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Embaby A, Maged LA, Abdel-Hamid HM, El Hadidi KT. Factors associated with severe infection in rheumatoid arthritis patients: lessons learned from the COVID-19 pandemic. Infection 2024:10.1007/s15010-024-02187-z. [PMID: 38381306 DOI: 10.1007/s15010-024-02187-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/15/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE This aimed to identify the factors associated with severe/critical coronavirus disease 2019 (COVID-19) infection in rheumatoid arthritis (RA) patients. METHODS Two-hundred RA patients diagnosed according to the American College of Rheumatology/ European League Against Rheumatism (ACR/EULAR) classification criteria with proven COVID-19 infection were recruited and categorized according to the world health organization (WHO) COVID-19 severity grading into 2 groups: patients with mild/moderate COVID-19 (n = 164) and patients with severe/critical COVID-19 (n = 36). Comparison between both groups was done to identify the risk factors associated with severe/critical infection. Incidence of RA disease activity flare defined as increase in clinical disease activity index (CDAI) more than 10 points following infection was calculated. RESULTS Multivariate analysis identified history of previous serious infection, age > 60 years, and diabetes as factors positively associated, whereas COVID-19 vaccination was negatively associated with severe/critical infection. Following COVID-19 infection, the number of patients with severe/critical COVID-19 who had high RA disease activity and the incidence of flares was significantly higher in comparison to patients with mild/moderate COVID-19 (P < 0.001 and 0.003; respectively). CONCLUSION Age > 60 years, diabetes, and history of previous serious infections are risk factors for severe/critical COVID-19, while vaccination has a protective role in RA patients. Infection particularly when severe is associated with risk of disease flare.
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Affiliation(s)
- Aya Embaby
- Rheumatology Department, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Lobna A Maged
- Rheumatology Department, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Hoda M Abdel-Hamid
- Chest Department, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Khaled T El Hadidi
- Rheumatology Department, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Xie W, Huang H, Zhang Z. Prediction of flare following glucocorticoids withdrawal in rheumatoid arthritis patients with continuation of csDMARDs: a real-life study. Intern Emerg Med 2023; 18:1759-1767. [PMID: 37418144 DOI: 10.1007/s11739-023-03362-0] [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: 04/03/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To determine the risk factors for flare after glucocorticoids (GC) withdrawal in rheumatoid arthritis (RA) patients with undergoing conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). METHODS RA patients who discontinued GC with continuation of csDMARD were selected from a longitudinal real-world cohort. Established RA was defined as disease duration over 12 months. Dissatisfied RA control was defined as the proportion of simplified disease activity index (SDAI)-based remission time to total time from GC initiation to discontinuation less than 50%. Logistic regression was used to analyze the independent risk factors for flare after GC discontinuation and results were expressed as odds ratio (OR). RESULTS There were 115 eligible RA patients discounted GC with continuation of csDMARDs (methotrexate: 80%; hydroxychloroquine: 61%; csDMARDs combination: 79%). Of these, 24 patients experienced flare after GC discontinuation. Compared with relapse-free patients, flare patients were more likely to have established RA (75% vs 49%, p = 0.025), higher median cumulative prednisolone dosages (3.3 vs 2.2 g, p = 0.004), and higher proportion of dissatisfied RA control during GC usage (66% vs 33%, p = 0.038). In multivariate analysis, significantly increased flare risk was predicted by established RA (OR 2.93 [1.02-8.43]), cumulative prednisolone dose > 2.5 g (OR 3.69 [1.34-10.19]) and dissatisfied RA control (OR 3.00 [1.09-8.30]). Flare risk was increased with increases in number of risk factors with highest OR of 11.56 in patients with three risk factors (p for trend = 0.002). CONCLUSIONS Flare following GC withdrawal is not common in RA patients with undergoing csDMARDs therapy. Established RA, higher cumulative GC dose and dissatisfied RA control before GC discontinuation are important factors associated with flare after GC withdrawal.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China.
