammation Group (GGIG), Ghent University, Ghent, Belgium
| | - Isabelle Peene
- Department of Rheumatology, Faculty of Medicine and Health Sciences, Host-Microbiota Interaction Lab (HMI) and Laboratory for Molecular Immunology and Inflammation, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; VIB Center for Inflammation Research (IRC), Ghent University, Technologiepark 71 - Zwijnaarde, 9052 Ghent, Belgium; Department of Rheumatology, AZ SintJan, Ruddershove 10, 8000 Brugge, Belgium
| | - Dirk Elewaut
- Department of Rheumatology, Faculty of Medicine and Health Sciences, Host-Microbiota Interaction Lab (HMI) and Laboratory for Molecular Immunology and Inflammation, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; VIB Center for Inflammation Research (IRC), Ghent University, Technologiepark 71 - Zwijnaarde, 9052 Ghent, Belgium; Ghent Gut Inflammation Group (GGIG), Ghent University, Ghent, Belgium
| | - Lars Vereecke
- Department of Rheumatology, Faculty of Medicine and Health Sciences, Host-Microbiota Interaction Lab (HMI) and Laboratory for Molecular Immunology and Inflammation, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; VIB Center for Inflammation Research (IRC), Ghent University, Technologiepark 71 - Zwijnaarde, 9052 Ghent, Belgium; Ghent Gut Inflammation Group (GGIG), Ghent University, Ghent, Belgium
| | - Karolien De Bosscher
- Department of Biomolecular Medicine, Ghent University, Ghent, Belgium; Translational Nuclear Receptor Research, VIB Center for Medical Biotechnology, Albert Baertsoenkaai 3, 9000, Ghent, Belgium.
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Shahab MA, Mir TA, Zafar S. Optimising drug therapy for non-infectious uveitis. Int Ophthalmol 2018; 39:1633-1650. [PMID: 29961190 DOI: 10.1007/s10792-018-0984-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 06/26/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Uveitis encompasses a wide variety of sight-threatening diseases characterized by intraocular inflammation. It is often classified as infectious and non-infectious uveitis. Unlike infectious uveitis, a distinct infectious agent cannot be identified in non-infectious uveitis and disease origin is usually autoimmune, drug related, or idiopathic. THE ISSUE AT HAND Non-infectious uveitis can often have a relapsing-remitting course, making it difficult to treat, and poses a significant challenge to ophthalmologists. The autoimmune nature of non-infectious uveitis warrants the use of anti-inflammatory and immunomodulatory agents for disease control. However, a subset of patients has persistent or recurrent ocular inflammation despite appropriate treatment, stressing the need for newer therapies aimed at more specific inflammatory targets such as tumour necrosis factor (TNF) alpha agents, anti-interleukin agents, and anti-interleukin receptor agents. OBJECTIVES This article discusses the various medical options available for the treatment of non-infectious uveitis in the light of the most recent evidence. CONCLUSION Successful management of non-infectious uveitis requires the clinician carefully balance advantages and disadvantages of each new and old therapy while considering individual circumstances. Counselling regarding the benefits and complications of each therapy can help patients make an informed choice.
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Pneumocystis Pneumonia and the Rheumatologist: Which Patients Are At Risk and How Can PCP Be Prevented? Curr Rheumatol Rep 2018; 19:35. [PMID: 28488228 DOI: 10.1007/s11926-017-0664-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Immunosuppressive therapy for connective tissue diseases (CTDs) is steadily becoming more intense. The resultant impairment in cell-mediated immunity has been accompanied by an increasing risk for opportunistic infection (OI). Pneumocystis pneumonia (PCP) has been recognized as an OI in patients with CTDs, but specific risk factors and precise indications for PCP prophylaxis remain poorly defined. This review was undertaken to update information on the risk of PCP in patients with CTDs and to examine current guidelines for PCP prophylaxis in this population. RECENT FINDINGS Data on the occurrence of PCP and indications for prophylaxis in patients with CTDs is sparse. Large systematic reviews did not incorporate patients with CTD secondary to the lack of randomized control trials. Upon reviewing guidelines published since 2015, prophylaxis for PCP is recommended only for patients with ANCA-positive vasculitis, specifically granulomatosis with polyangiitis (GPA), who are undergoing intense induction therapy. Evidence-based recommendations for the prophylaxis of PCP in patients with CTDs cannot be provided. There is expert consensus that PCP prophylaxis is warranted in patients with GPA undergoing induction therapy. Prophylaxis should perhaps also be considered for other CTD patients who are receiving similar intense immunosuppressive therapy especially if they are lymphopenic or have a low CD4 count.
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Berti A, Specks U, Keogh KA, Cornec D. Current and Future Treatment Options for Eosinophilic Granulomatosis With Polyangiitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0073-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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15
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Yates M, Watts RA, Bajema IM, Cid MC, Crestani B, Hauser T, Hellmich B, Holle JU, Laudien M, Little MA, Luqmani RA, Mahr A, Merkel PA, Mills J, Mooney J, Segelmark M, Tesar V, Westman K, Vaglio A, Yalçındağ N, Jayne DR, Mukhtyar C. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 2016; 75:1583-94. [PMID: 27338776 DOI: 10.1136/annrheumdis-2016-209133] [Citation(s) in RCA: 744] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/27/2016] [Indexed: 12/13/2022]
Abstract
In this article, the 2009 European League Against Rheumatism (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have been updated. The 2009 recommendations were on the management of primary small and medium vessel vasculitis. The 2015 update has been developed by an international task force representing EULAR, the European Renal Association and the European Vasculitis Society (EUVAS). The recommendations are based upon evidence from systematic literature reviews, as well as expert opinion where appropriate. The evidence presented was discussed and summarised by the experts in the course of a consensus-finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) determined. In addition to the voting by the task force members, the relevance of the recommendations was assessed by an online voting survey among members of EUVAS. Fifteen recommendations were developed, covering general aspects, such as attaining remission and the need for shared decision making between clinicians and patients. More specific items relate to starting immunosuppressive therapy in combination with glucocorticoids to induce remission, followed by a period of remission maintenance; for remission induction in life-threatening or organ-threatening AAV, cyclophosphamide and rituximab are considered to have similar efficacy; plasma exchange which is recommended, where licensed, in the setting of rapidly progressive renal failure or severe diffuse pulmonary haemorrhage. These recommendations are intended for use by healthcare professionals, doctors in specialist training, medical students, pharmaceutical industries and drug regulatory organisations.
