Immediate and delayed impact of oral glucocorticoid therapy on risk of serious infection in older patients with rheumatoid arthritis: a nested case-control analysis

Management of Late-Onset Rheumatoid Arthritis with Treat-to-Target Strategy

The incidence of patients with late-onset rheumatoid arthritis (LORA) is increasing. The clinical diagnosis of LORA is essentially the same as that of young-onset rheumatoid arthritis (YORA), but special attention should be paid to the differences in clinical features between LORA and YORA. Undertreatment of LORA can lead to reduced physical function and increased societal burden. The treat-to-target strategy has been successfully applied in patients with rheumatoid arthritis (RA), but evidence supporting this strategy is still insufficient for LORA. A wide range of factors should be considered and evaluated in addition to age and RA-related factors, including comorbidity/organ damage, psycho-neurological factors, socio-economic factors and frailty. Considering the proportion of patients with LORA achieving clinical remission or low disease activity in observational studies, the treat-to-target strategy could be stratified by age. Patients with LORA aged < 75 years are treated according to the treat-to-target algorithm used for all patients with RA, with clinical remission as the main target and low disease activity as the alternative target. In patients with LORA aged ≥ 75 years, the initial main target is set at low disease activity, which can be escalated to clinical remission with appropriate adaptation of treatment if a favourable balance of effectiveness and safety is struck at the time of achieving low disease activity by 6 months of treatment. Evidence of the efficacy/effectiveness and safety of methotrexate, biological disease-modifying antirheumatic drugs, Janus kinase inhibitors and glucocorticoids in patients with LORA is accumulating, but further research is warranted.

Higher risk of poor functional outcome and unfavourable clinical events for late-onset rheumatoid arthritis: results from the IORRA cohort

OBJECTIVES

To compare treatment outcomes in patients with late-onset RA (LORA) and younger-onset RA (YORA).

METHODS

We analyzed patients diagnosed with early RA (disease duration < 2 years) between 2000 and 2016 in the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort. Patients were categorized into LORA (onset at ≥65 years) and YORA (onset at <65 years). The primary outcomes were changes in Clinical Disease Activity Index (CDAI) and Japanese version of the Health Assessment Questionnaire (J-HAQ) at Year 5. The secondary outcomes included the incidence of prespecified adverse events.

RESULTS

Methotrexate, biological disease-modifying anti-rheumatic drugs, and glucocorticoids were used in 70.6, 8.4 and 38.0% of the LORA group (n = 813, median age: 71 years), and 81.6, 19.4 and 32.0% of the YORA group (n = 2457, median age: 51 years). Both groups exhibited significant initial improvements in CDAI and J-HAQ scores. At Year 5, mean CDAI scores were 4.39 and 4.03 for the LORA and YORA groups, respectively. J-HAQ score for YORA remained stable below 0.5 after Year 2, whereas that for LORA worsened progressively. At Year 5, mean J-HAQ scores were 0.56 for LORA and 0.33 for YORA. Patients with LORA had a higher incidence of adverse events, with adjusted hazard ratios of 4.70 for death and 2.58 for malignancy.

CONCLUSIONS

Patients with LORA and YORA exhibited similar improvements in disease activity over 5 years; however, those with LORA demonstrated a more pronounced decline in physical function.

British Society of Gastroenterology guidelines for diagnosis and management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease which, if untreated, often leads to cirrhosis, liver failure and death. The last British Society of Gastroenterology (BSG) guideline for the management of AIH was published in 2011. Since then, our understanding of AIH has advanced in many areas. This update to the previous guideline was commissioned by the BSG and developed by a multidisciplinary group. The aim of this guideline is to review and summarise the current evidence, in order to inform and guide diagnosis and management of patients with AIH and its variant syndromes. The main focus is on AIH in adults, but the guidelines should also be relevant to older children and adolescents.

Development and validation of a prediction model for serious infections in rheumatoid arthritis patients treated with tocilizumab in Japan

OBJECTIVES

To develop a prediction model for serious infections (SIs) in rheumatoid arthritis (RA) patients treated with tocilizumab in Japan and to evaluate the model's performance compared to previously developed models, i.e., 'DANBIO' and 'postmarketing surveillance' (PMS).

METHOD

This non-interventional retrospective cohort study utilized the Medical Data Vision database in Japan. The study population was derived from patients ≥ 18 years with RA who initiated tocilizumab between April 2008 and July 2021. SIs were assessed during the 1-year follow-up from tocilizumab initiation. The candidate predictors were identified based on previous studies, known risk factors, potentially relevant factors, and data availability. The prediction model was developed using logistic regression. The model's performance was compared with previously developed models using cross-entropy and area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 6501 RA patients, 4.57% experienced SIs during the 1-year follow-up. The model included 17 predictors for SI (e.g., age (odds ratio 1.013 (95% confidence interval 1.002-1.024)), history of SIs (2.569 (1.636-3.745)), diverticulitis (2.183 (1.000-3.989))). The model showed a lower cross-entropy and a higher AUC (0.1488; 0.712) compared to DANBIO (0.1932; 0.591) and PMS (0.1561; 0.565) models, and the sensitivity, specificity, positive predictive value, and negative predictive value using 5% threshold were 72%, 64%, 7%, and 98%, respectively.

CONCLUSIONS

The model developed in this study seems to have the potential to inform the risk of SIs in RA patients treated with tocilizumab and may help the early identification of patients at risk of SIs to reduce morbidity and mortality.

Pulmonary Immunocompromise in Chronic and High-dose Steroid Therapy

Glucocorticoid (GC) use is often the mainstay of treatment in many pulmonary, autoimmune, allergic, and oncologic diseases, along with organ transplantation. Short-term and long-term GC use is estimated to be around 1% to 2% worldwide. It has been associated with significant infectious complications such as streptococcus and influenza, mycobacterial infections, and opportunistic infections, specifically Pneumocystis pneumonia, invasive fungal infections, and strongyloidiasis. It is important to use minimal effective dose for the shortest duration to minimize complications. This review summarizes the prevalence of steroid prescriptions, mechanisms, manifestations, and mitigation strategies of pulmonary immunocompromise in patients on chronic and high-dose steroid therapies.

The one-year infection risk among patients diagnosed with giant cell arteritis: use of antibiotics and hospitalisations

OBJECTIVES

Patients with giant cell arteritis (GCA) primarily have their infections managed by primary care providers and hospitalisation is rarely necessary. Existing studies in GCA focus on infection-related hospitalisations only, whereas the use of antibiotic prescriptions is largely unknown. This study aims to examine the one-year overall infection risk among patients with GCA.

METHODS

This nationwide observational cohort study included patients aged ≥50 years with a first-time GCA diagnosis in the Danish National Patient Registry (1996-2022). Patients with GCA were matched 1:10 by sex and date of birth with general population individuals and followed from date of diagnosis. Overall infections were defined as redeemed antibiotic prescriptions or infection-related hospitalisations. Utilising a pseudo-observation approach, we assessed 1-year cumulative incidence proportions (CIP), risk differences (RD) and relative risks (RR) of infections.

RESULTS

The study included 17 773 incident patients with GCA and 177 730 reference individuals. Patients with GCA had a 1-year CIP of 52.4% (95% CI: 51.7-53.2) for overall infections and 17.6% (95% CI: 17.1-18.2) for infection-related hospitalisations. Compared with the reference cohort, patients with GCA had a RR of 1.40 (95% CI: 1.38-1.42) for overall infections and 2.71 (95% CI: 2.61-2.82) for infection-related hospitalisations. Additionally, higher cumulative glucocorticoid doses, advanced age (≥70 years) and higher comorbidity were associated with an increased risk of infections among patients with GCA.

CONCLUSIONS

The use of antibiotic prescriptions and infection-related hospitalisations in the first year after a GCA diagnosis is high compared with the background population. The cumulative glucocorticoid dose is associated with the infection risk.

Risk of hospitalization with infection in adults with primary AIHA treated with rituximab: a French nationwide study

ABSTRACT

Autoimmune hemolytic anemia (AIHA) is a rare and sometimes life-threatening disease. Infections are frequent and often severe during the course of AIHA. Rituximab is commonly used to treat patients with AIHA. This study aimed to assess the risk of hospitalization with infection after rituximab in patients with primary AIHA. We selected all adult patients newly diagnosed for primary AIHA and treated with rituximab between 2012 and 2018 in the French national health database. Patients were considered exposed to rituximab within 6 months after the first infusion. The main outcome was hospitalization with infection, identified by a discharge diagnosis of infection during the rituximab exposure. The cohort consisted of 959 patients (mean age of 67 years, standard deviation of 17.8 years; 60.5% of women). The 6-month cumulative incidence of hospitalization with infection was 17.6% (95% confidence interval [CI], 15.2-20.0). The most frequently characterized infections were pulmonary (40.2%). Opportunistic infections were observed in 28 (16.6%) patients, including 11 cases of pneumocystosis. All cases of pneumocystosis occurred in patients concomitantly exposed to corticosteroids, none of them had prophylaxis and all but 2 were aged ≥70 years. Overall, the main factors associated with hospitalization with infection were an age ≥70 years and the exposure to corticosteroids. The 30-day overall mortality after hospitalization with infection was 12.5% (95% CI, 8.0-18.0). In conclusion, the incidence of hospitalizations with infection, including opportunistic infections, as well as the subsequent mortality, are high in adult patients with primary AIHA treated with rituximab. Pneumocystosis prophylaxis should be encouraged in older patients exposed to corticosteroids.

