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Momen Majumder MS, Hasan ATMT, Choudhury MR, Ahmed S, Miah MT, Amin MR, Shahin MA, Islam A, Shazzad MN, Hassan MM, Ahmedullah AK, Rahman MM, Yesmeen S, Uddin T, Haq SA. 2023 Management Recommendations of Bangladesh Rheumatology Society on Pharmacological Treatment of Rheumatoid Arthritis With Synthetic and Biologic Disease-Modifying Drugs. Cureus 2024; 16:e59395. [PMID: 38707172 PMCID: PMC11070067 DOI: 10.7759/cureus.59395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/07/2024] Open
Abstract
Rheumatoid arthritis (RA) is the most common inflammatory polyarthritis in Bangladesh. Bangladesh Rheumatology Society (BRS) proposes these management recommendations to treat the considerable burden of RA in the resource-constrained situation based on the best current evidence combined with societal challenges and opportunities. BRS formed a task force (TF) comprising four rheumatologists. The TF searched for all available literature, including updated American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), and Asia-Pacific League of Associations for Rheumatology (APLAR) and several other guidelines, and systematic literature reviews until October 2023, and then a steering committee was formed, which included rheumatologists and internists. We followed the EULAR standard operating procedures to categorize levels of evidence and grading of recommendations. This recommendation has two parts -- general (diagnosis of RA, nomenclature of disease-modifying anti-rheumatic drugs [DMARDs], disease activity indices) and management portion. The TF agreed on four overarching principles and 12 recommendations. Overarching principles deal with early diagnosis and disease activity monitoring. Recommendations 1-5 discuss using glucocorticoids, NSAIDs, and conventional synthetic DMARDs (csDMARD). Recommendations 6-9 stretch the use of targeted synthetic DMARDs (tsDMARDs) and biological DMARDs (bDMARDs). The suggested DMARD therapy includes initiation with methotrexate (MTX) or another csDMARD (in case of contraindication to MTX) in the first phase and the addition of a tsDMARD in the second phase, switching to an alternative tsDMARDs or bDMARDs in the subsequent phases. The TF included the Padua prediction score for the thromboembolism risk estimation. Recommendations 10-12 cover infection screening, vaccination, and DMARD tapering. Bangladesh has a higher prevalence of RA. This recommendation will serve as a tool to treat this high burden of patients with RA scientifically and more effectively.
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Affiliation(s)
| | | | | | - Shamim Ahmed
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Md Titu Miah
- Internal Medicine, Directorate General of Medical Education, Mohakhali, Dhaka, BGD
| | - Md Robed Amin
- Internal Medicine, Directorate General of Health Services (DGHS), Dhaka, BGD
| | - Md A Shahin
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Ariful Islam
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | | | - M Masudul Hassan
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | | | | | - Sabrina Yesmeen
- Rheumatology, BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders) General Hospital, Dhaka, BGD
| | - Taslim Uddin
- Rehabilitation Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Syed A Haq
- Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
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Stefanski AL, Dörner T, Kneitz C. [Influence of underlying disease and immunosuppression on the immunocompetence in inflammatory rheumatic diseases]. Z Rheumatol 2024; 83:87-97. [PMID: 37644129 DOI: 10.1007/s00393-023-01408-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 08/31/2023]
Abstract
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.
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Affiliation(s)
- A-L Stefanski
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Deutschland.