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Affiliation(s)
- M Yates
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK Norwich Medical School, University of East Anglia, Norwich, UK
| | - R A Watts
- Norwich Medical School, University of East Anglia, Norwich, UK Department of Rheumatology, Ipswich Hospital NHS Trust, Ipswich, Suffolk, UK
| | - I M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - B Crestani
- Assistance Publique-Hôpitaux de Paris, Department of Pulmonology, Bichat-Claude Bernard University Hospital, Paris, France
| | - T Hauser
- Immunologie-Zentrum Zürich, Zürich, Switzerland
| | - B Hellmich
- Vaskulits-Zentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Kreiskliniken Esslingen, Kirchheim-Teck, Germany
| | - J U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - M Laudien
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Kiel, Kiel, Germany
| | - M A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - R A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - A Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, Université Paris 7 René Diderot, Paris, France
| | - P A Merkel
- Division of Rheumatology and the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Mills
- Vasculitis UK, West Bank House, Winster, Matlock, UK
| | - J Mooney
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - M Segelmark
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden Department of Nephrology, Linköping University, Linköping, Sweden
| | - V Tesar
- Department of Nephrology, 1st School of Medicine, Charles University, Prague, Czech Republic
| | - K Westman
- Department of Nephrology, Lund University, Skåne University Hospital, Lund and Malmö, Sweden
| | - A Vaglio
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - N Yalçındağ
- Department of Ophthalmology, School of Medicine, Ankara University, Ankara, Turkey
| | - D R Jayne
- Lupus and Vasculitis Unit, Addenbrooke's Hospital, Cambridge, UK
| | - C Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
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Pneumocystose chez les patients immunodéprimés non infectés par le VIH. Rev Med Interne 2016; 37:327-36. [DOI: 10.1016/j.revmed.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/02/2015] [Indexed: 12/15/2022]
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Cost-effectiveness of Prophylaxis Against Pneumocystis jiroveci Pneumonia in Patients with Crohn's Disease. Dig Dis Sci 2015; 60:3743-55. [PMID: 26177704 DOI: 10.1007/s10620-015-3796-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/30/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emerging evidence suggests that Pneumocystis jiroveci pneumonia is occurring more frequently in Crohn's disease patients on immunosuppressive medications, especially corticosteroids. Considering its excess mortality and the efficacy of chemoprophylaxis in reducing P. jiroveci pneumonia in acquired immunodeficiency syndrome, there is debate without consensus on the need for chemoprophylaxis in Crohn's disease patients on corticosteroids. AIMS We sought to address this debate using insights from simulation modeling. METHODS We used a Markov microsimulation model to simulate the natural history of Crohn's disease in 1 million virtual patients receiving appropriate care and who faced P. jiroveci pneumonia risks that varied with corticosteroid use. We examined several chemoprophylaxis strategies and compared their population-level economic and clinical impact using various indices including costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios. We also performed several nested probabilistic sensitivity analyses to estimate the health and economic impact of chemoprophylaxis in patients on triple immunosuppressive therapy. RESULTS At the current PJP incidence, no PJP chemoprophylaxis was the preferred strategy from a population perspective. Considered chemoprophylactic strategies led to higher average costs and fewer P. jiroveci pneumonia cases. However, they also led to lower average quality-adjusted life expectancy and were thus dominated. Nevertheless, these alternative strategies became preferred with progressively higher risks of P. jiroveci pneumonia. Our results also suggest that PJP chemoprophylaxis may be cost-effective in patients on triple immunosuppressive therapy. CONCLUSION Our findings support a case-by-case consideration of P. jiroveci pneumonia chemoprophylaxis in Crohn's disease patients receiving corticosteroids.
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Groh M, Pagnoux C, Baldini C, Bel E, Bottero P, Cottin V, Dalhoff K, Dunogué B, Gross W, Holle J, Humbert M, Jayne D, Jennette JC, Lazor R, Mahr A, Merkel PA, Mouthon L, Sinico RA, Specks U, Vaglio A, Wechsler ME, Cordier JF, Guillevin L. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA) Consensus Task Force recommendations for evaluation and management. Eur J Intern Med 2015; 26:545-53. [PMID: 25971154 DOI: 10.1016/j.ejim.2015.04.022] [Citation(s) in RCA: 281] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 03/09/2015] [Accepted: 04/26/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To develop disease-specific recommendations for the diagnosis and management of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) (EGPA). METHODS The EGPA Consensus Task Force experts comprised 8 pulmonologists, 6 internists, 4 rheumatologists, 3 nephrologists, 1 pathologist and 1 allergist from 5 European countries and the USA. Using a modified Delphi process, a list of 40 questions was elaborated by 2 members and sent to all participants prior to the meeting. Concurrently, an extensive literature search was undertaken with publications assigned with a level of evidence according to accepted criteria. Drafts of the recommendations were circulated for review to all members until final consensus was reached. RESULTS Twenty-two recommendations concerning the diagnosis, initial evaluation, treatment and monitoring of EGPA patients were established. The relevant published information on EGPA, antineutrophil-cytoplasm antibody-associated vasculitides, hypereosinophilic syndromes and eosinophilic asthma supporting these recommendations was also reviewed. DISCUSSION These recommendations aim to give physicians tools for effective and individual management of EGPA patients, and to provide guidance for further targeted research.
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Affiliation(s)
- Matthieu Groh
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases (Vasculitis, Scleroderma), INSERM U1016, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Christian Pagnoux
- Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Chiara Baldini
- Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth Bel
- Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Paolo Bottero
- Allergy and Clinical Immunology Outpatient Clinic, Ospedale "G. Fornaroli" di Magenta, Azienda Ospedaliera di Legnano, Milan, Italy
| | - Vincent Cottin
- Department of Respiratory Medicine, National Referral Center for Rare Lung Diseases, Hôpital Louis-Pradel, Hospices Civils de Lyon, Lyon, France
| | - Klaus Dalhoff
- Medical Clinic, Department of Rheumatology, Vasculitis Center, University Clinic of Schleswig-Holstein, Lübeck and Bad Bramstedt, Germany
| | - Bertrand Dunogué
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases (Vasculitis, Scleroderma), INSERM U1016, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Wolfgang Gross
- Medical Clinic, Department of Rheumatology, Vasculitis Center, University Clinic of Schleswig-Holstein, Lübeck and Bad Bramstedt, Germany
| | - Julia Holle
- Medical Clinic, Department of Rheumatology, Vasculitis Center, University Clinic of Schleswig-Holstein, Lübeck and Bad Bramstedt, Germany
| | - Marc Humbert
- Department of Respiratory and Critical Care Medicine, National Referral Center for Severe Pulmonary Hypertension, INSERM UMR-S 999, Hôpital Bicêtre, APHP, Université Paris-Sud, 94270 Le Kremlin-Bicêtre, France
| | - David Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, UNC Kidney Center, University of North Carolina, Chapel Hill, NC, USA
| | - Romain Lazor
- Interstitial and Rare Lung Disease Unit, Department of Respiratory Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Alfred Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, Université Paris 7 René Diderot, Paris, France
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases (Vasculitis, Scleroderma), INSERM U1016, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Renato Alberto Sinico
- Clinical Immunology Unit and Renal Unit, Department of Medicine, Azienda Ospedaliera San Carlo Borromeo, Milan, Italy
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Augusto Vaglio
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - Michael E Wechsler
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Jean-François Cordier
- Department of Respiratory Medicine, National Referral Center for Rare Lung Diseases, Hôpital Louis-Pradel, Hospices Civils de Lyon, Lyon, France
| | - Loïc Guillevin
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases (Vasculitis, Scleroderma), INSERM U1016, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France.