Cushing's syndrome and COVID-19

PURPOSE

This review aims to present current data on the course of COVID-19 in patients with Cushing syndrome (CS) and discuss treatment for CS during to the pandemic.

METHODS

Literature review using PubMed (pubmed.ncbi.nlm.nih.gov). The search included the following terms: "COVID19" in combination with "Cushing syndrome", "Hypercortisolism" and "Glucocorticoid".

RESULTS

Chronic hypercortisolism has been reported to increase infectious risk and worsens prognostic of patients with COVID-19 potentially due to its direct impact on the immune system: lymphopenia, impairment of monocytes and neutrophils activity, diminution of complement activation. Main metabolic complications of CS - i.e. diabetes, hypertension and obesity - have been recognized as COVID-19 complications risk factors. Patients with CS treated with steroidogenesis inhibitors might experience adrenal insufficiency during COVID-19. Special attention should be paid to patients with CS and COVID-19. The pandemic has impacted - and delayed - care of chronic illnesses including CS. Specific recommendations had been provided during the pandemic: favor telemedicine consultations, limit in-hospital explorations and postpone surgery when feasible.

CONCLUSION

There are enough evidence for an increased prevalence and severity of COVID-19 to recommend a specific attention and caution in patients with CS.

Compatibility of hypokalaemia caused by low-dose prednisolone plus abiraterone acetate therapy for metastatic castration-resistant prostate cancer

BACKGROUND

This study aimed to investigate the relationship between low-dose prednisolone (PSL) and the incidence of hypokalaemia at abiraterone acetate (abiraterone) plus PSL combination therapy targeting Japanese patients with metastatic castration-resistant prostate cancer (mCRPC).

METHODS

This retrospective observational study included 153 Japanese patients treated with abiraterone and PSL for mCRPC at Kariya Toyota General Hospital and Gifu General Medical Center between September 2014 and October 2022. The incidence of grade ≥ 2 hypokalaemia as well as serum potassium level variations and the continuous combination therapy duration were compared between the low-dose (5 mg/day of PSL) and the standard-dose (10 mg/day of PSL) groups.

RESULTS

This study included 153 patient of which 95 were matched to establish the analysis population. The low-dose and the standard-dose groups consisted of 13 and 82 patients, respectively. No significant difference in the incidence of grade ≥ 2 hypokalaemia was observed between the two groups [15.4% (2/13 patients) in the low-dose group and 12.2% (10/82 patients) in the standard-dose group, P = 0.667]. The low-dose group exhibited a decrease in serum potassium levels from 4.63 on day - 7 - 0 to 4.16 mmol/L on day 84 ± 10 (n = 7, P = 0.066), and serum potassium levels from day - 7 - 0 to 84 ± 10 in the low-dose group appeared to be great in the standard-dose group (n = 37, P = 0.475). The Kaplan-Meier curves for continuity of abiraterone and PSL therapy were not significantly different between the low-dose group (n = 13) and standard-dose group (n = 82, P = 0.427).

CONCLUSION

Combination therapy with abiraterone and 5 mg/day of PSL in Japanese patients with mCRPC did not change the incidence of grade ≥ 2 hypokalaemia. However, although not significant, 5 mg/day of PSL demonstrated a decreasing trend in serum potassium levels with a larger degree of change than that of 10 mg/day of PSL. Therefore, the combination of abiraterone and 5 mg/day PSL can be administered to Japanese patients with mCRPC. The patients must be monitored for hypokalaemia through measurement of serum potassium levels and observation of subjective symptoms such as muscle weakness, convulsion etc. In addition, the doctor or the pharmacist must explain these symptoms to the patient and instruct them to consult their medical staff immediately in the event of development of such symptoms.

Glucocorticoids treatment and adverse infectious events in rheumatic diseases

It is well known that rheumatic diseases are characterized by an increased infection risk, due to several factors, such as an intrinsically dysfunctional immune system, disease activity, and the use of immunosuppressive drugs. Glucocorticoids are widely used therapeutic agents for treating several chronic inflammatory and immune diseases, due to their anti-inflammatory and immunosuppressive effects. Their use is burdened by well-known side effects in dose- and duration of use-dependent manner. Physicians need to be aware of the mechanism of action of glucocorticoids, their side effects, particularly infectious side effects, and the significance of cumulative dose and duration of glucocorticoid treatment. Additionally, physicians shoultdleveld have knowledge of each patient and their comorbidities. They could use appropriate tools for assessing glucocorticoid-related toxicity and morbidity, particularly in the context of chronic glucocorticoid administration. This comprehensive understanding is crucial for ensuring the proper and safe use of these drugs, particularly in terms of minimizing infectious risks. The aim of this review is to focus on available data concerning the infectious risk associated to glucocorticoid treatment in rheumatic diseases, highlighting the role of the correct drug management in clinical practice and the role of the disease itself in the occurrence of this worthy side effect. We conducted a review of randomized controlled trials and observational studies about glucocorticoid use in autoimmune/rheumatic diseases, analyzing the infectious risk during glucocorticoid therapy, and its relationship with the used dose and duration of treatment.

The Incidence, Aetiology and Clinical Course of Serious Infections Complicating Biological and Targeted Synthetic Disease-Modifying Antirheumatic Drug Therapy in Patients with Rheumatoid Arthritis in Tropical Australia

Introduction: Patients receiving biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for rheumatological conditions are at an increased risk of serious, potentially life-threatening, infection. However, the incidence, aetiology, and clinical course of serious infection in patients receiving b/tsDMARDs in tropical settings are incompletely defined. Methods: We retrospectively reviewed all patients with rheumatoid arthritis receiving b/tsDMARDs between October 2012 and October 2021, at Cairns Hospital in tropical Australia. The incidence, aetiology, and clinical course of serious infections (those requiring admission to hospital or parenteral antibiotics) were determined. Results: 310 patients had 1468 patient years of b/tsDMARD therapy during the study period; 74/310 (24%) had 147 serious infections translating to an overall risk of 10.0 episodes of serious infection per 100 patient years. The respiratory tract (50/147, 34%) and skin (37/147, 25%) were the most frequently affected sites. A pathogen was identified in 59/147 (40%) episodes and was most commonly Staphylococcus aureus (24/147, 16%). Only 2/147 (1%) were confirmed "tropical infections": 1 case of Burkholderia pseudomallei and 1 case of mixed B. pseudomallei and community-acquired Acinetobacter baumannii infection. Overall, 13/147 (9%) episodes of serious infection required Intensive Care Unit admission (0.9 per 100-patient years of b/tsDMARD therapy) and 4/147 (3%) died from their infection (0.3 per 100-patient years of b/tsDMARD therapy). The burden of comorbidity and co-administration of prednisone were the strongest predictors of death or a requirement for ICU admission. Conclusions: The risk of serious infection in patients taking b/tsDMARDs in tropical Australia is higher than in temperate settings, but this is not explained by an increased incidence of traditional tropical pathogens.

Therapeutic Potential of Lactiplantibacillus plantarum FB091 in Alleviating Alcohol-Induced Liver Disease through Gut-Liver Axis

Alcoholic liver disease (ALD) poses a significant global health burden, often requiring liver transplantation and resulting in fatalities. Current treatments, like corticosteroids, effectively reduce inflammation but carry significant immunosuppressive risks. This study evaluates Lactiplantibacillus plantarum FB091, a newly isolated probiotic strain, as a safer alternative for ALD treatment. Using an in vivo mouse model, we assessed the effects of L. plantarum FB091 on alcohol-induced liver damage and gut microbiota composition. Alcohol and probiotics administration did not significantly impact water/feed intake or body weight. Histopathological analysis showed that L. plantarum FB091 reduced hepatocellular ballooning and inflammatory cell infiltration in liver tissues and mitigated structural damage in colon tissues, demonstrating protective effects against alcohol-induced damage. Biomarker analysis indicated that L. plantarum FB091 decreased aspartate aminotransferase levels, suggesting reduced liver damage, and increased alcohol dehydrogenase activity, indicating enhanced alcohol metabolism. Additionally, cytokine assays revealed a reduction in pro-inflammatory TNF-α and an increase in anti-inflammatory IL-10 levels in colon tissues of the L. plantarum FB091 group, suggesting an anti-inflammatory effect. Gut microbiota analysis showed changes in the L. plantarum FB091 group, including a reduction in Cyanobacteria and an increase in beneficial bacteria such as Akkermansia and Lactobacillus. These changes correlated with the recovery and protection of liver and colon health. Overall, L. plantarum FB091 shows potential as a therapeutic probiotic for managing ALD through its protective effects on liver and colon tissues, enhancement of alcohol metabolism, and beneficial modulation of gut microbiota. Further clinical studies are warranted to confirm these findings in humans.

Considerations for the use of biological therapies in elderly patients with rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that primarily affects middle-aged individuals but is increasingly prevalent among the elderly due to longer life expectancies. Treating elderly onset RA (EORA) is challenging for clinicians because of unique disease characteristics, comorbidities, polypharmacy, age-related physiological changes, and limited studies on the safety and efficacy of biological therapies in this population. This review aims to evaluate the use of various biological therapies in elderly RA patients.

AREAS COVERED

This narrative review examines various aspects of RA in the elderly using published literature, randomized control trials, meta-analyses, and recommendations from the National Institute for Health and Care Excellence (NICE) and The European Alliance of Associations for Rheumatology (EULAR).