| | - T Dörner
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
- Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Deutschland
| | - C Kneitz
- Rheumatologische Schwerpunktpraxis Schwerin, Schwerin, Deutschland
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Barth K, Gill H, Singh N. Long-term safety of biologic and targeted synthetic disease modifying drugs in rheumatology. Curr Opin Rheumatol 2024; 36:113-119. [PMID: 38126228 PMCID: PMC10836640 DOI: 10.1097/bor.0000000000000995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW The landscape for treatment of rheumatic diseases is ever evolving, with several new drugs recently approved across diseases and more in the pipeline. This timely review aims to highlight the latest literature on long-term safety profiles of salient established and emerging biologic (b) and targeted synthetic (ts) disease modifying antirheumatic drugs (DMARDs). RECENT FINDINGS The risk of infection remains elevated with the use of most b and tsDMARDs, with specifically risk of hepatitis B reactivation with rituximab and zoster infection with JAK inhibitors (JAKi). The results of the ORAL surveillance trial led to new black box warnings for JAKi and evoked critical risk-benefit discussions surrounding JAKi and DMARDs overall. SUMMARY Such well conducted trials are needed to gather long term comparative safety data of DMARDs. In the interim, real world observational studies also have a role to play in our understanding of long-term drug safety, provided that detailed attention is paid to minimize biases inherent in observational studies.
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Affiliation(s)
- Kaia Barth
- Fellow, Division of Rheumatology, University of Washington, Seattle, USA
| | - Harsimrat Gill
- Medical Student, Department of Medicine, University of Washington, Seattle, USA
| | - Namrata Singh
- Assistant Professor, Division of Rheumatology, University of Washington, Seattle, USA
- Adjunct Assistant Professor, Department of Epidemiology, University of Washington, Seattle, USA
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Spałek MM, Jałowska M, Bowszyc-Dmochowska M, Dmochowski M. Rituximab in the Management of Autoimmune Bullous Diseases: A Treatment-Resistant Case Series from a Single Central European Referral Center. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:270. [PMID: 38399557 PMCID: PMC10890531 DOI: 10.3390/medicina60020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Rituximab (RTX) has been the predominant treatment for autoimmune bullous diseases (AIBDs). The objective of this research was to assess the advantages and safety characteristics of RTX treatment in individuals with AIBD. This assessment focused on clinical remission and a reduction in glucocorticosteroid usage, its effect on the titers of autoantibodies targeting desmoglein-1 (DSG-1) and desmoglein-3 (DSG-3), and adverse occurrences during a 12-month follow-up period in a dermatology department within a Central European university context. Materials and Methods: Our case series involved eleven patients, including eight patients with pemphigus vulgaris, two with pemphigus foliaceus, and one with epidermolysis bullosa acquisita. They received a 1 g dose of rituximab, repeated over a two-week interval. Results: The reduction in a prednisone-equivalent dosage after 2, 6, and 12 months following the second RTX infusion was 65.05%, 73.99%, and 76.93%, in that order. The titers of antibodies against DSG-1 exhibited reductions of 43.29%, 75.86%, and 54.02% at 2, 6, and 12 months, respectively. By contrast, the antibody concentrations targeting DSG-3 displayed a decrease of 27.88%, 14.48%, and 5.09% at the corresponding time points. Over the course of the 12-month monitoring period, 18.18% of patients experienced disease relapse, while the remaining individuals achieved either complete or partial remission with minimal or no therapy. Adverse effects were noted in 36.36% of the patient population; they were mild, and no serious adverse effects were reported. Conclusions: RTX represents an efficacious and well-tolerated therapeutic option for the management of AIBD and merits consideration in cases of refractory AIBD. However, further research is imperative to delineate the most optimal dosage, dosing frequency, and total quantity of maintenance infusions required. Additionally, there is a compelling need for studies that explore the impact of RTX on individuals with AIBD who do not exhibit a significant reduction in anti-desmoglein autoantibody levels.
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Affiliation(s)
- Maciej Marek Spałek
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland; (M.M.S.); (M.J.)
| | - Magdalena Jałowska
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland; (M.M.S.); (M.J.)
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland; (M.M.S.); (M.J.)