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Stern A, Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev 2014; 2014:CD005590. [PMID: 25269391 PMCID: PMC6457644 DOI: 10.1002/14651858.cd005590.pub3] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) is a disease affecting immunocompromised patients. PCP among these patients is associated with significant morbidity and mortality. OBJECTIVES To assess the effectiveness of PCP prophylaxis among non-HIV immunocompromised patients; and to define the type of immunocompromised patient for whom evidence suggests a benefit for PCP prophylaxis. SEARCH METHODS Electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE and EMBASE (to March 2014), LILACS (to March 2014), relevant conference proceedings; and references of identified trials. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing prophylaxis with an antibiotic effective against PCP versus placebo, no intervention, or antibiotic(s) with no activity against PCP; and trials comparing different antibiotics effective against PCP among immunocompromised non-HIV patients. We only included trials in which Pneumocystis infections were available as an outcome. DATA COLLECTION AND ANALYSIS Two review authors independently assessed risk of bias in each trial and extracted data from the included trials. We contacted authors of the included trials to obtain missing data. The primary outcome was documented PCP infections. Risk ratios (RR) with 95% confidence intervals (CI) were estimated and pooled using the random-effects model. MAIN RESULTS Thirteen trials performed between the years 1974 and 2008 were included, involving 1412 patients. Four trials included 520 children with acute lymphoblastic leukemia and the remaining trials included adults with acute leukemia, solid organ transplantation or autologous bone marrow transplantation. Compared to no treatment or treatment with fluoroquinolones (inactive against Pneumocystis), there was an 85% reduction in the occurrence of PCP in patients receiving prophylaxis with trimethoprim/sulfamethoxazole, RR of 0.15 (95% CI 0.04 to 0.62; 10 trials, 1000 patients). The evidence was graded as moderate due to possible risk of bias. PCP-related mortality was also significantly reduced, RR of 0.17 (95% CI 0.03 to 0.94; nine trials, 886 patients) (low quality of evidence due to possible risk of bias and imprecision), but in trials comparing PCP prophylaxis against placebo or no treatment there was no significant effect on all-cause mortality (low quality of evidence due to imprecision). Occurrence of leukopenia or neutropenia and their duration were not reported consistently. No significant differences in overall adverse events or events requiring discontinuation were seen comparing trimethoprim/sulfamethoxazole to no treatment or placebo (four trials, 470 patients, moderate quality evidence). No differences between once daily versus thrice weekly trimethoprim/sulfamethoxazole were seen (two trials, 207 patients). AUTHORS' CONCLUSIONS Given an event rate of 6.2% in the control groups of the included trials, prophylaxis for PCP using trimethoprim/sulfamethoxazole is highly effective among non-HIV immunocompromised patients, with a number needed to treat to prevent PCP of 19 patients (95% CI 17 to 42). Prophylaxis should be considered for patients with a similar baseline risk of PCP.
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Affiliation(s)
- Anat Stern
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Hefziba Green
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Liat Vidal
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
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Hogan J, Avasare R, Radhakrishnan J. Is newer safer? Adverse events associated with first-line therapies for ANCA-associated vasculitis and lupus nephritis. Clin J Am Soc Nephrol 2014; 9:1657-67. [PMID: 24832093 DOI: 10.2215/cjn.01600214] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinical outcomes in ANCA-associated vasculitis (AAV) and lupus nephritis have improved greatly with treatment regimens containing high-dose glucocorticoids and cyclophosphamide. However, with the use of these medications come significant adverse events, most notably infections, cytopenias, malignancies, and reproductive abnormalities. Multiple recent randomized controlled trials in AAV and lupus nephritis have compared cyclophosphamide-based regimens with agents such as rituximab, mycophenolate mofetil, and azathioprine, with the hope of providing better clinical outcomes with improved safety profiles. Although some of these newer regimens are now considered first-line treatments of these diseases, their adverse event profiles have been disappointingly similar to those of cyclophosphamide-based protocols. Physicians and patients should consider the adverse event profiles generated by these trials in the context of their extensive use in other patient populations, as well as available measures to prevent such events, when choosing the ideal regimen for an individual patient.
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Affiliation(s)
- Jonathan Hogan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Rupali Avasare
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Jai Radhakrishnan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
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21
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Pyle RC, Butterfield JH, Volcheck GW, Podjasek JC, Rank MA, Li JTC, Harish A, Poe KL, Park MA. Successful outpatient graded administration of trimethoprim-sulfamethoxazole in patients without HIV and with a history of sulfonamide adverse drug reaction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:52-8. [PMID: 24565769 DOI: 10.1016/j.jaip.2013.11.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 10/22/2013] [Accepted: 11/01/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The outcomes of trimethoprim-sulfamethoxazole (TMP-SMX) desensitization have been widely reported in the HIV literature but less so in the non-HIV literature. OBJECTIVE To evaluate the safety and efficacy of graded administration of TMP-SMX in patients without HIV and with a history of TMP-SMX adverse drug reaction (ADR). METHODS A retrospective chart review, 2004-2012, of all the patients without HIV seen in the Division of Allergic Diseases and with a history of TMP-SMX ADR who underwent outpatient graded administration of TMP-SMX was conducted. The medical record was reviewed for age, sex, details of the initial ADR to TMP-SMX, an indication for TMP-SMX administration, and outcome. Patients also were contacted by telephone, and medical records were reviewed to determine long-term outcomes. RESULTS Seventy-two patients (46 women [64%]; mean [SD] age, 57.7 ± 13.89 years]) were included. The most common patient-reported reactions to TMP-SMX were rash 39 (54%), and hives 9 (13%). TMP-SMX administration was needed for the following indications: prophylaxis (62 [86%]) and treatment of infection (10 [14%]). Forty-three of the patients (60%) underwent a 1-day TMP-SMX administration protocol. Thirty-five of the 43 (81%) underwent a 6-step (90 minutes to 6 hours) protocol and 7 of the 43 (16%) underwent a novel 14-step TMP-SMX protocol. Twenty-nine (40%) underwent a >1-day TMP-SMX administration protocol. Our overall success rate was 90% (mean duration of 11 months). Ninety-eight percent of the patients successfully completed a 1-day graded administration protocol, and 76% successfully completed a >1-day protocol. TMP-SMX was stopped in 8 patients because of the ADR. CONCLUSION We report the largest case series of successful outpatient graded administration of TMP-SMX with both 1-day and >1-day protocols, which have shown to be safe and well tolerated in patients without HIV and with a history of sulfonamide ADR.
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Affiliation(s)
- Regan C Pyle
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn
| | - Joseph H Butterfield
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn
| | - Gerald W Volcheck
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn
| | - Jenna C Podjasek
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz
| | - James T C Li
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn
| | | | - Kimberly L Poe
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn.
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Roux A, Gonzalez F, Roux M, Mehrad M, Menotti J, Zahar JR, Tadros VX, Azoulay E, Brillet PY, Vincent F. Update on pulmonary Pneumocystis jirovecii infection in non-HIV patients. Med Mal Infect 2014; 44:185-98. [PMID: 24630595 DOI: 10.1016/j.medmal.2014.01.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 12/04/2013] [Accepted: 01/15/2014] [Indexed: 11/27/2022]
Abstract
Pneumocystis jirovecii is the only fungus of its kind to be pathogenic in humans. It is primarily responsible for pneumonia (PJP). The key to understanding immune defences has focused on T-cells, mainly because of the HIV infection epidemic. Patients presenting with PJP all have a CD4 count below 200/mm(3). The introduction of systematic primary prophylaxis and the use of new anti-retroviral drugs have significantly reduced the incidence of this disease in the HIV-infected population, mainly in developed countries. The increasingly frequent use of corticosteroids, chemotherapy, and other immunosuppressive drugs has led to an outbreak of PJP in patients not infected by HIV. These patients presenting with PJP have more rapid and severe symptoms, sometimes atypical, leading to delay the initiation of a specific anti-infective therapy, sometimes a cause of death. However, the contribution of new diagnostic tools and a better understanding of patients at risk should improve their survival.
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Affiliation(s)
- A Roux
- Service de pneumologie, hôpital Foch, 92151 Suresnes, France
| | - F Gonzalez
- Service de réanimation médico-chirurgicale, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - M Roux
- Service de radiologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - M Mehrad
- Service des urgences, Gustave Roussy, Cancer Campus Grand Paris, 94805 Villejuif, France
| | - J Menotti
- Service de parasitologie-mycologie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Université Paris-Diderot, Sorbonne Paris-Cité, 75010 Paris, France
| | - J-R Zahar
- UPLIN, CHU d'Angers, 49100 Angers, France; Université d'Angers, 49100 Angers, France
| | - V-X Tadros
- Service de réanimation médico-chirurgicale, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - E Azoulay
- Service de réanimation médicale, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Université Paris-Diderot, Sorbonne Paris-Cité, 75010 Paris, France
| | - P-Y Brillet
- Service de radiologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France; Université Paris-13, 93009 Bobigny, France
| | - F Vincent
- Service de réanimation polyvalente, CHI Le Raincy-Montfermeil, 10, rue du Général-Leclerc, 93370 Montfermeil, France.
