Safe Use of Antirheumatic Agents in Patients with Comorbidities

Practical Pearls About Current Rheumatic Medications

New and existing rheumatic disease is frequently encountered in the primary care setting. The number of medications used to treat various rheumatic conditions continues to increase. Some medications have very specific indications, whereas others have increasing off-label uses. Regardless of the indication, the medications used in rheumatology have variable dosing recommendations, significant side effects, recommended monitoring parameters, and potential medication interactions. Clinicians need to be aware of the potential uses as well as possible pitfalls associated with medications used in rheumatology.

A case of acute respiratory failure in a rheumatoid arthritis patient after the administration of abatacept

Drug-induced pulmonary disease is an important consideration in the differential diagnosis of patients with rheumatoid arthritis (RA) who present with respiratory symptoms. We report a patient with RA who developed acute respiratory failure two weeks after the administration of abatacept. The clinical findings were consistent with drug-induced acute respiratory failure, most likely acute eosinophilic pneumonia. Pulse steroid was administered at 1000 mg/kg/day in the emergency department. Chest X-ray and arterial blood gas values revealed significant improvement on the second day of hospitalization. However, in the second week, the patient's fever rose up to 40°C, procalcitonin level increased to 15 ng/mL (<0.5 ng/mL is normal), and the patient died because of sepsis in the fourth week. This is the second report of respiratory failure, after the abatacept administration in the literature. We have reported an acute respiratory failure that occurred after use of the biological agent abatacept. With the increasing use of novel immunomodulatory agents, it is important for clinicians and pathologists to add the possibility of a drug reaction to the traditional differentials of acute respiratory failures occurring in these settings.

The safety of biologic therapies in RA-associated interstitial lung disease

Interstitial lung disease (ILD) is a common extra-articular manifestation associated with increased morbidity and mortality in patients with rheumatoid arthritis (RA). Early case reports of serious respiratory adverse events (SRAEs) following treatment with anti-TNF agents have led to concerns about biologic therapy in patients with RA-associated ILD (RA-ILD), and a tendency for biologic agents targeting factors other than TNF to be prescribed in such patients. At present, the appropriateness of such decisions is not clear. Given that the therapeutic goal for RA is remission, clinicians increasingly face the challenge of choosing the optimal biologic agent in patients with RA-ILD and uncontrolled joint disease. However, no evidence-based guidelines exist to guide physicians in deciding whether to commence biologic therapy in this setting, or in selecting which drug is most appropriate. Herein, we review the evidence for the comparative pulmonary safety of anti-TNF agents and non-TNF-targeting biologic agents in RA-ILD. In addition, we propose a framework for assessment of baseline disease severity to guide treatment decisions, and for monitoring during therapy. Because of substantial gaps in the available evidence, we also describe a research agenda aimed at obtaining data that will help inform future clinical practice.

Rheumatoid arthritis in the elderly: recent advances in understanding the pathogenesis, risk factors, comorbidities and risk–benefit of treatments

Rheumatoid arthritis (RA) increases in incidence and prevalence with age, with a peak in the sixth decade of life. Elderly onset RA (EORA) may be genetically different from younger onset RA, and with immune dysfunction associated with aging, environmental factors may also influence EORA onset. Smoking, periodontitis and viral infections are examples of environmental factors that have been shown to be associated with development of EORA, and even hormonal changes with menopause may be a source of RA activation in older patients. EORA can be distinguished from polymyalgia rheumatica, inflammatory hand osteoarthritis or psoriatic arthritis by rheumatoid factor or anticitrullinated protein antibodies. Comorbidities influence treatment risk–benefit and require proactive management; these include arteriosclerotic cardiovascular disease, obesity, diabetes, GI tract conditions, lung disease, renal disease or malignancies, as well as susceptibility to infection. As inclusion of older RA patients is lower in clinical trials, safety data in this group are limited and this influences treatment choice, especially for biologics. Despite the efficacy of biologics, they are less likely to be used in older RA patients. This is problematic as glucocorticoids, when used in the elderly, are associated with serious infections, cardiovascular and fracture risk, among other side effects. Similarly, analgesics and NSAIDs should be used cautiously. Taking into account comorbidities, treat-to-target strategies with nonbiologic disease-modifying antirheumatic drugs and biologics can be applied with an expectation of acceptable risk–benefit in these patients.