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Kitamura N, Kobayashi H, Nagasawa Y, Sugiyama K, Tsuzuki H, Tanikawa Y, Ikumi N, Okada Y, Takahashi Y, Asai S, Tamura N, Ogasawara M, Kawamoto T, Kuwatsuru R, Tamaki H, Kidoguchi G, Tateishi M, Kimura M, Mochida Y, Harigane K, Shimazaki T, Koike T, Tanimura K, Kataoka H, Amano K, Yasuoka H, Takei M. Risk factors associated with relapse after methotrexate dose reduction in patients with rheumatoid arthritis receiving golimumab and methotrexate combination therapy. Int J Rheum Dis 2023. [PMID: 37058849 DOI: 10.1111/1756-185x.14695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/06/2023] [Accepted: 03/25/2023] [Indexed: 04/16/2023]
Abstract
AIM To identify risk factors for relapse after methotrexate (MTX) dose reduction in rheumatoid arthritis (RA) patients receiving golimumab (GLM)/MTX combination therapy. METHOD Data on RA patients ≥20 years old receiving GLM (50 mg) + MTX for ≥6 months were retrospectively collected. MTX dose reduction was defined as a reduction of ≥12 mg from the total dose within 12 weeks of the maximum dose (≥1 mg/wk average). Relapse was defined as Disease Activity Score in 28 joints using C-reactive protein level (DAS28-CRP) score ≥3.2 or sustained (≥ twice) increase of ≥0.6 from baseline. RESULTS A total of 304 eligible patients were included. Among the MTX-reduction group (n = 125), 16.8% of patients relapsed. Age, duration from diagnosis to the initiation of GLM, baseline MTX dose, and DAS28-CRP were comparable between relapse and no-relapse groups. The adjusted odds ratio (aOR) of relapse after MTX reduction was 4.37 (95% CI 1.16-16.38, P = 0.03) for prior use of non-steroidal anti-inflammatory drugs (NSAIDs), and the aORs for cardiovascular disease (CVD), gastrointestinal disease and liver disease were 2.36, 2.28, and 3.03, respectively. Compared to the non-reduction group, the MTX-reduction group had a higher proportion of patients with CVD (17.6% vs 7.3%, P = 0.02) and a lower proportion of prior use of biologic disease-modifying antirheumatic drugs (11.2% vs. 24.0%, P = 0.0076). CONCLUSION Attention should be given to RA patients with history of CVD, gastrointestinal disease, liver disease, or prior NSAIDs-use when considering MTX dose reduction to ensure benefits outweigh the risks of relapse.
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Affiliation(s)
- Noboru Kitamura
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hitomi Kobayashi
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Yosuke Nagasawa
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Kaita Sugiyama
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Tsuzuki
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Tanikawa
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Natsumi Ikumi
- Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Yuito Okada
- Clinical Trials Research Center, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Takahashi
- Clinical Trials Research Center, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Asai
- Department of Pharmacology and Biofunction Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Naoto Tamura
- Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Michihiro Ogasawara
- Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Toshio Kawamoto
- Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology & Center for Promotion of Data Science, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Genki Kidoguchi
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Mutsuto Tateishi
- Department of Rheumatology, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Makiko Kimura
- Department of Rheumatology, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Yuichi Mochida
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Kengo Harigane
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Takayuki Shimazaki
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Takao Koike
- Hokkaido Medical Center for Rheumatic Diseases, Sapporo, Japan
| | | | - Hiroshi Kataoka
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center Saitama Medical University, Saitama, Japan
| | - Hidekata Yasuoka
- Department of Internal Medicine, Division of Rheumatology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masami Takei
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
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Bozzalla-Cassione E, Grignaschi S, Xoxi B, Luvaro T, Greco MI, Mazzucchelli I, Bugatti S, Montecucco C, Manzo A. Insights Into the Concept of Rheumatoid Arthritis Flare. Front Med (Lausanne) 2022; 9:852220. [PMID: 35372374 PMCID: PMC8968115 DOI: 10.3389/fmed.2022.852220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/04/2022] [Indexed: 01/10/2023] Open
Abstract
Identification of a pathological change in the course of systemic chronic immune-inflammatory diseases is key to delivering effective treatment strategies. In this context, one of the most compelling issues is the concept of flare. The multifaceted expression of disease activity in rheumatoid arthritis (RA) makes it challenging to provide an omni-comprehensive definition of flare, encompassing the pathology's different objective and subjective domains. Our incomplete understanding of the pathophysiological mechanisms underlying this process contributes to the partial comprehension of its potential clinical expression. This review focuses on the proposed pathophysiological processes underlying disease recrudescence in RA and the variable definitions adopted to capture flare in clinical practice through its objective, subjective, and temporal domains. Overall, what emerges is a complex landscape far from being unraveled.
