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Enos CW, Ormaza Vera A, Van Voorhees AS. Clinical Data on Laboratory Testing for Patients Taking Systemic Immunomodulatory Agents: Do We Order Them Enough or Too Much? JAMA Dermatol 2024; 160:271-272. [PMID: 38294807 DOI: 10.1001/jamadermatol.2023.5891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Clinton W Enos
- Department of Dermatology, Eastern Virginia Medical School, Norfolk
| | - Ana Ormaza Vera
- Department of Dermatology, Eastern Virginia Medical School, Norfolk
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Lupea-Chilom DS, Solovan CS, Farcas SS, Gogulescu A, Andreescu NI. Latent Tuberculosis in Psoriasis Patients on Biologic Therapies: Real-World Data from a Care Center in Romania. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1015. [PMID: 37374219 DOI: 10.3390/medicina59061015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/20/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Psoriasis is a chronic and inflammatory condition that has a huge impact on the patient's quality of life. Biological treatment improved psoriasis therapy, with impressive results seen in the evolution of the disease and the patient's quality of life. However, the risk of mycobacterium tuberculosis (MTB) infection reactivation is well-known to biological therapy, which raises problems especially in an endemic country. Materials and Methods: In this study, we followed moderate to severe psoriasis patients who had latent tuberculosis infection (LTBI) following treatment with a biological therapy approved in Romania. Results: The patients were evaluated at baseline and then followed-up with Mantoux tests and chest X-rays every year, resulting in 54 patients being diagnosed with LTBI. At the initial evaluation, 30 patients with LTBI were identified, and 24 more were identified during biological therapy. These patients were given prophylactic treatment. Out of the 97 participants in this retrospective study, 25 required association of methotrexate (MTX) alongside biological therapy. We compared the prevalence of positive Mantoux tests in patients with combined therapy with that of patients only on biological treatment, and the results were higher in the combined therapy group. Conclusion: All the patients in the study were vaccinated against tuberculosis (TB) after birth, and none were diagnosed with active tuberculosis (aTB) before or after the start of therapy according to the pulmonologist.
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Affiliation(s)
- Doriana-Sorina Lupea-Chilom
- Department of Dermatology, University of Medicine and Pharmacy "Victor Babeş", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Caius Silviu Solovan
- Department of Dermatology, University of Medicine and Pharmacy "Victor Babeş", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Simona Sorina Farcas
- Department of Microscopic Morphology-Genetics, Center of Genomic Medicine, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Armand Gogulescu
- Department of Medical Rehabilitation, University of Medicine and Pharmacy "Victor Babeş", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Nicoleta Ioana Andreescu
- Department of Microscopic Morphology-Genetics, Center of Genomic Medicine, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
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De Simone C, Fargnoli MC, Amerio P, Bianchi L, Esposito M, Pirro F, Potenza C, Ricceri F, Rongioletti F, Stingeni L, Prignano F. Risk of infections in psoriasis: assessment and challenges in daily management. Expert Rev Clin Immunol 2021; 17:1211-1220. [PMID: 34696673 DOI: 10.1080/1744666x.2021.1997592] [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] [Indexed: 02/07/2023]
Abstract
INTRODUCTION In daily practice management of psoriasis, evaluation of risk factors for infections is having a growing influence. Indeed, in psoriatic patients, risk of infections may be due to psoriasis itself, immunomodulatory therapy, and comorbidities that may increase this risk and patient hospitalization. AREAS COVERED Given the greater understanding of psoriasis pathogenesis and the increasing number of treatment options, it is particularly important to customize therapy according to each, single patient; psoriasis features and comorbidities are also essential to tailor treatment goals. EXPERT OPINION In this perspective, the current knowledge on the infectious risk in psoriatic patient, related to comorbidities, such as diabetes mellitus, cardiovascular disease, and chronic obstructive pulmonary, to 'special populations,' to chronic infections, such as latent tuberculosis, chronic hepatitis B and C, and HIV, and to the most recent Covid-19 pandemic scenario, is reviewed and discussed in order to suggest the most appropriate approach and achieve the best available therapeutic option.