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Simon TA, Suissa S, Skovron ML, Frisell T, Askling J, Michaud K, Pedro S, Strangfeld A, Meissner Y, Boers M, Hoffman V, Dominique A, Gomez A, Hochberg MC. Infection outcomes in patients with rheumatoid arthritis treated with abatacept and other disease-modifying antirheumatic drugs: Results from a 10-year international post-marketing study. Semin Arthritis Rheum 2024; 64:152313. [PMID: 38044241 DOI: 10.1016/j.semarthrit.2023.152313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 09/15/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To evaluate risk of infections requiring hospitalization and opportunistic infections, including tuberculosis, in patients with rheumatoid arthritis (RA) treated with abatacept versus conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) and other biologic/targeted synthetic (b/ts) DMARDs. METHODS Five international observational data sources were used: two biologic registries (Sweden, Germany), a disease registry (USA) and two healthcare claims databases (Canada, USA). Crude incidence rates (IRs) per 1000 patient-years, with 95 % CIs, were used to estimate rate ratios (RRs) comparing abatacept versus csDMARDs or other b/tsDMARDs. RRs were adjusted for demographic factors, comorbidities, and other potential confounders and then pooled across data sources using a random effects model (REM). RESULTS The data sources included 6450 abatacept users, 136,636 csDMARD users and 54,378 other b/tsDMARD users, with a mean follow-up range of 2.2-6.2 years. Across data sources, the IRs for infections requiring hospitalization ranged from 16 to 56 for abatacept, 19-46 for csDMARDs, and 18-40 for other b/tsDMARDs. IRs for opportunistic infections were 0.4-7.8, 0.3-4.3, and 0.5-3.8; IRs for tuberculosis were 0.0-8.4, 0.0-6.0, and 0.0-6.3, respectively. The pooled adjusted RR (95 % CI), only reported for infections requiring hospitalization, was 1.2 (0.6-2.2) for abatacept versus csDMARDs and 0.9 (0.6-1.3) versus other b/tsDMARDs. CONCLUSIONS Data from this international, observational study showed similar hospitalized infection risk for abatacept versus csDMARDs or other b/tsDMARDs. IRs for opportunistic infections, including tuberculosis, were low. These data are consistent with the known safety profile of abatacept.
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Affiliation(s)
- Teresa A Simon
- Bristol Myers Squibb, 7 Haines Cove Drive, Toms River, Princeton, NJ 08753, USA.
| | | | - Mary Lou Skovron
- Bristol Myers Squibb, 7 Haines Cove Drive, Toms River, Princeton, NJ 08753, USA
| | - Thomas Frisell
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA; FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA
| | - Sofia Pedro
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA
| | - Anja Strangfeld
- Pharmacoepidemiology and Health Services Research, German Rheumatism Research Center, Berlin, Germany; Charité University Medicine, Berlin, Germany
| | - Yvette Meissner
- Pharmacoepidemiology and Health Services Research, German Rheumatism Research Center, Berlin, Germany
| | - Maarten Boers
- Department of Epidemiology & Data Science, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | | | - Alyssa Dominique
- Bristol Myers Squibb, 7 Haines Cove Drive, Toms River, Princeton, NJ 08753, USA
| | - Andres Gomez
- Bristol Myers Squibb, 7 Haines Cove Drive, Toms River, Princeton, NJ 08753, USA
| | - Marc C Hochberg
- Departments of Medicine and Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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Dominique A, Hetland ML, Finckh A, Gottenberg JE, Iannone F, Caporali R, Kou TD, Nordstrom D, Hernandez MV, Sánchez-Piedra C, Sánchez-Alonso F, Pavelka K, Bond TC, Simon TA. Safety outcomes in patients with rheumatoid arthritis treated with abatacept: results from a multinational surveillance study across seven European registries. Arthritis Res Ther 2023; 25:101. [PMID: 37308978 DOI: 10.1186/s13075-023-03067-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) have an increased risk of infection and malignancy compared with the general population. Infection risk is increased further with the use of disease-modifying antirheumatic drugs (DMARDs), whereas evidence on whether the use of biologic DMARDs increases cancer risk remains equivocal. This single-arm, post-marketing study estimated the incidence of prespecified infection and malignancy outcomes in patients with RA treated with intravenous or subcutaneous abatacept. METHODS Data were included from seven European RA quality registries: ATTRA (Anti-TNF Therapy in Rheumatoid Arthritis [Czech Republic]), DANBIO (Danish Rheumatologic Database), ROB-FIN (National Registry of Antirheumatic and