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Roblot F. Management ofPneumocystispneumonia in patients with inflammatory disorders. Expert Rev Anti Infect Ther 2014; 3:435-44. [PMID: 15954859 DOI: 10.1586/14787210.3.3.435] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pneumocystis jirovecii is an atypical fungus that causes Pneumocystis pneumonia in immunocompromised patients. Underlying diseases associated with Pneumocystis pneumonia mainly consist of hematologic malignancies, solid tumors, organ transplant recipients and inflammatory disorders. Currently, inflammatory disorders represent 20% of underlying diseases. Corticosteroids are considered as a major risk factor. Recently introduced immunosuppressive drugs, such as antitumor necrosis factor monoclonal antibodies, could enhance the risk of Pneumocystis pneumonia. In patients with inflammatory disorders, lymphopenia is probably a determining factor but CD4+ T-cell count associated with the risk of Pneumocystis pneumonia remains unassessed. The diagnosis is based upon clinical, radiologic and biologic data. The identification of P. jirovecii usually requires a lower respiratory tract specimen, even if oral washes samples seem to be promising. According to recent data, immunofluorescent stains should be considered as the new gold standard, and specialized techniques such as PCR should be applied for sputum samples or oral washes. Recommendations on prophylaxis remains controversial except in patients with Wegener's granulomatosis and systemic lupus erythematosus. Cotrimoxazole is the preferred agent for prophylaxis as well as for treatment. An adjunctive corticosteroid therapy is usually prescribed despite the lack of evidence for utility in patients with inflammatory disorders. As person-to-person transmission is the most likely mode of acquiring P. jirovecii, isolation precautions should be advised.
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Affiliation(s)
- F Roblot
- Department of Internal Medicine, University Hospital, Poitiers, France.
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Plakke MJ, Jalota L, Lloyd BJ. Pneumocystis pneumonia in a non-HIV patient on chronic corticosteroid therapy: a question of prophylaxis. BMJ Case Rep 2013; 2013:bcr-2012-007912. [PMID: 23456156 DOI: 10.1136/bcr-2012-007912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
A man in his late 50s with a history of membranoproliferative glomerulonephritis presented with fever and mild dyspnoea. He was HIV-negative and had been on corticosteroids as immunosuppression for 6 months prior to tapering them off 1 week before presentation. He was not taking prophylaxis for Pneumocystis jirovecii pneumonia. After unsuccessful treatment for community-acquired pneumonia, his condition worsened and he required intubation and mechanical ventilation. Full respiratory workup including bronchoscopy revealed P jirovecii as a source for the patient's infection. He was treated successfully with a 21-day course of trimethoprim-sulfamethoxazole and eventually weaned off the ventilator. He has had no complications to date. In our review of this case and the existing literature, we believe that proper utilisation of prophylaxis for pneumocystis pneumonia may have prevented our patient's transfer to intensive care unit. In our article, we discuss this issue and explore current evidence for prophylaxis.
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Affiliation(s)
- Michael J Plakke
- Department of Internal Medicine, The Reading Hospital and Medical Center, West Reading, Pennsylvania, USA.
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Cardenas-Garcia J, Farmakiotis D, Baldovino BP, Kim P. Wegener's granulomatosis in a middle-aged woman presenting with dyspnea, rash, hemoptysis and recurrent eye complaints: a case report. J Med Case Rep 2012; 6:335. [PMID: 23034218 PMCID: PMC3492078 DOI: 10.1186/1752-1947-6-335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 02/27/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction Wegener’s granulomatosis presenting as diffuse alveolar hemorrhage is uncommon. However, the recognition of multisystem disease involving joints, kidney, eye and lung is critical for diagnosing Wegener's vasculitis. This is not the first report of this kind in the literature. Case presentation A 51-year-old Croatian woman presented to our Emergency Department with a history of progressively worsening productive cough and shortness of breath, epistaxis and two episodes of hemoptysis. She developed respiratory failure due to diffuse alveolar hemorrhage, which was successfully treated with high-dose steroids, cyclophosphamide and plasmapheresis. Her clinical course was complicated with methicillin-resistant Staphyloccocus aureus pneumonia, which has been associated with Wegener’s granulomatosis flares. Conclusion The recognition of multisystem disease is critical for diagnosing Wegener's vasculitis. Diffuse alveolar hemorrhage can be a fulminant manifestation of Wegener’s granulomatosis, in which case immediate and aggressive treatment with pulse steroids, high-dose cyclophosphamide and plasma exchange can be life-saving.
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Affiliation(s)
- Jose Cardenas-Garcia
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Suite 3N1 1400 Pelham Pkwy S,, Bronx, NY, 10461, USA.
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Doherty GA, Miksad RA, Cheifetz AS, Moss AC. Comparative cost-effectiveness of strategies to prevent postoperative clinical recurrence of Crohn's disease. Inflamm Bowel Dis 2012; 18:1608-16. [PMID: 21905173 PMCID: PMC3381977 DOI: 10.1002/ibd.21904] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 08/25/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND A number of treatments have been shown to reduce the risk of postoperative recurrence of Crohn's disease (CD). The optimal strategy is unknown. The aim was to evaluate the comparative cost-effectiveness of postoperative strategies to prevent clinical recurrence of CD. METHODS Three prophylactic strategies were compared to "no prophylaxis"; mesalamine, azathioprine (AZA) / 6-mercaptopurine (6-MP), and infliximab. The probability of clinical recurrence, endoscopic recurrence, and therapy discontinuation due to adverse drug reactions (ADRs) were extracted from randomized controlled trials (RCTs). Quality-of-life scores and treatment costs were derived from published data. The primary model evaluated quality-adjusted life years (QALYs) and cost-effectiveness at 1 year after surgery. Sensitivity analysis assessed the impact of a range of recurrence rates on cost-effectiveness. An exploratory analysis evaluated cost-effectiveness outcomes 5 years after surgery. RESULTS A strategy of "no prophylaxis" was the least expensive one at 1 and 5 years after surgery. Compared to this approach, AZA/6-MP had the most favorable incremental cost-effectiveness ratio (ICER) ($299,188/QALY gained), and yielded the highest net health benefits of the medication strategies at 1 year. Sensitivity analysis determined that the ICER of AZA/6-MP was preferable to mesalamine up to a recurrence rate of 52%, but mesalamine dominated at higher rates. In the 5-year exploratory analysis, mesalamine had the most favorable ICER over 5 years ($244,177/QALY gained). CONCLUSIONS Compared to no prophylactic treatment, AZA/6-MP has the most favorable ICER in the prevention of clinical recurrence of postoperative CD up to 1 year. At 5 years, mesalamine had the most favorable ICER in this model.