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Affiliation(s)
- Clara De Simone
- Institute of Dermatology, Catholic University, Rome, Italy.,Dermatology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Concetta Fargnoli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Paolo Amerio
- Department of Medicine and Aging Science and Dermatologic Clinic, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Luca Bianchi
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University of Rome, Italy
| | - Maria Esposito
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federico Pirro
- Institute of Dermatology, Catholic University, Rome, Italy.,Dermatology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Concetta Potenza
- Dermatology Unit "Daniele Innocenzi", Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Federica Ricceri
- Unit of Dermatology, Department of Health Science, University of Florence, Florence, Italy
| | - Franco Rongioletti
- Dermatology Clinic, Department of Medical Sciences and Public Health, University of Cagliari, via Università 40, 09124 Cagliari, Italy, IRCCS San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Luca Stingeni
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Francesca Prignano
- Unit of Dermatology, Department of Health Science, University of Florence, Florence, Italy
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Okada F, Fukushi JI, Matsubara H, Ishitani EI, Sonoda Y, Katsuki I. Tuberculosis osteomyelitis in an old fused hip; activated by prednisolone, salazosulfapyridine, and low-dose methotrexate therapy in a patient with rheumatoid arthritis. Mod Rheumatol Case Rep 2020; 4:171-175. [PMID: 33087003 DOI: 10.1080/24725625.2020.1739194] [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] [Indexed: 02/07/2023]
Abstract
Osteoarticular tuberculosis can occur in patients with rheumatoid arthritis (RA) receiving immunosuppressive therapy. Here, we describe a case of tubercular osteomyelitis in an old fused hip of a patient with RA who received prednisolone, salazosulfapyridine (SASP), and low-dose methotrexate (MTX). A 77-year-old man with a 4-year history of RA was admitted with a complaint of general fatigue. His symptoms of RA had been well controlled with a combination of prednisolone, SASP, and low-dose MTX. Because the laboratory data showed an increase in serum C-reactive protein levels, we suspected pneumonia. There was expansion of a pre-existing consolidation in the right lower lobe of his lung on chest computed tomography, and the sputum culture was positive for Klebsiella oxytoca. His family physician prescribed empiric antibiotics for pneumonia. Although the QuantiFERON® test result was positive, the acid-fast bacillus staining result was negative in the sputum. He started complaining of pain in his left hip, where arthrodesis was performed for an unknown reason at the age of 20 years. Sonographic examination of his left thigh revealed fluid collection. The aspiration culture of the fluid was positive for Mycobacterium tuberculosis. He was initiated on rifampicin, isoniazid, pyrazinamide, and ethambutol. Surgical debridement of the fused left hip was performed twice along with a removal of previously implanted materials. Although infrequent, osteoarticular tuberculosis can occur during immunosuppressive therapy, especially in elderly patients. Physicians should be aware of a history of possible tuberculosis infection, such as hip arthrodesis, when prescribing MTX along with SASP and corticosteroid in the elderly.