EXPERT OPINION

In EORA patients, the initiation of biological therapy is often delayed. Methotrexate remains the first-line treatment for both EORA and young onset RA (YORA). The combination of methotrexate and biological treatment shows comparable safety and efficacy in both EORA and YORA, except for rituximab, which is less effective in patients over 75. For elderly RA patients, biological (b-) disease-modifying antirheumatic drugs (DMARDs) are preferred as the first advanced therapy over targeted synthetic (ts-) DMARDs due to their superior safety profile.

Predicted 25-hydroxyvitamin D over the adult lifetime and the risk of ovarian cancer

The evidence from previous studies of serum 25-hydroxyvitamin D (25(OH)D) and ovarian cancer risk is not conclusive. However, the 25(OH)D levels were generally only measured in late adulthood, which may not capture the etiologically relevant exposure periods. We investigated predicted 25(OH)D over the adult lifetime in relation to ovarian cancer risk in a population-based case-control study conducted from 2011 to 2016 in Montreal, Canada (n = 490 cases and 896 controls). Predicted 25(OH)D was computed using previously validated regression models. Unconditional multivariable logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% CIs for average predicted 25(OH)D over the adult lifetime and ovarian cancer risk. In addition, the relative importance of different periods of past 25(OH)D exposure was explored using a weighted cumulative exposure (WCE) model. For each 20-nmol/L increase in average predicted 25(OH)D over the adult lifetime, the aOR (95% CI) was 0.73 (0.55-0.96). In WCE analyses, the inverse association was strongest for exposures 5 to 20 years and 35 to 55 years prior to diagnosis, with aORs (95% CIs) of 0.82 (0.69-0.94) and 0.79 (0.66-1.02), respectively, for each 20-nmol/L increase in predicted 25(OH)D. These results support an inverse association between 25(OH)D levels in adulthood and ovarian cancer risk. This article is part of a Special Collection on Gynecological Cancers.

Association between glucocorticoid administration and outcomes in patients with ARDS based on the MIMIC-III database

This study aimed to investigate the association between glucocorticoid administration and outcomes in critically ill patients with ARDS using the Medical Information Mart for Intensive Care (MIMIC)-III database. Data were collected from the MIMIC-III database, which consists of critically ill participants between 2001 and 2012 in the USA. A total of 1831 adult critically ill patients with ARDS were enrolled from the MIMIC-III database. The 60-day and in-hospital mortality, were the primary endpoints. Secondary outcomes included length of stay (LOS) in the hospital and intensive care unit (ICU), 28-day ventilator-free days, ICU mortality, and 28-day mortality. A total of 1831 patients were included in the data analysis. After propensity score (PS) matching, 464 patients diagnosed with ARDS were matched between the glucocorticoid treatment and control groups. Glucocorticoids were associated with increased in-hospital mortality [hazard ratio (HR) 1.32; 95% CI 1.01-1.71; P = .039], longer ICU stay [HR 2.25; 95% CI 0.84-3.65; P = .002], and shorter ventilation-free days at 28 days in all ARDS patients [HR -2.70; 95% CI -4.28--1.13; P = .001]. The 60-day mortality was higher in the glucocorticoid group (44.83% vs 35.34%; P = .154; HR 1.24; 95% CI 0.93-1.66). Excluding the impact of the glucocorticoid initiation time, from day 15 to day 60, mortality was significantly higher in the glucocorticoid group compared to the non-glucocorticoid group (27.16% vs 12.70%; P < .001; HR 1.75; 95% CI 1.32-2.32). Glucocorticoid administration was associated with worse 60-day and in-hospital survival, longer ICU stay, and shorter ventilator-free days on day 28 in patients with ARDS. Our findings suggest careful consideration of glucocorticoids for ARDS.

Low-Dose Glucocorticoids in Older Patients with Rheumatoid Arthritis: What Does the Evidence Say?

The short-term use of glucocorticoids (GCs) in combination with methotrexate was recommended for the initial treatment of rheumatoid arthritis by the European League Against Rheumatism. A randomized controlled trial (GLORIA) showed that treatment of older patients with low-dose GCs in combination with disease-modifying anti-rheumatic drugs was more efficacious than disease-modifying anti-rheumatic drugs plus placebo in terms of disease activity control and prevention of joint destruction. Glucocorticoid-related adverse events were likely to increase relative to placebo, with no increase in serious adverse events and fractures over 2 years. Observational studies showed an increased risk of serious infections, cardiovascular events, and fractures associated with long-term continuation of GCs in older patients, but the adverse events may be associated not only with GC toxicity but also with poor disease control of rheumatoid arthritis. In the GLORIA study, low-dose GCs during 2 years could be tapered off safely, but many patients had a flare of disease activity after discontinuation of GCs. In the two representative large Japanese registries (IORRA and NinJa), the proportion of patients using GCs and non-tumor necrosis factor inhibitors increased with increasing age at disease onset, with a decreasing trend in methotrexate use. The proportion of patients in remission with GC treatment also increased with increasing age at onset. These suggested that it is not easy to discontinue GCs in older patients. If GCs cannot be terminated in the short term, it may be acceptable to use GCs to control disease activity for up to 2 years.

Incidence of serious infections in the working-age Japanese adult population with rheumatoid arthritis treated with tumor necrosis factor-α inhibitors and interleukin-6 inhibitors: A nationwide retrospective cohort study

AIM

This retrospective cohort study aimed to compare the risk of serious infections in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor-α inhibitors (TNFαi) and interleukin-6 inhibitors (IL-6i), with no prior use of biological disease-modifying antirheumatic drugs (bDMARDs).

METHODS

We employed the nationwide insurance claims database encompassing the years 2005 to 2018 in Japan. The inclusion criteria specified patients who were prescribed any type of bDMARDs, including TNFαi and IL-6i. The following exclusion criteria were applied: missing prescription dates, RA not diagnosed, below 16 years of age, bDMARDs prescribed within 6 months of registration, RA diagnosed post-bDMARDs prescription, and incidence of serious infections within 2 weeks before bDMARDs therapy. We applied stabilized inverse probability weights and utilized a Cox regression model to estimate the risk of serious infections associated with TNFαi and IL-6i.

RESULTS

The cohort of 2493 patients with RA was categorized into a TNFαi group and an IL-6i group of 2018 and 475 participants, respectively. The median follow-up duration (interquartile range) was 347 (147-820) days in the TNFαi group and 369 (149-838) days in the IL-6i group. In the inverse probability-weighted cohort, the incidence rates (95% confidence interval) of serious infections were 2.13 (1.65-2.71) and 3.25 (2.15-4.69) per 100 person-years for the TNFαi and IL-6i groups, respectively. The hazard ratio (95% confidence interval) comparing the TNFαi group to the IL-6i group was 0.66 (0.36-1.20, p = 0.168).

DISCUSSION

The results underscore the lack of evidence to preferentially favor either TNFαi or IL-6i as later-line therapy in the management of bDMARDs-naive RA to mitigate the risk of serious infections.

Immunosuppression and cancer risk in kidney transplant recipients: A retrospective cohort study

We assessed whether contemporary immunosuppression agents were associated with cancer among kidney transplant recipients (KTR), and if this association varied by age and sex. We studied a retrospective province-wide cohort of primary KTR (1997-2016). Employing multivariable Cox models, we estimated associations of cumulative doses of prednisone, mycophenolate and tacrolimus administered over the past 10 years, lagged by 2 years, with the incidence of primary malignant neoplasms (PMN). We assessed interactions with age and sex. To assess the impact of exposure recency, we used weighted cumulative exposure (WCE) modeling. Among 1064 KTR, 108 (10.2%) developed PMN over median follow-up of 73 months (interquartile range: 32-120). Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of 0.96 (0.64-1.43), 1.34 (0.96-1.86), and 1.06 (0.88-1.29) were estimated for cumulative daily doses of prednisone (5 mg), mycophenolate (1000 mg), and tacrolimus (2 mg) administered continuously over the past 10 years, respectively. PMN risk associated with cumulative tacrolimus exposure was modified by age (interaction p = .035) and was more pronounced in 15-year and 30-year-old KTR (aHRs of 1.57 [1.08-2.28] and 1.31 [1.03-1.66], respectively) in comparison to older KTR. PMN risk increase associated with higher cumulative mycophenolate dose was more pronounced in females (aHR = 1.86 [1.15-3.00]) than in males (aHR = 1.16 [0.74-1.81]; interaction p = .131). WCE analyses suggested increased PMN risk the higher the mycophenolate doses taken 5-10 years ago. A trend toward increased PMN risk with long-term mycophenolate exposure, particularly in females, and more pronounced risk with long-term tacrolimus exposure in younger KTR, identify opportunities for tailored immunosuppression to mitigate cancer risk.