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Park JW, Kim MJ, Kim HA, Kim JH, Lee EB, Shin K. The Aftermath of Tapering Tocilizumab After Achieving Treatment Target in Patients With Rheumatoid Arthritis: A Nationwide Cohort Study. Front Med (Lausanne) 2022; 9:839206. [PMID: 35211491 PMCID: PMC8860908 DOI: 10.3389/fmed.2022.839206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/17/2022] [Indexed: 01/08/2023] Open
Abstract
Background Although recent guidelines recommend that tapering of biologic disease-modifying anti-rheumatic drugs (bDMARDs) can be considered in patients with rheumatoid arthritis (RA), there has been little evidence supporting the strategy during the non-tumor necrosis factor inhibitor treatment. This study aims to investigate the effectiveness and safety of tapering tocilizumab (TCZ) dose in patients with RA who attain low disease activity (LDA) after TCZ therapy in a nationwide cohort. Methods Data were collected from a nationwide cohort of patients with RA receiving biologic disease-modifying anti-rheumatic drugs in South Korea (KOBIO-RA). This study included 350 patients who were treated with TCZ and achieved Clinical Disease Activity Index-low disease activity (CDAI)-LDA (CDAI ≤ 10) after 1 year of treatment. We performed longitudinal analysis considering clinical data measured at all 1-year intervals for the included patients using the generalized estimating equation. A total of 575 intervals were classified into two groups according to their dose quotient (DQ) of TCZ (tapering group vs. standard-dose group). The main outcome was maintaining CDAI-LDA in the following 1-year interval. Results Tapering TCZ dose strategy was used in 282 (49.0%) intervals with a mean (SD) DQ of 66.0 (15.5) %. Loss of CDAI-LDA occurred in 91 (15.1%) intervals. Multivariable GEE showed that the tapering group was associated with more frequent failure to sustain CDAI-LDA (adjusted OR [95% CI]: 0.57 [0.33–0.99]), which subsequently led to impaired functional status. The likelihood of achieving DAS28-deep remission (DAS28-ESR <1.98) was also significantly lower in the tapering group (adjusted OR 0.68 [0.46–0.99]). CDAI remission was achieved in only 69 (12.0%) of the total intervals, with no significant difference in the proportion of intervals achieving the target between the two groups. Incidence of adverse events was comparable in both groups except for hypercholesterolemia, which was lower in the tapering group. Conclusions Tapering TCZ dose after achieving LDA increases the risk of losing LDA without a significant merit in safety.
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Affiliation(s)
- Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Min Jung Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul Boramae Medical Center, Seoul, South Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Hyun Kim
- Division of Rheumatology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul Boramae Medical Center, Seoul, South Korea
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Araujo CSR, Medeiros-Ribeiro AC, Saad CGS, Bonfiglioli KR, Domiciano DS, Shimabuco AY, Silva MSR, Yuki EFN, Pasoto SG, Pedrosa T, Kupa LDVK, Zou G, Pereira RMR, Silva CA, Aikawa NE, Bonfa E. Two-week methotrexate discontinuation in patients with rheumatoid arthritis vaccinated with inactivated SARS-CoV-2 vaccine: a randomised clinical trial. Ann Rheum Dis 2022; 81:889-897. [PMID: 35193873 DOI: 10.1136/annrheumdis-2021-221916] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the effect on immunogenicity and safety of 2-week methotrexate (MTX) discontinuation after each dose of the Sinovac-CoronaVac vaccine versus MTX maintenance in patients with rheumatoid arthritis (RA). METHODS This was a single-centre, prospective, randomised, investigator-blinded, intervention study (NCT04754698, CoronavRheum) including adult patients with RA (stable Clinical Disease Activity Index (CDAI) ≤10, prednisone ≤7.5 mg/day) randomised (1:1) to withdraw MTX (MTX-hold) for 2 weeks after each vaccine dose or maintain MTX (MTX-maintain), evaluated at day 0 (D0), D28 and D69. Coprimary outcomes were anti-SARS-CoV-2 S1/S2 IgG seroconversion (SC) and neutralising antibody (NAb) positivity at D69. Secondary outcomes were geometric mean titres (GMT) and flare rates. For immunogenicity analyses, we excluded patients with baseline positive IgG/NAb, and for safety reasons those who flared at D28 (CDAI >10) and did not withdraw MTX twice. RESULTS Randomisation included 138 patients with 9 exclusions (5 COVID-19, 4 protocol violations). Safety evaluation included 60 patients in the MTX-hold and 69 patients in the MTX-maintain group. Further exclusions included 27 patients (13 (21.7%) vs 14 (20.3%), p=0.848) with positive baseline IgG/NAb and 10 patients (21.3%) in MTX-hold with CDAI >10 at D28. At D69, the MTX-hold group (n=37) had a higher rate of SC than the MTX-maintain group (n=55) (29 (78.4%) vs 30 (54.5%), p=0.019), with parallel augmentation in GMT (34.2 (25.2-46.4) vs 16.8 (11.9-23.6), p=0.006). No differences were observed for NAb positivity (23 (62.2%) vs 27 (49.1%), p=0.217). At D28 flare, the rates were comparable in both groups (CDAI, p=0.122; Disease Activity Score in 28 joints with C reactive protein, p=0.576), whereas CDAI >10 was more frequent in MTX-hold at D69 (p=0.024). CONCLUSION We provided novel data that 2-week MTX withdrawal after each dose of the Sinovac-CoronaVac vaccine improves anti-SARS-CoV-2 IgG response. The increased flare rates after the second MTX withdrawal may be attributed to the short-term interval between vaccine doses. This strategy requires close surveillance and shared decision making due to the possibility of flares.
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Affiliation(s)
| | | | - Carla G S Saad
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Karina Rossi Bonfiglioli
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Diogo Souza Domiciano
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Andrea Yukie Shimabuco
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | | | | | - Sandra Gofinet Pasoto
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Tatiana Pedrosa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | | | - Gioanna Zou
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Rosa M R Pereira
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Clóvis Artur Silva
- Pediatric Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Nádia Emi Aikawa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
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