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Affiliation(s)
- Glen A. Doherty
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rebecca A. Miksad
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- MGH Institute for Technology Assessment, Boston, Massachusetts
| | - Adam S. Cheifetz
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Alan C. Moss
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Takenaka K, Komiya Y, Ota M, Yamazaki H, Nagasaka K. A dose-escalation regimen of trimethoprim-sulfamethoxazole is tolerable for prophylaxis against Pneumocystis jiroveci pneumonia in rheumatic diseases. Mod Rheumatol 2012; 23:752-8. [PMID: 22907597 DOI: 10.1007/s10165-012-0730-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 07/23/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the safety and efficacy of a dose-escalation regimen of trimethoprim-sulfamethoxazole (TMP/SMX) for prophylaxis against Pneumocystis jiroveci pneumonia (PCP) in rheumatic diseases. METHODS Data from 41 patients, who received glucocorticoids with or without immunosuppressive agents and prophylactic use of TMP/SMX, were retrospectively analyzed. Thirteen patients were started on a daily dose of 10% of single-strength (SS) TMP/SMX, which was increased gradually (dose-escalation group), while 28 patients were started on 1 SS tablet daily (routine group). RESULTS In the dose-escalation group, the retention rate was 100% at 6 months. In the routine group, 5 patients discontinued TMP/SMX; the retention rate was 82.1%. Moreover, the retention rate when taking a daily dose of 50% or more of SS TMP/SMX, or 1 SS tablet thrice-weekly, was significantly higher in the dose-escalation group (100 versus 71.4%, P = 0.032). No PCP was observed in the dose-escalation group; however, 1 patient in the routine group, who had discontinued TMP/SMX, developed PCP. The rate of adverse effects was less, although nonsignificant, in the dose-escalation group (30.8 versus 46.4%, P = 0.344). CONCLUSIONS In rheumatic diseases, a dose-escalation regimen of TMP/SMX resulted in a higher retention rate and was safer than the routine regimen.
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Affiliation(s)
- Kenchi Takenaka
- Department of Rheumatology, Ome Municipal General Hospital, 4-16-5 Higashi-Ome, Ome, Tokyo 198-0042, Japan
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Kermani TA, Ytterberg SR, Warrington KJ. Pneumocystis jiroveci pneumonia in giant cell arteritis: A case series. Arthritis Care Res (Hoboken) 2011; 63:761-5. [PMID: 21240966 DOI: 10.1002/acr.20435] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe the clinical presentation, laboratory findings, and outcome of patients with Pneumocystis jiroveci pneumonia (PCP) and biopsy-proven giant cell arteritis (GCA) seen at a tertiary referral center. METHODS Using International Classification of Diseases, Ninth Revision codes, all patients with GCA and PCP between January 1, 1976 and December 31, 2008 were identified. Medical records were reviewed. PCP was defined by the identification of Pneumocystis jiroveci organisms in the clinical setting of pneumonia. RESULTS We identified 7 patients with GCA (5 women and 2 men) who developed PCP (the mean ± SD age at diagnosis was 71.6 ± 6.1 years). The median time from GCA diagnosis to PCP diagnosis was 3 months (range 1-18 months). All patients were taking prednisone (the median dosage 50 mg/day [range 30-80]) when diagnosed as having PCP. No patients were receiving PCP prophylaxis. PCP was diagnosed by positive smear on bronchoalveolar lavage fluid in 6 patients (86%) and by positive sputum polymerase chain reaction in 1 patient. All the patients were hospitalized (median duration 17 days [range 12-39 days]). Four patients (57%) were admitted to the intensive care unit. Three patients (43%) required mechanical ventilation. Two patients (29%) died; both were on mechanical ventilation. CONCLUSION Although PCP is rare among patients with GCA, this preventable infection is associated with significant morbidity and mortality.
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ANCA-associated vasculitides-lessons from the adult literature. Pediatr Nephrol 2010; 25:1397-407. [PMID: 20358231 DOI: 10.1007/s00467-010-1496-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 01/29/2010] [Accepted: 02/01/2010] [Indexed: 02/08/2023]
Abstract
Anti-neutrophil cytoplasmic antigen antibody (ANCA)-associated disease is a rare manifestation of primary systemic vasculitis in paediatric patients but one that carries significant morbidity, potential long-term disability and early mortality. It therefore requires a high index of suspicion, targeted investigation, prompt treatment and long-term follow-up with specialist input at every stage. The well-recognised diversity and overlap in clinical, laboratory and histopathological features of the ANCA-associated systemic vasculitides continue to hamper accurate diagnosis, confounding epidemiological data and necessitating a blanket approach to treatment, which is largely extrapolated from studies in adult patients and carries significant side-effects. Herein we summarise current knowledge of the epidemiology, pathogenesis, principal manifestations, investigation and evidence-based management, extrapolated from adult studies, of these disorders. We also discuss recent efforts towards classification of the childhood vasculitides that emphasise the value of histological diagnosis. Progress in our understanding of the pathophysiology underlying ANCA-associated disease should lead to targeted, safer and more effective therapies for these conditions. Nonetheless, many questions remain outstanding, and academic paediatricians face real challenges in identifying and collating the few cases they encounter into study cohorts. Meeting this challenge will require international collaboration, not only among paediatricians but also with the specialists taking over care of these patients as they reach adulthood.
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Holle JU, Moosig F, Gross WL. Diagnostic and therapeutic management of Churg-Strauss syndrome. Expert Rev Clin Immunol 2010; 5:813-23. [PMID: 20477699 DOI: 10.1586/eci.09.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Churg-Strauss syndrome is a rare small-vessel vasculitis that is associated with asthma, granulomatous inflammation, peripheral/tissue eosinophilia and a positive antineutrophil cytoplasmic antibody status (in approximately 40% of patients). The disease can be organ- and life-threatening, either due to tissue eosinophil infiltration such as myocarditis or due to vasculitis manifestations, for example glomerulonephritis. Furthermore, life-threatening disease can also occur due to the side effects of immunosuppression, for example, infection. A thorough diagnostic work-up should be performed in order to identify all organs involved and to rule out other disorders with similar features, such as hypereosinophilic syndrome. Therapeutic management is conducted according to disease stage and activity. Glucocorticoids remain the mainstay of therapy; however, further immunosuppressants (e.g., cyclophosphamide for life-threatening disease) are usually required. Future promising therapy options target cytokines involved in the disease process, such as IL-5.
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Affiliation(s)
- Julia U Holle
- University Hospital Schleswig-Holstein, Campus Luebeck, Dept of Rheumatology and Klinikum Bad Bramstedt, Dept of Rheumatology and Immunology, Oskar-Alexander-Strasse 26, 24576 Bad, Bramstedt, Germany.
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31
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Rúa-Figueroa Fernández de Larrinoa I, Erausquin Arruabarrena C. Tratamiento de las vasculitis sistémicas asociadas a ANCA. ACTA ACUST UNITED AC 2010; 6:161-72. [DOI: 10.1016/j.reuma.2009.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 01/15/2009] [Indexed: 11/30/2022]
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Verma A, Shivakumar A, Moonat A, Jakoby M. It started with a rash. Am J Med 2010; 123:314-6. [PMID: 20362749 DOI: 10.1016/j.amjmed.2010.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Revised: 01/05/2010] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Akshra Verma
- Department of Internal Medicine, University of Illinois, Urbana-Champaign, Urbana, IL, USA.
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Cettomai D, Gelber AC, Christopher-Stine L. A survey of rheumatologists' practice for prescribing pneumocystis prophylaxis. J Rheumatol 2010; 37:792-9. [PMID: 20194450 DOI: 10.3899/jrheum.090843] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pneumocystis pneumonia (PCP) occurs in immunocompromised hosts, in both the presence and absence of human immunodeficiency virus (HIV) infection, with substantial morbidity and a heightened mortality. We assessed practice patterns among rheumatologists for prescribing PCP prophylaxis. METHODS Invitations to an online international survey were e-mailed to 3150 consecutive members of the American College of Rheumatology. RESULTS Completed surveys were returned by 727 (23.1%) members. Among respondents, 505 (69.5%) reported prescribing prophylaxis. Factors associated with significantly higher frequency of prescribing PCP prophylaxis included female gender (OR 1.47, p = 0.03), US-based (OR 1.77, p = 0.004), academic-based (OR 2.75, p < 0.001), in practice less than 10 years (OR 4.08, p < 0.001), having previously treated PCP (OR 2.62, p < 0.001), and in a practice with a higher proportion of patients maintained on chronic glucocorticoids (OR 2.04, p < 0.001) or other immunosuppressant medications (OR 3.19, p = 0.003). In multivariate analysis, rheumatologists early in their careers and those with academic and US-based practices were more likely to prescribe prophylaxis. Among prescribers, the most important determinants for issuing prophylaxis were treatment regimen (68.6%), rheumatologic diagnosis (9.3%), and medication dosage (8.3%). CONCLUSION Nearly one-third (30%) of the rheumatologists surveyed reported that they never prescribed PCP prophylaxis. While the patient characteristics for which prophylaxis was prescribed varied widely, physician demographics were strongly predictive of PCP prophylaxis use. These findings suggest that development of consensus guidelines might influence clinical decision-making regarding PCP prophylaxis in HIV-negative patients with rheumatologic diagnoses.