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Affiliation(s)
- Fumi Okada
- Department of Orthopaedic surgery, Fukuoka Shion Hospital, Ogori-shi, Japan
| | - Jun-Ichi Fukushi
- Department of Orthopaedic surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka-shi, Japan
| | - Hirokazu Matsubara
- Department of Orthopaedic surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga-shi, Japan
| | - Ei-Ichi Ishitani
- Department of Orthopaedic surgery, Fukuoka Shion Hospital, Ogori-shi, Japan
| | - Yasuo Sonoda
- Department of Orthopaedic surgery, Fukuoka Shion Hospital, Ogori-shi, Japan
| | - Ichiro Katsuki
- Department of Orthopaedic surgery, Fukuoka Shion Hospital, Ogori-shi, Japan
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Cantini F, Niccoli L, Capone A, Petrone L, Goletti D. Risk of tuberculosis reactivation associated with traditional disease modifying anti-rheumatic drugs and non-anti-tumor necrosis factor biologics in patients with rheumatic disorders and suggestion for clinical practice. Expert Opin Drug Saf 2019; 18:415-425. [PMID: 31066297 DOI: 10.1080/14740338.2019.1612872] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Two classes of biologics, anti-tumor necrosis factor (TNF) and non-anti-TNF targeted, are currently available for the treatment of rheumatic diseases. AREAS COVERED Discussion on the need for LTBI diagnosis in rheumatic patients treated csDMARDs and non-anti-TNFs through a review of the literature. The literature, updated to 15 April 2019, on tuberculosis (TB) reactivation risk in patients exposed to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and non-anti-TNF biologics was reviewed. EXPERT OPINION An increased risk of TB reactivation in patients receiving csDMARDs (except sulphasalazine) resulted, while a review of clinical trials, and Periodic Safety Update Reports from pharmaceutical Companies evidenced a very low or absent risk for non-anti-TNF biologics. Hence, a contradiction emerges considering that latent TB infection (LTBI) screening is recommended for non-anti-TNF candidates but not for csDMARDs. Concerning the low TB incidence countries, several actions could be undertaken, including to screen all patients independently on the treatment, to omit the procedure in non-anti-TNF candidates, or to perform the LTBI investigations only in high-risk patients. According to WHO guidelines, LTBI screening in low TB risk countries seems unnecessary, except in high TB risk subjects.
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Affiliation(s)
- Fabrizio Cantini
- a Department of Rheumatology , Hospital of Prato , Prato , Italy
| | - Laura Niccoli
- a Department of Rheumatology , Hospital of Prato , Prato , Italy
| | - Alessandro Capone
- b Clinical Department , National Institute for Infectious Diseases L. Spallanzani-IRCCS , Rome , Italy
| | - Linda Petrone
- c Translational Research Unit, Department of Epidemiology and Preclinical Research , "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS , Rome , Italy
| | - Delia Goletti
- c Translational Research Unit, Department of Epidemiology and Preclinical Research , "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS , Rome , Italy
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Psoriasis: Which therapy for which patient. J Am Acad Dermatol 2019; 80:43-53. [DOI: 10.1016/j.jaad.2018.06.056] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/24/2018] [Accepted: 06/01/2018] [Indexed: 12/17/2022]
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Carrascosa J, de la Cueva P, Ara M, Puig L, Bordas X, Carretero G, Ferrándiz L, Sánchez-Carazo J, Daudén E, López-Estebaranz J, Vidal D, Herranz P, Jorquera E, Coto-Segura P, Ribera M. Methotrexate in Moderate to Severe Psoriasis: Review of the Literature and Expert Recommendations. ACTAS DERMO-SIFILIOGRAFICAS 2016. [DOI: 10.1016/j.adengl.2016.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Methotrexate in Moderate to Severe Psoriasis: Review of the Literature and Expert Recommendations. ACTAS DERMO-SIFILIOGRAFICAS 2015; 107:194-206. [PMID: 26614486 DOI: 10.1016/j.ad.2015.10.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/16/2015] [Accepted: 10/05/2015] [Indexed: 12/28/2022] Open
Abstract
Methotrexate (MTX) is the most frequently used conventional systemic drug in the treatment of psoriasis. Despite over 50years of experience in this setting, certain aspects of the use of this drug in clinical practice are still little standardized and poorly understood. For this reason, a group of 15 experts took part in a consensus development conference to achieve consensus on a series of recommendations on the use of MTX in psoriasis. The guidelines, which were developed on the basis of a systematic review of the literature, were validated by 2 rounds of voting and categorized by level of evidence and grade of recommendation. Before MTX can be used to treat moderate to severe psoriasis, the patient must be evaluated to assess the suitability of the treatment, including consideration of vaccination status and screening for tuberculosis and pregnancy. The recommended starting dose for a patient with no risk factors is 10 to 20mg/wk, the therapeutic dose for most patients is 15mg/wk, and the maximum dose is 20mg/wk. Most patients who respond to treatment will show improvement within 8weeks. Parenteral administration of MTX is desirable when there is a risk of erroroneous dosing, nonadherence, gastrointestinal intolerance, or inadequate response to the therapeutic dose taken orally. Noninvasive methods are preferred for monitoring hepatotoxicity. MTX is a good treatment option for patients with a history of cancer, but is not recommended in patients with chronic hepatitisB infection or individuals who are seropositive for human immunodeficiency virus.