Overview of Rheumatoid Arthritis-Associated Interstitial Lung Disease and Its Treatment

Interstitial lung disease (ILD) is a common pulmonary complication of rheumatoid arthritis (RA), causing significant morbidity and mortality. Optimal treatment for RA-ILD is not yet well defined. Reliable prognostic indicators are largely byproducts of prior ILD progression, including low or decreasing forced vital capacity and extensive or worsening fibrosis on imaging. In the absence of validated tools to predict treatment response, decisions about whether to initiate or augment treatment are instead based on clinical judgment. In general, treatment should be initiated in patients who are symptomatic, progressing, or at high risk of poor outcomes. Retrospective data suggest that mycophenolate mofetil, azathioprine, and rituximab are likely effective therapies for RA-ILD. Abatacept is also emerging as a potential first-line treatment option for patients with RA-ILD. Further, recent data demonstrate that immunosuppression may be beneficial even in patients with a usual interstitial pneumonia (UIP) pattern on imaging, suggesting that immunosuppression should be considered irrespective of imaging pattern. Recent randomized controlled trials have shown that antifibrotic medications, such as nintedanib and likely pirfenidone, slow forced vital capacity decline in RA-ILD. Consideration can be given to antifibrotic initiation in patients progressing despite immunosuppression, particularly in patients with a UIP pattern. Future research directions include developing tools to predict which patients will remain stable from patients who will progress, discriminating patients who will respond to treatment from nonresponders, and developing algorithms for starting immunosuppression, antifibrotics, or both as first-line therapies.

Unintended Consequences: Risk of Opportunistic Infections Associated With Long-term Glucocorticoid Therapies in Adults

Glucocorticoids are widespread anti-inflammatory medications used in medical practice. The immunosuppressive effects of systemic glucocorticoids and increased susceptibility to infections are widely appreciated. However, the dose-dependent model frequently used may not accurately predict the risk of infection in all patients treated with long-term glucocorticoids. In this review, we examine the risks of opportunistic infections (OIs) in patients requiring glucocorticoid therapy by evaluating the influence of the glucocorticoid dose, duration, and potency, combined with biological and host clinical factors and concomitant immunosuppressive therapy. We propose strategies to prevent OIs, which involve screening, antimicrobial prophylaxis, and immunizations. While this review focuses on patients with autoimmune, inflammatory, or neoplastic diseases, the potential risks and preventative strategies are likely applicable to other populations. Clinicians should actively assess the benefit-harm ratios of systemic glucocorticoids and implement preventive efforts to decrease their associated infections complications.

Real-world management of patients with neuromyelitis optica spectrum disorder using satralizumab: Results from a Japanese claims database

BACKGROUND

Satralizumab, a humanized anti-interleukin-6 receptor monoclonal antibody, has been approved globally for the treatment of neuromyelitis optica spectrum disorder (NMOSD), based on positive results from two randomized, double-blind, phase 3 studies: SAkuraSky (NCT02028884) and SAkuraStar (NCT02073279). There remains an unmet need to understand the real-world management of NMOSD, especially in patients undergoing tapering of concomitant therapy. We examined real-world treatment patterns, including concomitant glucocorticoids and immunosuppressants, and relapse in satralizumab-treated patients with NMOSD, using a Japanese administrative hospital claims database.

METHODS

We used retrospective data from the Medical Data Vision hospital-based administrative claims database. The index date was the date of first satralizumab prescription and the study period was set between August 2018 and March 2022. Patients were included in the overall population if they had a first prescription for satralizumab between August 2020 and March 2022, an International Classification of Disease, Version10 code of G36.0 prior to March 2022, and were observable for ≥90 days prior to the index date. The primary endpoint was the percentage of patients with relapse-free reduction of oral glucocorticoids to 0 mg/day at 360 days of continued satralizumab treatment. Secondary endpoints included time to relapse, number of relapses after the index date while being on continuous satralizumab treatment, annualized relapse rate before and after the index date, and concomitant medication use. Relapse and dose reduction were identified using definition specifically developed for this study.

RESULTS

Of the 131 patients included in the overall population, most were female (90.8 %), aged 18-65 years (75.6 %), and were prescribed oral glucocorticoids (93.1 %). Azathioprine (19.1 %) and tacrolimus, a calcineurin inhibitor (18.3 %), were the most common immunosuppressants at index date. Six (4.6 %) patients had a history of biologic use (tocilizumab, 1 [0.8 %]; eculizumab, 5 [3.8 %]). Among 111 patients observable for 360 days pre-index, there were 0.6 ± 0.8 (mean ± SD) relapses during 360 days before the index date. The median (interquartile range) duration of satralizumab exposure was 197.0 (57.0-351.0) days. Most (125/131; 95.4 %) patients were relapse-free post-index; 6 (4.6 %) patients relapsed within 90 days after the index date, of which 2 had the first relapse within 7 days after the index date. Among 21 patients with 360-day follow-up, 6 (28.6 %) patients were on 0 mg/day dose of glucocorticoid prescription without relapse 360 days post-index. Of these 6 patients, 2 had no prescription of oral glucocorticoids at the index date and remained glucocorticoid- and relapse-free 360 days after the index date.

CONCLUSION

These real-world data support the phase 3 clinical trials. Our results, over a median duration of satralizumab exposure of 197.0 days, showed that a majority (125/131, 95.4 %) of patients were relapse-free after initiating satralizumab treatment. The number of glucocorticoid-free patients without relapse increased over time under continuous satralizumab prescription. Further studies are needed to confirm if satralizumab can be used as a potential immunosuppressant- and glucocorticoid-sparing agent.

Purulent pericarditis caused by methicillin-sensitive Staphylococcus aureus bacteriuria

BACKGROUND

Purulent pericarditis (PP)- a purulent infection involving the pericardial space-requires a high index of suspicion for diagnosis as it often lacks characteristic signs of pericarditis and carries a mortality rate as high as 40% even with treatment. Common risk factors include immunosuppression, diabetes mellitus, thoracic surgery, malignancy, and uremia. Most reported cases of PP occur in individuals with predisposing risk factors, such as immunosuppression, and result from more commonly observed preceding infections, such as pneumonia, osteomyelitis, and meningitis. We report a case of PP due to asymptomatic bacteriuria in a previously immunocompetent individual on a short course of high-dose steroids.

CASE PRESENTATION

An 81-year-old male presented for severe epigastric pain that worsened with inspiration. He had been on high-dose prednisone for presumed inflammatory hip pain. History was notable for urinary retention requiring intermittent self-catheterization and asymptomatic bacteriuria and urinary tract infections due to methicillin-sensitive Staphylococcus aureus (MSSA). During the index admission he was found to have a moderate pericardial effusion. Pericardial fluid cultures grew MSSA that had an identical antibiogram to that of the urine cultures. A diagnosis of purulent pericarditis was made.

CONCLUSION

PP requires a high index of suspicion, especially in hosts with atypical risk factors. This is the second case of PP occurring as a result of asymptomatic MSSA bacteriuria. Through reporting this case we hope to highlight the importance of early recognition of PP and the clinical implications of asymptomatic MSSA bacteriuria in the setting of urinary instrumentation and steroid use.

[Influence of underlying disease and immunosuppression on the immunocompetence in inflammatory rheumatic diseases]

Patients with inflammatory rheumatic diseases have a higher risk of infections in comparison to the general population. For this patient group, in addition to cardiovascular diseases, infections play an important role with respect to morbidity and mortality. Even if it is difficult to make concrete statements with respect to individual diseases, it can be assumed that there is a lower risk of infections in inflammatory joint diseases in comparison to connective tissue diseases and vasculitides. The increased risk of infections is determined by multiple factors, whereby the underlying factors are classified into three main categories: patient-related factors (age, comorbidities, lifestyle), disease-related factors (immunological dysfunction as part of the disease pathophysiology) and drug-related factors (type and dosage of the immunosuppression and/or immunomodulation). An improved understanding of the complexity of these associations enables the optimization of treatment and disease control taking the individual risk factors into account, with the aim of a significant reduction in the risk of infections.

Development and Comparison of Treatment Decision Tools for Glucocorticoid-Induced Osteoporosis

Long-term Glucocorticoid (GC) use results in compromised bone strength and fractures, and several treatment recommendations have been developed to prevent fractures, but none have been validated in a real-world setting. This study aims to create a treatment decision tool and compares this tool to the treatment suggestions from the American College of Rheumatology (ACR), International Osteoporosis Foundation and European Calcified Tissue Society (IOF-ECTS), and GC-adjusted Fracture Risk Assessment Tool (GC-FRAX), above the intervention threshold. We utilized registry data gathered at Chang Gung Memorial Hospital at Kaohsiung, Taiwan, between September 2014 and April 2021. This research is a single-center, observational, and case-controlled study. We recruited participants using prednisone for at least 2.5 mg/day or the equivalent dose for over 3 months, excluding those younger than 40, those with malignancies, or those currently undergoing anti-osteoporosis therapy. The primary endpoint was new fragility fractures within 3 years, including morphometric vertebral fractures detected at baseline and with a follow-up thoracic-lumbar spine X-ray. Participants were randomly allocated into derivation and validation sets. We developed the Steroid-Associated Fracture Evaluation (SAFE) tool in the derivation cohort by assessing the weights of exploratory variables via logistic regression. Prediction performance was compared in the validation set by the receiver operating characteristic (ROC) curve, the area under the curve (AUC), and sensitivity and specificity. A total of 424 treatment-naïve subjects were enrolled, and 83 (19.6%) experienced new fractures within 3 years. The final formula of the SAFE tool includes osteoporosis (1 point), an accumulated GC dose ≥ 750 mg within 6 months (or equivalent prednisolone of ≥4.5 mg/day for 6 months) (1 point), a BMI ≥ 23.5 (1 point), previous fractures (1 point), and elderliness of ≥70 years (2 points). In the validation set, a treatment decision based on the SAFE ≥ 2 points demonstrated an AUC of 0.65, with a sensitivity/specificity/accuracy of 75.9/54.0/58.9, with an ACR of 0.56 (100.0/11.0/31.0), IOF-ECTS 0.61 (75.9/46.0/52.7), and GC-FRAX 0.62 (82.8/42.0/51.2). Among current GIOP recommendations, the SAFE score serves as an appropriate treatment decision tool with increased accuracy and specificity.