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Affiliation(s)
- Deanna Cettomai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA
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Recent advances to achieve remission induction in antineutrophil cytoplasmic antibody-associated vasculitis. Curr Opin Rheumatol 2010; 22:37-42. [PMID: 19770660 DOI: 10.1097/bor.0b013e328331cfeb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Significant advances in the treatment of antineutrophil cytoplasmic antibody-associated vasculitis have been made in the past 10 years. This review aims to detail advances in treatment aimed at induction of remission. RECENT FINDINGS Cyclophosphamide-based regimes remain the standard of care, at least in generalized disease. Safer therapeutic regimes with reduced cumulative dose of cyclophosphamide have been developed such as the use of pulsed cyclophosphamide. Preliminary data are available, suggesting rituximab may be an alternative to cyclophosphamide, but additional safety data are required. Evidence suggests that plasma exchange should be added to those with more severe disease and it is acceptable to use methotrexate as an induction agent for those with limited or early systemic disease. Using current regimens, remission is achieved in over 90% of patients, but toxicity remains an important issue. Attention should be paid to reducing treatment toxicity. SUMMARY Findings of recent clinical trials should change clinical practice and improve outcome of patients with antineutrophil cytoplasmic antibody-associated vasculitis.
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Pujari SS, Kempen JH, Newcomb CW, Gangaputra S, Daniel E, Suhler EB, Thorne JE, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Foster CS. Cyclophosphamide for ocular inflammatory diseases. Ophthalmology 2009; 117:356-65. [PMID: 19969366 DOI: 10.1016/j.ophtha.2009.06.060] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Revised: 05/22/2009] [Accepted: 06/24/2009] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To evaluate the outcomes of cyclophosphamide therapy for noninfectious ocular inflammation. DESIGN Retrospective cohort study. PARTICIPANTS Two hundred fifteen patients with noninfectious ocular inflammation observed from initiation of cyclophosphamide. METHODS Patients initiating cyclophosphamide, without other immunosuppressive drugs (other than corticosteroids), were identified at 4 centers. Dose of cyclophosphamide, response to therapy, corticosteroid-sparing effects, frequency of discontinuation, and reasons for discontinuation were obtained by medical record review of every visit. MAIN OUTCOME MEASURES Control of inflammation, corticosteroid-sparing effects, and discontinuation of therapy. RESULTS The 215 patients (381 involved eyes) meeting eligibility criteria carried diagnoses of uveitis (20.4%), scleritis (22.3%), ocular mucous membrane pemphigoid (45.6%), or other forms of ocular inflammation (11.6%). Overall, approximately 49.2% (95% confidence interval [CI], 41.7%-57.2%) gained sustained control of inflammation (for at least 28 days) within 6 months, and 76% (95% CI, 68.3%-83.7%) gained sustained control of inflammation within 12 months. Corticosteroid-sparing success (sustained control of inflammation while tapering prednisone to 10 mg or less among those not meeting success criteria initially) was gained by 30.0% and 61.2% by 6 and 12 months, respectively. Disease remission leading to discontinuation of cyclophosphamide occurred at the rate of 0.32/person-year (95% CI, 0.24-0.41), and the estimated proportion with remission at or before 2 years was 63.1% (95% CI, 51.5%-74.8%). Cyclophosphamide was discontinued by 33.5% of patients within 1 year because of side effects, usually of a reversible nature. CONCLUSIONS The data suggest that cyclophosphamide is effective for most patients for controlling inflammation and allowing tapering of systemic corticosteroids to 10 mg prednisone or less, although 1 year of therapy may be needed to achieve these goals. Unlike with most other immunosuppressive drugs, disease remission was induced by treatment in most patients who were able to tolerate therapy. To titrate therapy properly and to minimize the risk of serious potential side effects, a systematic program of laboratory monitoring is required. Judicious use of cyclophosphamide seems to be beneficial for severe ocular inflammation cases where the potentially vision-saving benefits outweigh the substantial potential side effects of therapy, or when indicated for associated systemic inflammatory diseases.
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Affiliation(s)
- Siddharth S Pujari
- The Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts, USA
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Moosig F, Holle JU, Gross WL. Value of anti-infective chemoprophylaxis in primary systemic vasculitis: what is the evidence? Arthritis Res Ther 2009; 11:253. [PMID: 19886977 PMCID: PMC2787252 DOI: 10.1186/ar2826] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Although infections are a major concern in patients with primary systemic vasculitis, actual knowledge about risk factors and evidence concerning the use of anti-infective prophylaxis from clinical trials are scarce. The use of high dose glucocorticoids and cyclophosphamide pose a definite risk for infections. Bacterial infections are among the most frequent causes of death, with Staphylococcus aureus being the most common isolate. Concerning viral infections, cytomegalovirus and varicella-zoster virus reactivation represent the most frequent complications. The only prophylactic measure that is widely accepted is trimethoprim/sulfamethoxazole to avoid Pneumocystis jiroveci pneumonia in small vessel vasculitis patients with generalised disease receiving therapy for induction of remission.
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Affiliation(s)
- Frank Moosig
- Department of Rheumatology, University Hospital of Schleswig Holstein and Klinikum Bad Bramstedt, Oskar Alexander Str, 26, 24576 Bad Bramstedt, Germany.
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Turnbull J, Harper L. Adverse effects of therapy for ANCA-associated vasculitis. Best Pract Res Clin Rheumatol 2009; 23:391-401. [PMID: 19508946 DOI: 10.1016/j.berh.2009.04.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The introduction of cyclophosphamide- and prednisolone-based treatment regimens has significantly improved outcome in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis. However, these regimens are nonspecific immunosuppressants associated with significant toxicity, including increased risk of infection, leucopenia, diabetes and malignancy. In addition, disease damage, particularly renal failure, increases the risk of toxicity. Improvements in disease management should include the increased awareness of treatment-related toxicity and its prevention.
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Affiliation(s)
- Jennifer Turnbull
- Renal Immunobiology, Division of Immunity and Infection, University of Birmingham, Birmingham, UK
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Torre D, Crespi E, Bernasconi M, Rapazzini P. Risk factors analysis for pneumocystis jiroveci pneumonia (PCP) in patients with haematological malignancies and pneumonia. ACTA ACUST UNITED AC 2009; 37:375-8. [PMID: 16051578 DOI: 10.1080/00365540410021180] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A retrospective matched case-control investigation was conducted to assess risk factors suggesting Pneumocystis jiroveci pneumonia (PCP) when pneumonia occurs in adult patients with haematological malignancies. Cases and controls included were HIV-negative, presented with pneumonia and had benefited from a bronchoalveolar lavage (BAL). The presence of Pneumocystis jiroveci cysts was systematically investigated by cytochemical staining and/or immunofluorescence. Cases were patients with Pneumocystis jiroveci cysts isolated on BAL fluid (n = 31, mean age 51+/-14 y; range 20-73 y). Controls were patients without Pneumocystis jiroveci cysts (n = 62, mean age 54+/-13 y; range 25-75 y) and were matched to case patients by age and y of pneumonia diagnosis. Statistical analysis indicated that the following factors were associated with PCP: vincristine (p = 0.009, odds ratio (OR) =2.11, 95% confidence interval (CI): 1.19-3.72), a daily corticosteroid therapy for more than 1 month (p = 0.05) during the past y, and a lymphocyte count less than 0.5 x 10(9)/l on the d of pneumonia diagnosis (p = 0.04). Clinicians should be aware, in order to evoke this diagnosis when pneumonia occurs in patients with these risk factors. The goal of this exploratory study was to identify risk factors that could eventually be further investigated by a larger prospective multicentre study.