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Chen YJ, Wu CY, Shen JL, Chen TT, Chang YT. Association between traditional systemic antipsoriatic drugs and tuberculosis risk in patients with psoriasis with or without psoriatic arthritis: Results of a nationwide cohort study from Taiwan. J Am Acad Dermatol 2013; 69:25-33. [DOI: 10.1016/j.jaad.2012.12.966] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 12/08/2012] [Accepted: 12/18/2012] [Indexed: 12/17/2022]
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National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents. J Am Acad Dermatol 2008; 59:209-17. [DOI: 10.1016/j.jaad.2008.03.023] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 03/10/2008] [Accepted: 03/18/2008] [Indexed: 12/12/2022]
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Abstract
Extraintestinal manifestations of inflammatory bowel disease (IBD) is a common clinical problem affecting up to half of all IBD patients; pulmonary disease, however, ranks among less common extraintestinal manifestations of IBD. Pulmonary disease in patients with IBD is most frequently drug induced due to treatment with sulfasalazine or mesalamine leading to eosinophilic pneumonia and fibrosing alveolitis or due to treatment with methotrexate leading to pneumonitis. Recently, various opportunistic infections have been shown to be a further important cause of pulmonary abnormalities in those IBD patients who are treated with immunosuppressants such as anti TNF-α monoclonal antibodies, methotrexate, azathioprine or calcineurin antagonists. In not drug related pulmonary disease a wide spectrum of disease entities ranging from small and large airway dysfunction to obstructive and interstitial lung disorders exist. Patients with lung disorders and inflammatory bowel disease should be evaluated for drug-induced lung disease and opportunistic infections prior to considering pulmonary disease as an extraintestinal manifestation of inflammatory bowel disease.
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Leccese K, Ferreira J, Delorme J, Montreuil B. Tuberculous pseudoaneurysm of the femoral artery complicated by cutaneous tuberculosis of the foot: a case report. J Vasc Surg 2006; 44:654-7. [PMID: 16950450 DOI: 10.1016/j.jvs.2006.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Accepted: 05/15/2006] [Indexed: 11/24/2022]
Abstract
An infected pseudoaneurysm of the right common femoral artery in a 69-year-old patient receiving methotrexate therapy was confirmed to have been caused by Mycobacterium tuberculosis. After surgical excision of the aneurysm and revascularization using femoral vein, cutaneous manifestations of M tuberculosis infection in the foot complicated the course. We hypothesized that methotrexate may have triggered the reactivation of dormant tuberculosis in this patient. Because extrapulmonary tuberculous pseudoaneurysms are clinically similar to other types of infected pseudoaneurysm, M tuberculosis infection should always be suspected during the initial diagnosis. We propose that mycobacterial cultures should be routine when initial cultures and Gram stain are negative.