Pattern and Predictors of Infection Among Patients With Rheumatological Disease on Immunosuppressive Medications: A Retrospective Study in a Tertiary Care Hospital in Bangladesh

Background Immunomodulatory therapy for chronic rheumatic disease carries a risk for infectious complications. In Bangladesh, there is limited information regarding patterns and factors associated with infections among patients receiving immunosuppressive medications. Objective The present study aimed to find out patterns and predictors associated with infection among patients who were on different immunosuppressive medications due to chronic rheumatological disease. Methodology This was a retrospective study; all confirmed cases of (new and old) different rheumatological diseases on disease-modifying agents attended at the rheumatology clinic of Dhaka Medical College Hospital from January 2019 to December 2021 were enrolled. Result Among 489 cases, 90 (18.4%) patients had documented infections. The most common rheumatological diseases were systemic lupus erythematosus (28, 31.1%), ankylosing spondylitis (26, 28.8%), and rheumatoid arthritis (20, 22.2%). COVID-19 (28, 31.1%) was the most commonly occurring infection followed by urinary tract infection (14, 15.6%), fungal infection (12, 13.3%), herpes zoster (10, 11.1%), pulmonary tuberculosis (TB) (eight, 8.8%), latent TB (seven, 7.7%), community-acquired pneumonia (six, 6.6%), and sepsis (three, 3.3%). Infection was most prevalent among patients who received steroids of more than 10 mg per day (17, 18.8%) than those less than 10 mg steroid per day (six, 6.7%), Factors associated with infections were (odds ratio, 95% CI, p-value) underweight (2.3, [1.3-2.7], 0.001), anemia (1.8, [1.1-5.7], 0.01), neutropenia (1.6, [1.1-2.9], <0.002), hypoalbuminemia (3.1, [1.6-4.9], 0.001), hypovitaminosis D (1.9, [1.3-4.5], 0.001), high blood sugar (1.5, [1.1-5.3], 0.02), inadequate counseling of steroid side effect (1.7, [1.1-3.9], 0.03), prednisolone >10mg/day (2.2, [1.19-4.10], 0.001). Conclusion COVID-19 pneumonia, urinary tract infections, fungal infection, tuberculosis, herpes zoster, and community-acquired pneumonia were commonly occurring infections among patients receiving different immunosuppressive medications. Factors like poor nutritional status, presence of anemia, leucopenia, hypoalbuminemia, hyperglycemia, and hypovitaminosis D had a significant association with infection. Moreover, inadequate counseling of steroid side effects and history of daily intake of prednisolone (>10mg/day) were also significant factors associated with infection.

Factors associated with impaired physical function in elderly rheumatoid arthritis patients who had achieved low disease activity

OBJECTIVES

We aimed to investigate factors associated with impaired physical function [defined as Health Assessment Questionnaire Disability Index (HAQ-DI) >0.5] of old-old (aged 75-84 years) patients with rheumatoid arthritis.

METHODS

Data from 15,185 rheumatoid arthritis patients in the National Database of Rheumatic Disease in Japan were extracted from 2017 to 2018. We enrolled 3708 patients aged 55-84 years in Simplified Disease Activity Index (SDAI) ≤11 and Steinbrocker Stage I/II. Factors associated with HAQ-DI >0.5 were analysed by multivariable logistic regression.

RESULTS

About half of the old-old patients received methotrexate, which was lower than middle-aged (55-64 years) and young-old patients (65-74 years). The proportion of glucocorticoids in the old-old patients was highest among the three groups, and biological disease-modifying antirheumatic drugs were similarly used. The prevalence of HAQ-DI >0.5 was significantly higher in old-old patients with low disease activity than in those with remission. The same was true in the middle-aged and young-old patients. Multivariable analysis showed age, higher SDAI, glucocorticoid use, and methotrexate nonuse were significantly associated with HAQ-DI >0.5 in the old-old patients.

CONCLUSIONS

Achieving SDAI remission was an ideal goal for old-old patients in terms of physical function. Glucocorticoids and a low proportion of methotrexate use may influence the physical function of old-old patients.

Comparison of the Serial Humoral Immune Response according to the Immunosuppressive Treatment after SARS-CoV-2 mRNA Vaccination

Objective The objective of this study was to estimate the humoral immune response evaluated by immunoglobulin G (IgG) against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike receptor-binding domain (RBD-IgG) following the third mRNA coronavirus disease 2019 (COVID-19) vaccination in patients with kidney disease who received immunosuppressive treatment. Methods The primary outcome was RBD-IgG levels after the third SARS-CoV-2 vaccination. The primary comparison was the RBD-IgG levels between patients with kidney disease who received immunosuppressive treatment (n=124) and those who did not (n=33). Results The RBD-IgG levels were significantly lower in the patients with kidney disease who received immunosuppressive treatment than in those who did not receive immunosuppressive treatment. The RBD-IgG levels were lower in patients treated with glucocorticoid monotherapy than in those who did not receive immunosuppressive treatment. Even in patients who received ≤5 mg prednisolone, the RBD-IgG levels were significantly lower. Nine of the 10 patients who received rituximab within one year before the first vaccination did not experience seroconversion after the third vaccination. Meanwhile, all nine patients who received rituximab only after the second vaccination experienced seroconversion, even if B cell recovery was insufficient. Patients treated with mycophenolate mofetil plus glucocorticoid plus belimumab had significantly lower RBD-IgG levels than those treated with mycophenolate mofetil plus glucocorticoid. Conclusion The RBD-IgG levels were lower in patients with kidney disease who received immunosuppressive treatment than in those who did not receive immunosuppressive treatment. Low-dose glucocorticoid monotherapy affected the humoral immune response following the third mRNA COVID-19 vaccination.

Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad?

It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.

Minimal effective dose of maintenance steroid therapy for relapse of cryptogenic organizing pneumonia

BACKGROUND

Long-term maintenance steroid therapy (MST) is frequently required for repeated relapses of cryptogenic organizing pneumonia (COP); however, the optimal minimal dose has not been clarified. Therefore, this study evaluated the minimal MST dose required to prevent repeated relapses and identify relapse predictors.

METHODS

We retrospectively reviewed the medical records of patients with steroid-treated COP and compared background factors between the non-relapse and relapse groups. We also reviewed the treatment course in the relapse group and determined the minimal effective steroid dose based on the MST dose at relapse events and the current relapse prevention dose.

RESULTS

In total, 48 patients were identified, including 27 (56%) in the non-relapse group and 21 (44%) in the relapse group. Receiver operating characteristic curve analysis identified prednisolone at 5 mg/day as the optimal cut-off value in the relapse group. Relapse-free time in patients with relapsed COP was significantly longer in the MST dose ≥5 mg/day group than in the <5 mg/day group (log-rank P = 0.003; hazard ratio, 0.19; 95% confidence interval [CI], 0.04-0.60). Multivariate logistic regression analysis demonstrated that a high eosinophil percentage and CD4/CD8 ratio in bronchoalveolar lavage fluid (BALF) were predictors of relapse (odds ratio [OR], 1.12; 95% CI, 1.02-1.23; P = 0.008 and OR, 3.87; 95% CI, 1.29-11.6; P = 0.008, respectively).

CONCLUSIONS

Our results indicate that 5 mg/day of prednisolone may be the minimal effective dose for preventing repeated relapses, and a high BALF eosinophil percentage and CD4/CD8 ratio are independent predictors of relapse.

Total Steroid Intake is Associated With Hospital Mortality in Patients With Pan-Peritonitis due to Colorectal Perforation

BACKGROUND

Patients with pan-peritonitis (PP) due to colorectal perforation have high mortality rate because colorectal perforation causes septic shock. The association between total steroid intake (TSI) and hospital mortality of such patients is not clear.

METHODS

One hundred forty-two patients who underwent surgery for PP due to colorectal perforation were reviewed. Patients were divided into two groups by 8000 mg of TSI. The cut-off value of TSI was determined using a receiver operating characteristic curve for hospital mortality.

RESULTS

The cut-off value of TSI for hospital mortality was 8000 mg. Patients with TSI>8000 mg had high rate of hemodialysis, hospital mortality, and elevated neutrophil ratio (>95%) compared with those with TSI≤8000 mg. Multivariate analyses revealed that TSI (>8000/≤8000, mg) (OR, 9.669; 95% CI, 1.011-92.49; P = .049) was significantly associated with hospital mortality as well as bleeding volume (>1000/≤1000, mL) (OR, 26.08; 95% CI, 3.566-190.4; P = .001), lymphocyte ratio (≤4/>4, %) (OR, 7.988; 95% CI, 1.498-42.58; P = .015) and C-reactive protein (≤7.5/>7.5, mg/dL) (OR, 41.66; 95% CI, 4.784-33.33; P = .001).

DISCUSSION

There was a significant association between TSI and hospital mortality in patients with PP due to colorectal perforation as well as intraoperative bleeding and systemic inflammatory markers.