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Affiliation(s)
- Donato Torre
- Section of Infectious Diseases, General Hospital, Cittiglio, Varese, Italy.
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Autoimmunvaskulitiden. Internist (Berl) 2009; 50:298-309. [DOI: 10.1007/s00108-008-2251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Manna R, Cadoni G, Ferri E, Verrecchia E, Giovinale M, Fonnesu C, Calò L, Armato E, Paludetti G. Wegener's granulomatosis: an update on diagnosis and therapy. Expert Rev Clin Immunol 2008; 4:481-95. [PMID: 20477576 DOI: 10.1586/1744666x.4.4.481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Wegener's granulomatosis (WG) is a unique clinicopathological disease characterized by necrotizing granulomatous vasculitis of the respiratory tract, pauci-immune necrotizing glomerulonephritis and small-vessel vasculitis. Owing to its wide range of clinical manifestations, WG has a broad spectrum of severity that includes the potential for alveolar hemorrhage or rapidly progressive glomerulonephritis, which are immediately life threatening. WG is associated with the presence of circulating antineutrophil cytoplasm antibodies (c-ANCAs). The most widely accepted pathogenetic model suggests that c-ANCA-activated cytokine-primed neutrophils induce microvascular damage and a rapid escalation of inflammation with recruitment of mononuclear cells. The diagnosis of WG is made on the basis of typical clinical and radiologic findings, by biopsy of involved organ, the presence of c-ANCA and exclusion of all other small-vessel vasculitis. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids is considered standard therapy. A number of trials have evaluated the efficacy of less-toxic immunosuppressants and antibacterials for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remission in certain subpopulations of patients. Recent investigation has focused on other immunomodulatory agents (e.g., TNF-alpha inhibitors and anti-CD20 antibodies), intravenous immunoglobulins and antithymocyte globulins for treating patients with resistant WG.
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Affiliation(s)
- R Manna
- Clinical Autoimmunity Unit, Department of Internal Medicine, Catholic University of the Sacred Heart, Largo A Gemelli, 8-00168 Rome, Italy.
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Abstract
Most frequent reasons for intensive care unit (ICU) admission in vasculitis patients are severe respiratory insufficiency due to diffuse alveolar haemorrhage, sepsis and/or pneumonia and an acute abdomen due to bowel infarction. Other reasons are massive gastrointestinal bleeding, thromboembolism and/or scissures. In a patient, not previously diagnosed as having vasculitis, diagnosis can be difficult and must be made as soon as possible, since immunosuppressive therapy should be instituted immediately. Immunosuppressive therapy in severe cases consists of high-dose corticosteroids and cyclophosphamide. In addition, in many cases plasma exchange has to be instituted as well. Prognosis is related to disease activity scores of vasculitis and of severity of illness as measured by the APACHE III scoring system and/or the SOFA score. Septic shock is still the leading cause of death in patients with vasculitis. Nowadays, death due to active untreated vasculitis is rare in experienced clinics.
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Affiliation(s)
- J W Cohen Tervaert
- Department of Clinical and Experimental Immunology, Univerity Hospital Maastricht, The Netherlands.
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Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev 2007:CD005590. [PMID: 17636808 DOI: 10.1002/14651858.cd005590.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) is a disease affecting immunocompromised patients. PCP among these patients is associated with significant morbidity and mortality. OBJECTIVES To assess the effectiveness of PCP prophylaxis among non-HIV immunocompromised patients. To define the type of immunocompromised patients for whom evidence suggests a benefit for PCP prophylaxis. SEARCH STRATEGY Electronic searches of The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 1, 2007), PubMed (March 2007), LILACS (March 2007), relevant conference proceedings; references of identified trials; the first author of each included trial was contacted. SELECTION CRITERIA RCTs or quasi- RCTs comparing prophylaxis with an antibiotic effective against Pneumocystis versus placebo, no intervention, an antibiotic/s with no activity against Pneumocystis or another antibiotic effective against Pneumocystis for immune-compromised non-HIV patients. Only trials pre-defining Pneumocystis infections as an outcome were included. DATA COLLECTION AND ANALYSIS Two authors independently appraised the quality of each trial and extracted data from included trials. Relative risks (RR), with 95% confidence intervals (CI) were estimated and pooled using the random effects model. MAIN RESULTS Eleven trials including 1155 patients (520 children), performed between the years 1974 and 1997, were included. Compared to no treatment or treatment with fluoroquinolones (inactive against Pneumocystis), there was a 91% reduction in the occurrence of PCP in patients receiving prophylaxis with trimethoprim/sulfamethoxazole, RR 0.09 (95% CI 0.02 to 0.32), eight trials, 821 patients. No significant difference was encountered in all cause mortality, RR 0.81 (95% CI 0.27 to 2.37), five trials, 509 patients, while PCP-related mortality was significantly reduced, RR 0.17 (95% CI 0.03 to 0.94), seven trials, 701 patients. Occurrence of leukopenia, neutropenia and their duration were not reported consistently. No significant difference in any adverse event was seen comparing trimethoprim/sulfamethoxazole to no treatment/ placebo (four trials, 470 patients). No differences between once daily versus thrice weekly trimethoprim/sulfamethoxazole were seen (two trials, 207 patients). AUTHORS' CONCLUSIONS Given an event rate of 7.5% as in included trials' control group, prophylaxis for PCP using TMP/SMX is highly effective among non-HIV patients, with a number needed to treat of 15 patients (95% CI 13 to 20). Prophylaxis should be considered for the types of patients with hematological malignancies, bone marrow transplantation and solid organ transplantation included in these trials.
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Affiliation(s)
- H Green
- Rabin Medical Center, Internal Medicine E, Beilinson Campus, Petah-Tikva, Israel, 49100.