Biological Treatment in Finland), ORA (Orencia and Rheumatoid Arthritis [France]), GISEA (Italian Group for the Study of Early Arthritis), BIOBADASER (Spanish Register of Adverse Events of Biological Therapies in Rheumatic Diseases), and the SCQM (Swiss Clinical Quality Management) system. Each registry is unique with respect to design, data collection, definition of the study cohort, reporting, and validation of outcomes. In general, registries defined the index date as the first day of abatacept treatment and reported data for infections requiring hospitalization and overall malignancies; data for other infection and malignancy outcomes were not available for every cohort. Abatacept exposure was measured in patient-years (p-y). Incidence rates (IRs) were calculated as the number of events per 1000 p-y of follow-up with 95% confidence intervals. RESULTS Over 5000 patients with RA treated with abatacept were included. Most patients (78-85%) were female, and the mean age range was 52-58 years. Baseline characteristics were largely consistent across registries. Among patients treated with abatacept, IRs for infections requiring hospitalization across the registries ranged from 4 to 100 events per 1000 p-y, while IRs for overall malignancy ranged from 3 to 19 per 1000 p-y. CONCLUSIONS Despite heterogeneity between registries in terms of design, data collection, and ascertainment of safety outcomes, as well as the possibility of under-reporting of adverse events in observational studies, the safety profile of abatacept reported here was largely consistent with previous findings in patients with RA treated with abatacept, with no new or increased risks of infection or malignancy.
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Affiliation(s)
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Axel Finckh
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | | | | | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- ASST PINI-CTO Hospital, Milan, Italy
| | | | - Dan Nordstrom
- Departments of Medicine and Rheumatology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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The impact of immunomodulating treatment on the immunogenicity of COVID-19 vaccines in patients with immune-mediated inflammatory rheumatic diseases compared to healthy controls. A Swedish nationwide study (COVID19-REUMA). Vaccine 2023; 41:3247-3257. [PMID: 37076360 PMCID: PMC10070777 DOI: 10.1016/j.vaccine.2023.03.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023]
Abstract
Objectives To elucidate antibody responses after the second and third dose of COVID-19 vaccine in patients with inflammatory rheumatic diseases (IRD) treated with biologic/targeted disease modifying anti-rheumatic drugs (b/ts DMARDs). Methods Antibody levels to antigens representing spike full length protein and spike S1 were measured before vaccination, 2-12 weeks after the second dose, before and after the third dose using multiplex bead-based serology assay. Positive antibody response was defined as antibody levels over cut off (seropositivity) in seronegative individuals or ≥4-fold increase in antibodies in individuals seropositive for both spike proteins. Results Patients (n=414) receiving b/ts DMARDs (283 had arthritis, 75 systemic vasculitis and 56 other autoimmune diseases) and controls (n=61) from five Swedish regions participated. Treatments groups were: rituximab (n=145); abatacept (n=22); Interleukin 6 receptor inhibitors [IL6i (n=79)]; JAnus Kinase Inhibitors [JAKi (n=58)], Tumour Necrosis Factor inhibitor [TNFi (n=68)] and Interleukin12/23/17 inhibitors [IL12/23/17i (n=42)]. Percentage of patients with positive antibody response after two doses was significantly lower in rituximab (33,8%) and abatacept (40,9%) (p<0,001) but not in IL12/23/17i, TNFi or JAKi groups compared to controls (80,3%). Higher age, rituximab treatment and shorter time between last rituximab course and vaccination predicted impaired antibody response. Antibody levels collected 21-40 weeks after second dose decreased significantly (IL6i: p=0,02; other groups: p<0,001) compared to levels at 2-12 week but most participants remained seropositive. Proportion of patients with positive antibody response increased after third dose but was still significantly lower in rituximab (p<0,001). Conclusions Older individuals and patients on maintenance rituximab have an impaired response after two doses of COVID-19 vaccine which improves if the time between last rituximab course and vaccination extends and also after an additional vaccine dose. Rituximab patients should be prioritized for booster vaccine doses. TNFi, JAKi and IL12/23/17i does not diminished humoral response to primary and an additional vaccination.