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Affiliation(s)
- Kathryn Leccese
- Department of Surgery, Division of Vascular Surgery, Hôpital Maisonneuve-Rosemont
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Lins MC, de Moura EG, Lisboa PC, Bonomo IT, Passos MCF. Effects of maternal leptin treatment during lactation on the body weight and leptin resistance of adult offspring. ACTA ACUST UNITED AC 2005; 127:197-202. [PMID: 15680487 DOI: 10.1016/j.regpep.2004.12.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2004] [Accepted: 12/01/2004] [Indexed: 11/21/2022]
Abstract
We investigate whether leptin treatment to lactating rats affects food intake, body weight and leptin serum concentration and its anorectic effect on their adult offspring. Lactating rats were divided into 2 groups: Lep-single injected with recombinant rat leptin (8 microg/100 g of body weight, daily for the last 3 consecutive days of lactation) and control group (C) that received the same volume of saline. After weaning all pups had free access to the control diet, their body weight and food intake were monitored at each 4 days until 180 days of age, when they were tested for its food intake and response to either leptin (0.5 mg/kg body wt, ip) or saline vehicle. The offspring of the leptin-treated dams gained more weight and had higher food intake from day 37 onward (p<0.05), higher amount of retroperitoneal white adipose tissue (RPWAT) (37%, p<0.05) and higher leptin serum concentration (40%, p<0.05) at 180 days of age compared to control group. The food intake at 2, 4, 6 and 24 h was unaffected after acute injection of leptin in these animals, suggesting resistance to the anorectic effect of leptin. The maternal leptin treatment during lactation makes their adult offspring more susceptible to overweight with resistance to the anorectic effect of leptin.
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Affiliation(s)
- Márcia Clements Lins
- Departamento de Ciências Fisiológicas-5 andar, Instituto de Biologia-Universidade do Estado do Rio de Janeiro, Av. 28 de setembro, 87-Rio de Janeiro, RJ, 20550-030, Brazil
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Wolfe F, Michaud K, Anderson J, Urbansky K. Tuberculosis infection in patients with rheumatoid arthritis and the effect of infliximab therapy. ACTA ACUST UNITED AC 2004; 50:372-9. [PMID: 14872478 DOI: 10.1002/art.20009] [Citation(s) in RCA: 281] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE According to the Centers for Disease Control and Prevention, the 1999 and 2000 incidence rates for tuberculosis (TB) in the US population were 6.4 and 5.8, respectively, per 100,000 persons. Recently, reports of TB following infliximab administration have raised questions regarding the rate of TB in patients with rheumatoid arthritis (RA) generally and in those treated with infliximab in clinical practice. We undertook this study to determine the baseline rate of TB in RA prior to the introduction of infliximab and to determine the rate of TB among those currently receiving infliximab. METHODS We surveyed patients with questionnaires, followed by detailed validation from medical records and physician reports. In study 1, we evaluated 10,782 RA patients in 1998-1999 prior to the widespread use of infliximab. In study 2, we evaluated 6,460 infliximab-treated patients in 2000-2002. RESULTS In study 1, the lifetime rate of TB was 696 per 100,000 patients (95% confidence interval [95% CI] 547-872). Of these cases, 76.8% occurred prior to the onset of RA. During the period of prospective followup, 1 case of TB developed during 16,173 patient-years of followup, yielding a rate of 6.2 cases (95% CI 1.6-34.4) per 100,000 patients. In study 2, the TB incidence rate among infliximab-treated patients was 52.5 cases (95% CI 14.3-134.4) per 100,000 patient-years of exposure. Three of the 4 cases occurred in patients with a history of TB exposure, and no cases occurred in persons with recent TB skin tests or prophylaxis. CONCLUSION The rate of TB is not increased in RA patients generally. Among infliximab-treated patients, the rate is 52.5 cases (95% CI 14.3-134.4) per 100,000 patient-years of exposure. A thorough medical history regarding TB, as well as tuberculin testing and radiographic examination (if indicated), should be an essential component of anti-tumor necrosis factor therapy.
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Affiliation(s)
- Frederick Wolfe
- National Data Bank for Rheumatic Diseases, Wichita, Kansas, and University of Kansas School of Medicine, Wichita, Kansas 67214, USA.
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