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44
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Abstract
Wegener's granulomatosis (WG) is the most common pulmonary granulomatous vasculitis and was a uniformly fatal disease prior to the identification of efficacious pharmacological regimens. The pathogenesis of WG remains elusive but proteinase 3-specific anti-neutrophil cytoplasmic antibodies may be involved. Histologically, WG is defined by the triad of small vessel necrotising vasculitis, 'geographic' necrosis and granulomatous inflammation. Organ involvement characteristically includes the upper and lower respiratory tracts and kidney, but virtually any organ can be involved. The severity of the disease varies, ranging from asymptomatic disease to fulminant, fatal vasculitis. Similarly, the degree of organ involvement is highly variable; WG may be limited to a single organ (typically the lungs or upper respiratory tract), or may be systemic. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids, which induces complete remission in the majority of patients, is considered standard therapy. Since approximately 50% of patients experience a relapse following discontinuation of therapy, alternative regimens designed to maintain remissions after using cyclophosphamide and corticosteroids are usually necessary. This 'induction maintenance' approach to treatment has emerged as a central premise in planning therapy for patients with WG.A number of trials have evaluated the efficacy of less toxic immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil) and antibacterials (i.e. cotrimoxazole [trimethoprim/sulfamethoxazole]) for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remissions in certain sub-populations of patients. Given the efficacy of methotrexate (for early systemic WG) and cotrimoxazole (in WG limited solely to the upper airways) to induce remissions, and the relatively decreased associated morbidity compared with cyclophosphamide, these alternative regimens are preferred in appropriate patients. Similarly, therapeutic options to maintain disease remission that are less toxic than cyclophosphamide should be offered following induction of remission unless a specific contraindication exists. By following this premise, the development of cyclophosphamide-induced morbidities (e.g. haemorrhagic cystitis, uroepithelial cancers and prolonged myelosuppression) may be minimised. Recent investigation has focussed on other immunomodulatory agents (tumour necrosis factor-alpha inhibitors [infliximab and etanercept] and anti-CD20 antibodies [rituximab]) for treating patients with WG. However, the current data are conflicting and difficult to interpret. As a result, these newer agents cannot be recommended for routine use until vigorous clinical study confirms their efficacy.
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Affiliation(s)
- Eric S White
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan 48109, USA.
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45
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Aries PM, Hellmich B, Gross WL. [Glucocorticoids: importance in the treatment of vasculitis]. Z Rheumatol 2005; 64:155-61. [PMID: 15868332 DOI: 10.1007/s00393-005-0717-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Accepted: 02/15/2005] [Indexed: 10/25/2022]
Abstract
Only the modification of natural steroids in the middle of the last century gave insights into the structural requirements for the biological activity of the glucocorticoids (GC). While the delta-4,3-keto-11-beta, 17-alpha,21-trihydroxyl configuration is needed for the GC-activity, an artificial additional double binding in position 1 and 2 lead to a four fold increase of the GC-activity. Of the artificial GC, prednisolone is the most frequently used compound and essential in the therapy of vasculitis today. Dosage, duration and way of application depend on the diagnosis, disease stage, -extend as well as -activity. Considering the use and side-effects of the GC, experiences from cohort-studies of the late 80-ties help at clinical decision making. For giant cell arteritis (GCA) it was shown, that doses of less then 60 mg/day are needed for the induction of remission. Concerning the visual loss in GCA, time of initiating GC-therapy seems more important than the dosage. In the treatment of ANCA-associated vasculitis therapy with GC, later in combination with cyclophosphamide, lead to a significant reduction of mortality. Due to the fact of an increasing survival rate, therapy-related morbidity becomes a more and more important issue. There is a proven correlation between the dosage respectively duration of the GC-therapy and the risk of GC-associated side-effects, especially the incidence of severe infections. This article gives a short review of the present data of the role of GC in the treatment of vasculitis.
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Affiliation(s)
- P M Aries
- Universitätsklinikum Schleswig Holstein, Campus Lübeck und Rheumaklinik Bad Bramstedt, Oskar-Alexander-Strasse 26, 24576 Bad Bramstedt, Germany.
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Rodriguez M, Fishman JA. Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients. Clin Microbiol Rev 2005; 17:770-82, table of contents. [PMID: 15489347 PMCID: PMC523555 DOI: 10.1128/cmr.17.4.770-782.2004] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Pneumocystis infection in humans was originally described in 1942. The organism was initially thought to be a protozoan, but more recent data suggest that it is more closely related to the fungi. Patients with cellular immune deficiencies are at risk for the development of symptomatic Pneumocystis infection. Populations at risk also include patients with hematologic and nonhematologic malignancies, hematopoietic stem cell transplant recipients, solid-organ recipients, and patients receiving immunosuppressive therapies for connective tissue disorders and vasculitides. Trimethoprim-sulfamethoxazole is the agent of choice for prophylaxis against Pneumocystis unless a clear contraindication is identified. Other options include pentamidine, dapsone, dapsone-pyrimethamine, and atovaquone. The risk for PCP varies based on individual immune defects, regional differences, and immunosuppressive regimens. Prophylactic strategies must be linked to an ongoing assessment of the patient's risk for disease.
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Affiliation(s)
- Martin Rodriguez
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit St., GRJ 504, Boston, MA 02114, USA
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Harper L, Savage CO. ANCA-associated renal vasculitis at the end of the twentieth century--a disease of older patients. Rheumatology (Oxford) 2004; 44:495-501. [PMID: 15613403 DOI: 10.1093/rheumatology/keh522] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides are increasingly recognized in older patients. However, it is unknown whether disease presentation and response to treatment differs from younger patients. We aimed to examine the presentation, response to treatment and outcome of patients over 65 yr of age compared with a younger cohort. METHODS This retrospective, single centre, sequential cohort study reports presenting features and outcome of 233 consecutive new patients with ANCA-associated vasculitis between 1990 and 2000. RESULTS The median age of all patients was 65 yr (range 16-90 yr). Older patients (>65 yr) presented with more severe renal involvement at presentation (P < 0.001). Older patients were as likely to respond to treatment or undergo relapse as the younger patients. Older patients receiving immunosuppression had an increased risk of infection (P = 0.0027). Survival was worse in the older group (P = 0.016) and death occurred early. Mortality was associated with poor renal function (creatinine >400 micromol/l), infection and low serum albumin. Leucopenia was associated with severe renal impairment (P = 0.0048) and increased risk of infection (P = 0.0006). Multivariate analysis determined that serum creatinine >400 micromol/l and age were independent risk factors for poor prognosis. CONCLUSION ANCA-associated vasculitis occurs frequently in older patients and physicians should maintain a high index of suspicion. Older patients have a poorer prognosis due to more severe renal involvement and increased sensitivity to adverse effects of treatment. This study highlights the importance of careful dosing of cyclophosphamide: in those aged over 65 yr a 25% dose reduction is safe and reduces the risk of leucopenia. This study further highlights the importance of renal function on prognosis and the need for less toxic treatment regimens.
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Affiliation(s)
- L Harper
- Division of Immunlogy and Infection, The Medical School, University of Birmingham, Edgbaston, UK.
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Rencic A, Caeiro JP, Hernandez MI, Nousari HC. Prophylaxis in dermatologic patients receiving immunosuppressive therapy. Dermatol Ther 2002. [DOI: 10.1046/j.1529-8019.2002.01544.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fishman JA. Prevention of infection caused by Pneumocystis carinii in transplant recipients. Clin Infect Dis 2001; 33:1397-405. [PMID: 11565082 DOI: 10.1086/323129] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2001] [Revised: 06/05/2001] [Indexed: 11/04/2022] Open
Abstract
Pneumocystis carinii remains an important pathogen in patients who undergo solid-organ and hematopoietic transplantation. Infection results from reactivation of latent infection and via de novo acquisition of infection from environmental sources. The risk of infection depends on the intensity and duration of immunosuppression and underlying immune deficits. The risk is greatest after lung transplants, in individuals with invasive cytomegalovirus disease, during intensive immunosuppression for allograft rejection, and during periods of neutropenia. Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) prevents many opportunistic infections, including infection with P. carinii, Toxoplasma gondii, and community-acquired respiratory, gastrointestinal, and urinary tract pathogens. Intolerance of TMP-SMZ is common; desensitization is useful less often in transplant patients than in patients with AIDS. Alternative agents provide a narrower spectrum of protection than does TMP-SMZ and less adequate protection against Pneumocystis species. Clinically, the diagnosis of breakthrough Pneumocystis pneumonia often requires invasive procedures. Strategies for the prevention of Pneumocystis infection must be individualized on the basis of a stratification of risk for each patient.
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Affiliation(s)
- J A Fishman
- Infectious Disease Division and Transplantation Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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