Glucocorticoid exposure and the risk of serious infections in rheumatoid arthritis: a marginal structural model application

OBJECTIVE

Observational studies have reported an increased risk of infections associated with glucocorticoids in RA, not supported by evidence from randomized controlled trials. Inappropriately accommodating time-varying exposure and confounding in observational studies might explain the conflicting results. Therefore, we compared the incidence of serious infections between different oral glucocorticoid dose patterns over three years in a prospective inception cohort, adjusting for time-varying confounders in marginal structural models.

METHODS

We included 9654 newly diagnosed RA patients from the Swedish Rheumatology Quality Register between 2007-2018 and followed them for three years after the first rheumatology visit. Follow-up was divided into 90-day periods. A mean oral prednisone daily dose was calculated for each period and categorized into 'no use', 'low' (≤10 mg/day) and 'high' (>10 mg/day) doses. The incidence of serious infections (hospitalization for infection) over follow-up periods was modelled by pooled logistic regression allowing separate effects for recent and past exposure.

RESULTS

An increased incidence of serious infections was associated with higher compared with lower doses and with more recent compared with past glucocorticoid exposure. Over 3 years of follow-up, the marginal structural models predicted one additional serious infection for every 83 individuals treated with low GC doses for the first 6 months, and for every 125 individuals treated with high GC doses for the first 3 months, compared with no GC use.

CONCLUSION

Our results broadly agree with previous observational studies showing a dose dependent increased risk of infection associated with (recent) use of oral glucocorticoids.

Association between glucocorticoid discontinuation and incidence of infection in older adults with rheumatoid arthritis: A retrospective cohort study

AIM

Old age and glucocorticoid (GC) use increase the susceptibility to infection in patients with rheumatoid arthritis (RA). Accordingly, we investigated whether GC discontinuation reduces the incidence of infection in older adults with RA and analyzed factors associated with GC discontinuation.

METHODS

Medical records of patients with RA aged ≥60 years were retrieved, and the association between GC use and the incidence of infection was investigated. The participants were divided into three groups: GC-continued, GC-discontinued, and non-GC; the incidence of infection was statistically analyzed. Furthermore, patient treatments and comorbidities were examined.

RESULTS

Among 389 patients with RA included in the study (n = 122, n = 126, and n = 141 in the GC-discontinued, GC-continued, and non-GC groups, respectively), 65 (16.7%) patients developed infection, and the incidence of infection was significantly higher in the GC-continued group than in the GC-discontinued (p = .021) and non-GC (p = .0003) groups; there was no significant difference between the non-GC and GC-discontinued groups (p = .659). The GC-discontinued group was more likely to require biologic use throughout the disease course than the other two groups. Comorbidities, especially malignancies (p = .004), were more common in the GC-continued group than in the GC-discontinued group (p = .007).

CONCLUSION

In patients with RA aged ≥60 years receiving GCs, GC discontinuation reduced the incidence of infection. Therefore, a further analysis of factors that help reduce GC use is necessary.

Low-Dose Intravenous Methylprednisolone in Remission Induction Therapy for ANCA-Associated Vasculitis

Key Points

The contribution of IV methylprednisolone to glucocorticoid toxicity is often overlooked with limited evidence supporting its use. Markedly reduced cumulative glucocorticoid dosing for remission induction therapy in AAV is safe and effective. Reduced IV methylprednisolone and radical steroid avoidance strategies have not been shown to have any significant adverse effect on outcomes.

Background

Glucocorticoids (GCs) remain integral to the management of ANCA-associated vasculitis (AAV), but are associated with significant adverse effects. Recent studies have shown reduced oral GC dosing to be safe and effective; however, data guiding the use of intravenous (IV) methylprednisolone (MTP) are limited.

Method

A single-center retrospective cohort of patients with AAV were divided into two groups: low-dose GC (patients receiving 250 mg of IV MTP, followed by a tapering course of 30 mg of prednisolone daily) versus high-dose GC (1.5 g of IV MTP, followed by a tapering course of 40–60 mg of prednisolone daily). Primary outcomes included ESKD and mortality, and secondary outcomes included GC-related toxicity, remission, and relapse rates. This study was applied to patients with newly diagnosed AAV, including those with severe or life-threatening disease.

Results

Sixty-five patients were included in the final analysis—34 in the high-dose treatment group and 31 in the low-dose treatment group. At diagnosis, more advanced renal impairment and histological disease were present in the low-dose cohort. The rate of ESKD was similar between the groups at 6 and 12 months (P = 0.22, P = 0.60, respectively). More deaths occurred in the high-dose group (26.5% versus 6.5%, P = 0.05), although this was not significant on multivariable analysis (P = 0.06). Remission rates were comparable, and there was no significant difference in relapses. Adverse events were seen in both groups, but patients in the high-dose group experienced a higher incidence of severe infections, weight gain, and steroid-induced diabetes.

Conclusion

We demonstrate that a markedly reduced dose of IV MTP with a lower overall cumulative dose of GCs is safe and effective in the management of severe AAV disease, with no significant difference in primary outcomes.

Reverse causation biases weighted cumulative exposure model estimates, but can be investigated in sensitivity analyses

OBJECTIVES

To examine the effects of reverse causation on estimates from the weighted cumulative exposure (WCE) model that is used in pharmacoepidemiology to explore drug-health outcome associations, and to identify sensitivity analyses for revealing such effects.

STUDY DESIGN AND SETTING

314,099 patients with diabetes under Clalit Health Services, Israel, were followed over 2002-2012. The association between metformin and pancreatic cancer (PC) was explored using a WCE model within the framework of discrete-time Cox regression. We used computer simulations to explore the effects of reverse causation on estimates of a WCE model and to examine sensitivity analyses for revealing and adjusting for reverse causation. We then applied those sensitivity analyses to our data.

RESULTS

Simulation demonstrated bias in the weighted cumulative exposure model and showed that sensitivity analysis could reveal and adjust for these biases. In our data, a positive association was observed (hazard ratio (HR) = 3.24, 95% confidence interval (CI): 2.24-4.73) with metformin exposure in the previous 2 years. After applying sensitivity analysis, assuming reverse causation operated up to 4 years before cancer diagnosis, the association between metformin and PC was no longer apparent.

CONCLUSION

Reverse causation can cause substantial bias in the WCE model. When suspected, sensitivity analyses based on causal analysis are advocated.

Infection prevention and vaccination in the rheumatic diseases

Patients with chronic inflammatory rheumatisms (CIR) have a higher risk of infections compared to healthy subjects. Viral and bacterial pneumonia are the most frequent infections observed in CIR with targeted disease modifying anti-rheumatic drugs (DMARDs). Moreover, drugs used to treat CIR (especially biologic and synthetic targeted DMARDs) increase the risk of infection and expose CIR patients to opportunistic infections such as tuberculosis reactivation. To limit the risk of infection, the risk-benefit ratio should be evaluated for each patient based on their characteristics and comorbidities. To prevent infections, an initial pre-treatment work-up must be performed, especially before the initiation of conventional synthetic DMARDs or biological and synthetic targeted DMARDs. This pre-treatment assessment includes the case history, laboratory and radiology findings as well. The physician must make sure a patient's vaccinations are up-to-date. The vaccines recommended for patients with CIR being treated with conventional synthetic DMARDs, bDMARDs, tsDMARDs and/or steroids should be given. Patient education is also very important. During workshops, they learn how to manage their drug treatments in at-risk situations and learn which symptoms require treatment discontinuation.

Intra-articular and soft-tissue corticosteroid injections and risk of infections: Population-based self-controlled-risk-interval design

PURPOSE

Chronic and short-term treatment with oral corticosteroids is associated with an increased risk of infection. However, the potential risk of infection that may be associated with intra-articular and soft-tissue injections of corticosteroids has not been reported. The aim of this study was to assess the risk for infection following intra-articular or soft-tissue corticosteroid injections.

METHODS

Self-controlled-risk-interval study with 15 732 adults who were treated with intra-articular or soft-tissue corticosteroid injections during 2015-2018. The study was conducted in a large Israeli Health Maintenance Organization. We self-matched the participants and analyzed the incidence of infection over three periods: an exposure-period of 90 days following the injection, and two 90-day control periods. We identified the occurrence of several common infections in the patient's electronic medical record and analyzed the incidence rates of all infections (composite end-point) as well as each infection separately.

RESULTS

The incidence of any infection was higher during postexposure period compared with the control periods (46.5 vs. 42.1 events per 1000 persons), number needed to harm was 227 persons. Self-matching analysis showed increased incidence-rate-ratio (IRR) for the combined incidence of infections in the post-exposure period compared with the control periods (IRR = 1.10, 95% confidence interval [CI] 1.01-1.21). A sensitivity analysis showed that the highest IRR was during the first 30 days (IRR = 1.19, 95% CI 1.03-1.38), with higher IRR for patients aged 65 years and older (IRR = 1.37, 95% CI 1.08-1.73).

CONCLUSIONS

Intra-articular and soft-tissue corticosteroids injections may be associated with an increased risk of infections; however, the absolute risk increase is low.

Competition between skin antimicrobial peptides and commensal bacteria in type 2 inflammation enables survival of S. aureus

During inflammation, the skin deploys antimicrobial peptides (AMPs) yet during allergic inflammation it becomes more susceptible to Staphylococcus aureus. To understand this contradiction, single-cell sequencing of Il4ra^-/- mice combined with skin microbiome analysis reveals that lower production of AMPs from interleukin-4 receptor α (IL-4Rα) activation selectively inhibits survival of antibiotic-producing strains of coagulase-negative Staphylococcus (CoNS). Diminished AMPs under conditions of T helper type 2 (Th2) inflammation enable expansion of CoNS strains without antibiotic activity and increase Staphylococcus aureus (S. aureus), recapitulating the microbiome on humans with atopic dermatitis. This response is rescued in Camp^-/- mice or after topical steroids, since further inhibition of AMPs enables survival of antibiotic-producing CoNS strains. In conditions of Th17 inflammation, a higher expression of host AMPs is sufficient to directly inhibit S. aureus survival. These results show that antimicrobials produced by the host and commensal bacteria each act to control S. aureus on the skin.

Application of big data in ophthalmology

The advents of information technologies have led to the creation of ever-larger datasets. Also known as big data, these large datasets are characterized by its volume, variety, velocity, veracity, and value. More importantly, big data has the potential to expand traditional research capabilities, inform clinical practice based on real-world data, and improve the health system and service delivery. This review first identified the different sources of big data in ophthalmology, including electronic medical records, data registries, research consortia, administrative databases, and biobanks. Then, we provided an in-depth look at how big data analytics have been applied in ophthalmology for disease surveillance, and evaluation on disease associations, detection, management, and prognostication. Finally, we discussed the challenges involved in big data analytics, such as data suitability and quality, data security, and analytical methodologies.

Bacterial Infections Associated with Immunosuppressive Agents Commonly Used in Patients with Interstitial Lung Diseases

There are about 200 different types of interstitial lung disease (ILD), and a crucial initial step in the assessment of a patient with suspected ILD is achieving an appropriate diagnosis. Some ILDs respond to immunosuppressive agents, while immunosuppression can be detrimental in others, hence treatment is based on the most confident diagnosis with consideration of a patient's risk factors. Immunosuppressive medications have the potential to result in substantial, and perhaps life-threatening, bacterial infections to a patient. However, data on the risk of bacterial infections from immunosuppressive treatment specifically in patients with interstitial lung disease is lacking. We hereby review the immunosuppressive treatments used in ILD patients excluding sarcoidosis, highlight their risk of bacterial infections, and discuss the potential mechanisms that contribute to the increased risk of infections.

Long-term glucocorticoid exposure persistently impairs CD4+ T cell biology by epigenetically modulating the mTORC1 pathway

Conventional glucocorticoid (GC) treatment has a long-term influence on T-cell immunity, resulting in an increased risk of opportunistic infection after drug withdrawal. The underlying mechanisms remain ambiguous. This study demonstrated that long-term GC treatment induced persistent lymphopenia in patients with primary glomerular disease. GCs continuously suppressed the proportion of CD4+ T cells even after the daily dose was tapered down to the physiologic equivalences, leading to a significant decline of the CD4/CD8 ratio. Meanwhile, GCs impaired CD4+ T cell biology, leading to enhanced apoptotic cell death, reduced proliferative capacity, downregulated pro-inflammatory genes, and upregulated immunoregulatory genes. Specifically, GCs altered FOXP3 expression pattern in CD4+ T cells and favored their acquisition of an active T regulatory (Treg) cell phenotype with enhanced IL-10 production upon stimulation. Mechanistically, GCs tampered with the transcriptional regulation of mechanistic target of rapamycin complex 1 (mTORC1) pathway, resulting in an inhibitory impact on the signaling activity. Targeting mTORC1 signaling by siRNAs could sufficiently modify the viability of GC-exposed CD4+ T cells. By high-throughput sequencing of genome-wide DNA methylation and mRNA, we further uncovered a causal relationship between the altered DNA methylation level and transcription activity in a subset of mTORC1 pathway genes in long-term GC exposure. Taken together, this study reveals a novel regulation of mTORC1 signaling, which might dominate the long-term influence of GC on CD4+ T cell biology in a dose-independent manner.

Influence of discontinuation of prophylactic antimicrobial agent for trabeculectomy

BACKGROUND

There is no unified view of the necessity of prophylactic antimicrobial agents in trabeculectomy. Preoperative prophylactic antimicrobial agent injection and cefazolin sodium (CEZ) for trabeculectomy were discontinued at the Hiroshima University Hospital. In this study, we evaluated whether discontinuation of preoperative administration of CEZ in ophthalmology affects the incidence of postoperative infections.

METHODS

We retrospectively investigated patient background, concomitant medications, subconjunctival dexamethasone sodium phosphate (DEX) injection at the end of the surgery, and the incidence of infective endophthalmitis within 6 weeks after surgery in the CEZ and non-CEZ groups. We also performed propensity score matching for background matching. Statistical analysis was performed using the Mann-Whitney U-test and Fisher's exact test.

RESULTS

The incidence of postoperative endophthalmitis was not significantly different between 629 and 751 patients in the CEZ and no-CEZ groups, respectively (0 in the CEZ group and 2 in the no-CEZ group, P = 0.504). More patients in the CEZ group were taking diabetes drugs preoperatively (P = 0.028) and fewer patients were receiving subconjunctival DEX at the end of surgery (P < 0.001) than those in the non-CEZ group. Propensity scores were calculated using the risk factors for postoperative infection as covariates, and matching (580 patients in the CEZ group and 580 patients in the non-CEZ group) showed no significant difference in the incidence of postoperative endophthalmitis (P = 0.500).

CONCLUSIONS

There was no significant difference in the incidence of endophthalmitis after trabeculectomy between the CEZ and non-CEZ groups, suggesting a decreased need for CEZ injections before trabeculectomy.

Humoral response to mRNA-based COVID-19 vaccine in patients with immune thrombocytopenia

Data for COVID-19 vaccine response in patients with immune thrombocytopenia (ITP) are very limited. In a study of 28 patients with ITP, anti-severe acute respiratory syndrome coronavirus 2 spike antibody titres were measured after vaccination. The seroconversion rate for ITP patients was 91.3%, comparable to that in healthy controls (HCs). However, the antibody titre in ITP patients was significantly lower than that in HCs and declined with ageing. Furthermore, the antibody titre in ITP patients who received a minimum prednisolone dose of at least 5 mg/day at any time-point at or after initial vaccination was lower than that in other patients.

Development of a web tool to calculate the cumulative dose of glucocorticoids

INTRODUCTION

Glucocorticoids are associated with serious side effects related to dosing and time of use. Unfortunately, there is no standard method for determining glucocorticoid exposure, especially in patients undergoing long-term treatment.

OBJECTIVE

The aim of this work was to create a free and easy-to-use web application to calculate, in a systematic way, the total cumulative dose of corticosteroids.

METHODS

The total cumulative dose is calculated as the sum of all periods of treatment with different doses of corticosteroids, and is expressed as the equivalent dose of prednisone in mg. Glucocorticoid doses during periods in which the available information is missing or incomplete are estimated by systematic assumptions.

RESULTS

A simulation exercise using standard patterns of steroid use in polymyalgia rheumatica, and giant cell arteritis showed that even when the period of no information reached 50% of the time, the accuracy of the calculator had a mean absolute percentage error (MAPE)<7%.

CONCLUSION

This tool simplifies and standardizes the glucocorticoids cumulative dose calculation, thereby minimizing bias in the assessment of glucocorticoid cumulative dose.

Efficacy, duration of use and safety of glucocorticoids: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis

This systematic literature review (SLR) regarding the efficacy, duration of use and safety of glucocorticoids (GCs), was performed to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA). Studies on GC efficacy were identified from a separate search on the efficacy of disease-modifying antirheumatic drugs (DMARDs). A combined search was performed for the duration of use and safety of GCs in RA patients. Dose-defined and time-defined GC treatment of any dose and duration (excluding intra-articular GCs) prescribed in combination with other DMARDs were considered. Results are presented descriptively. Two included studies confirmed the efficacy of GC bridging as initial therapy, with equal efficacy after 2 years of initial doses of 30 mg/day compared with 60 mg/day prednisone. Based on a recently performed SLR, in clinical trials most patients starting initial GC bridging are able to stop GCs within 12 (22% patients continued on GCs) to 24 months (10% patients continued on GCs). The safety search included 12 RCTs and 21 observational studies. Well-known safety risks of GC use were confirmed, including an increased risk of osteoporotic fractures, serious infections, diabetes and mortality. Data on cardiovascular outcomes were Inconsistent. Overall, safety risks increased with increasing dose and/or duration, but evidence on which dose is safe was conflicting. In conclusion, this SLR has confirmed the efficacy of GCs in the treatment of RA. In clinical trials, most patients have shown to be able to stop GCs within 12-24 months. Well-known safety risks of GC use have been confirmed, but with heterogeneity between studies.

Respiratory tract infections and risk factors for infection in a cohort of 330 patients with axial spondyloarthritis or psoriatic arthritis

Respiratory tract infections (RTIs) are the most common infections in patients with rheumatic diseases under immunosuppressive treatment and may contribute to morbidity and mortality as well as increased healthcare costs. However, to date only limited data on infection risk in spondyloarthritis (SpA) patients are available. In this study we assessed the occurrence of respiratory tract infections in a monocentric real-world cohort consisting of 330 patients (168 psoriatic arthritis and 162 axial spondyloarthritis patients) and determined factors associated with increased infection risk. Out of 330 SpA patients, 89.3% had suffered from ≥ 1 upper respiratory tract infection (URTI) and 31.1% from ≥ 1 lower respiratory tract infection (LRTI) within the last two years. The most common URTIs were rhinitis and laryngitis/pharyngitis with 87.3% and 36.1%, respectively. Bronchitis constituted the most common LRTI, reported in 29.7% of patients. In a multivariate binomial logistic regression model occurrence of LRTI was associated with chronic lung disease (OR 17.44, p=0.006), glucocorticoid therapy (OR 9.24, p=0.012), previous history of severe airway infections (OR 6.82, p=0.013), and number of previous biological therapies (OR 1.72, p=0.017), whereas HLA B27 positivity was negatively associated (OR 0.29, p=0.025). Female patients reported significantly more LRTIs than male patients (p=0.006) and had a higher rate of antibiotic therapy (p=0.009). There were no significant differences between axSpA and PsA patients regarding infection frequency or antibiotic use. 45.4% of patients had required antibiotics for respiratory tract infections. Antibiotic therapy was associated with smoking (OR 3.40, p=0.008), biological therapy (OR 3.38, p=0.004), sleep quality (OR 1.13, p<0.001) and age (OR 0.96, p=0.030). Hypogammaglobulinemia (IgG<7g/l) was rare (3.4%) in this SpA cohort despite continuous immunomodulatory treatment. Awareness of these risk factors will assist physicians to identify patients with an increased infection risk, who will benefit from additional preventive measures, such as vaccination and smoking cessation or adjustment of DMARD therapy.

Humoral response after SARS-CoV-2 mRNA vaccination in patients with prostate cancer using steroids

OBJECTIVES

The effect of concomitant steroid use on the antibody response to a SARS-CoV-2 vaccine in patients with prostate cancer (PC) remains unknown. We aimed to evaluate the rates of antispike immunoglobulin G (IgG) antibody response to the BNT162b2 mRNA vaccine in patients with PC using steroids.

METHODS

This cross-sectional study conducted from June 21, 2021 to January 5, 2022 included 215 patients with PC who received the second dose of the BNT162b2 mRNA vaccine at least 7 days before the measurement of titers of IgG antibodies against the receptor-binding domain of SARS-CoV-2 spike (S) protein. We compared the rate of anti-SARS-CoV-2 S IgG ≥15 U/mL between patients with or without concomitant steroid use.

RESULTS

Of 215, we identified 33 patients who had concomitant steroid use. Of these, 12 and 21 patients were metastatic castration-sensitive PC and castration-resistant PC (CRPC), respectively. Patients with concomitant steroid use had a significantly lower rate of antibody titer ≥15 U/mL than those without steroid use (82% vs. 95%, P = 0.021). Patients with CRPC with concomitant steroid use (n =21) also had a lower rate of antibody titer ≥15 U/mL (71%) than those without steroid use (93%, P = 0.051), although this was not statistically different. Increased number of systemic treatments administered after diagnosis of CRPC (3 lines or more) were significantly associated with antibody titers <15 U/mL (97% vs. 77%, P <0.001).

CONCLUSION

The humoral response to the BNT162b2 mRNA vaccine was significantly lower in patients with concomitant steroid use. Anti-SARS-CoV-2 S antibody titers were affected by CRPC status, the accumulation of post-CRPC treatments, and steroid use.

Characteristics of patients with viral infections of the lower respiratory tract: A retrospective study

While the impact of respiratory virus infections has been well researched in some respiratory diseases, no clinical studies have discussed the subject of who would be more likely to develop respiratory virus infections among patients with various respiratory illnesses who come from different backgrounds. This study aimed to identify respiratory diseases that are frequently associated with respiratory virus infections along with the characteristics of patients who develop such infections in clinical settings. Tested specimens were obtained from the lower respiratory tract by bronchoscopy to provide more accurate data. Data of bronchoscopies at Ryukyu University Hospital between August 2012 and September 2016 were reviewed, and patients who underwent multiplex polymerase chain reaction (PCR) tests for detecting respiratory viruses in bronchoscopy specimens were retrospectively recruited for descriptive statistics. Differences among patients' primary pulmonary diseases and backgrounds were compared between the PCR-positive and -negative patients, and multivariate statistical analysis was performed to analyze factors associated with a positive PCR test result. Overall, 756 bronchoscopies were performed during the study period and PCR tests were performed for 177 patients. Of them, 27 tested positive for respiratory viruses, mainly parainfluenza virus and rhinovirus, and out of those, 7 were hospitalized for >1 month. Overall, all patients did not experience typical upper respiratory infection symptoms. In positive patients, 13 and 7 had diagnoses of interstitial lung disease and bacterial pneumonia, respectively. The diagnoses of 3 bacterial pneumonia cases were changed to viral pneumonia after receiving their PCR-positive tests. Respiratory virus infections were confirmed in 14 patients on immunosuppressant therapy and 4 on maintenance dialysis. Multivariate analysis revealed that immunosuppressant therapy and maintenance dialysis were independently associated with respiratory virus infections. Viruses were commonly detected in patients with interstitial lung diseases and bacterial pneumonia, while few patients were diagnosed with pure viral pneumonia. These illnesses were considered to be induced by respiratory infections. Immunosuppressant therapy and maintenance dialysis were associated with respiratory virus infections. Multiplex PCR testing is an essential diagnostic tool for respiratory virus infections in immunocompromised patients.

Association of low-dose glucocorticoid use and infection occurrence in systemic lupus erythematosus patients: a prospective cohort study

BACKGROUND

Infection is a major cause of mortality in patients with systemic lupus erythematosus (SLE). Therefore, minimizing the risk of infection is an important clinical goal to improve the long-term prognosis of SLE patients. Treatment with ≥7.5 mg prednisolone (PSL) or equivalent has been reported to increase the risk of infections. However, it remains unclear whether <7.5 mg PSL or equivalent dose affects the risk of infection in SLE patients. This study evaluated the association between the occurrence of infection in patients with SLE and low-dose glucocorticoid (GC) usage, especially <7.5 mg PSL or equivalent, to explore the GC dose that could reduce infection occurrence.

METHODS

This prospective cohort study included patients from the Japanese multicenter registry of patients with SLE (defined as ≥4 American College of Rheumatology 1997 revised criteria) over 20 years of age. The PSL dose was categorized as PSL 0-2.5, 2.6-5.0, 5.1-7.5, and 7.6-15.0 mg. The primary outcome was infection requiring hospitalization. We conducted a multivariable analysis using time-dependent Cox regression analysis to assess the hazard ratio of infection occurrence compared with a dose of 0-2.5 mg PSL or equivalent in the other three PSL dose groups. Based on previous reports and clinical importance, the covariates selected were age, sex, and concurrent use of immunosuppressants with GC. In addition, two sensitivity analyses were conducted.

RESULTS

The mean age of the 509 SLE patients was 46.7 years; 89.0% were female, and 77.2% used multiple immunosuppressants concomitantly. During the observation period, 52 infections requiring hospitalization occurred. The incidence of infection with a PSL dose of 5.0-7.5 mg was significantly higher than that in the PSL 0-2.5 mg group (adjusted hazard ratio: 6.80, 95% confidence interval: 2.17-21.27). The results of the two sensitivity analyses were similar.

CONCLUSIONS

Our results suggested that the use of 5.0-7.5 mg PSL or equivalent could pose an infection risk in SLE patients. This finding indicates that PSL dose should be reduced to as low as possible in SLE patients to avoid infection.

Factors associated with cytomegalovirus antigenemia in patients with rheumatic disease: A retrospective study

INTRODUCTION

This study aimed to examine the factors associated with cytomegalovirus (CMV) antigenemia and the time of onset of CMV antigenemia among patients with rheumatic diseases.

METHODS

A single-center, retrospective, observational study was conducted in our institution from January 2009 to December 2017. This study included patients with rheumatic diseases who had at least one CMV antigen measurement. Multivariate analysis and receiver operating characteristic analysis was performed.

RESULTS

A total of 249 patients underwent CMV antigenemia assay, and 84 (33.7%) patients tested positive. When the association between CMV antigenemia and possible associated factors was investigated, multivariate analysis showed that daily steroid dose increased the odds of having CMV [odds ratio 16.25, 95% confidence interval (CI), 5.360-49.253]. In this study, the cutoff value of daily steroid dose found in this study (0.45 mg/kg/day) was reasonable in clinical practice, and the area under the curve of the steroid dose was 0.838 [95% CI 0.781-0.882], which was the largest of the known indicators. Moreover, the median time from the start of immunosuppressive therapy to the onset of CMV antigenemia was 30 (interquartile range, 21-44) days, and most of the daily steroid users (85.7%) developed CMV antigenemia within 60 days.

CONCLUSIONS

The daily steroid dose is the most important factor associated with CMV antigenemia. Therefore, monitoring and treatment strategies based on the steroid dose, especially in the initial 2 months, are important.

Percutaneous Left Atrial Appendage Closure in a Patient with Diffuse Alveolar Hemorrhaging Associated with Anticoagulant Therapy and Atrial Fibrillation

Diffuse alveolar hemorrhaging (DAH) due to oral anticoagulation (OAC) is a life-threatening condition that leads to severe respiratory failure. There is a clinical dilemma in that OAC-induced DAH often forces the discontinuation of OAC therapy and the administration of high-dose corticosteroids, which increases the risk of stroke and cardiovascular events. We herein report the first case of OAC-induced DAH and atrial fibrillation (AF) in a patient who completely discontinued OAC therapy and high-dose corticosteroids after experiencing percutaneous left atrial appendage (LAA) occlusion. This case suggests that percutaneous LAA closure may aid in the management of OAC-induced DAH and AF.