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Raho G, Cordeddu W, Firinu D, Del Giacco S, Angioni G. Successful Combination of Remdesivir and Convalescent Plasma to Treat
a Patient with Rituximab-Related B-Cell Deficiency and Prolonged
COVID-19: A Case Report. ANTI-INFECTIVE AGENTS 2023; 21. [DOI: 10.2174/2211352520666220922091227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/23/2022] [Accepted: 08/18/2022] [Indexed: 09/22/2023]
Abstract
Background:
Treatment of severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) infection in immuno-compromised patients with complete B cell depletion
can be really challenging due to the lack of seroconversion and long-lasting disease.
Case Report:
We describe a case of long-lasting coronavirus disease (COVID-19) in a female patient with rheumatoid arthritis who was treated with rituximab and continued to show B-cell depletion. An ongoing replication of SARS-CoV-2 was demonstrated for a period of 8 months when nasopharyngeal swabs were tested. She was treated once with remdesivir but without lasting resolution, and she was then treated with convalescent plasma but with a similar effect. Only with a combination of both treatments was clinical resolution achieved. The patient's lack of seroconversion and the prolonged course of the disease illustrate the importance of humoral immunity in resolving SARS-CoV-2 infection. This case report highlights challenges in managing immunocompromised hosts, who may act as persistent shedders and sources of transmission.
Conclusions:
The combination of remdesivir and convalescent plasma resulted in successfully
achieving clinical resolution of SARS-CoV-2 infection in our patient.
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Affiliation(s)
- Giorgio Raho
- Department of Infectious and Tropical Disease Ospedale, S.S. Trinità Hospital, Cagliari, Italy
- Unit of Internal Medicine,
Allergy and Clinical Immunology, Department of Medical Sciences, Public Health University of Cagliari, Cagliari, Italy
| | - William Cordeddu
- Department of Infectious and Tropical Disease Ospedale, S.S. Trinità Hospital, Cagliari, Italy
| | - Davide Firinu
- Unit of Internal Medicine,
Allergy and Clinical Immunology, Department of Medical Sciences, Public Health University of Cagliari, Cagliari, Italy
| | - Stefano Del Giacco
- Unit of Internal Medicine,
Allergy and Clinical Immunology, Department of Medical Sciences, Public Health University of Cagliari, Cagliari, Italy
| | - Goffredo Angioni
- Department of Infectious and Tropical Disease Ospedale, S.S. Trinità Hospital, Cagliari, Italy
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Frisell T, Bower H, Morin M, Baecklund E, Di Giuseppe D, Delcoigne B, Feltelius N, Forsblad-d'Elia H, Lindqvist E, Lindström U, Askling J. Safety of biological and targeted synthetic disease-modifying antirheumatic drugs for rheumatoid arthritis as used in clinical practice: results from the ARTIS programme. Ann Rheum Dis 2023; 82:601-610. [PMID: 36787994 PMCID: PMC10176333 DOI: 10.1136/ard-2022-223762] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Longitudinal clinical registry-infrastructures such as Anti-Rheumatic Therapies in Sweden (ARTIS) allow simultaneous comparison of the safety of individual immunomodulatory drugs used in clinical practice, with consistent definitions of treatment cohorts, follow-up and outcomes. Our objective was to assess and compare incidence rates of key safety outcomes for individual targeted synthetic or biological disease-modifying antirheumatic drugs (b/ts DMARDs) in rheumatoid arthritis (RA), updating previous reports and including newer treatments including Janus Kinase inhibitors (JAKi). METHODS Nationwide register-based cohort study including all patients with RA in Sweden registered as starting any b/tsDMARD 1 January 2010 through 31 December 2020, followed until 30 June 2021 (N=20 117). The incidence rates of selected outcomes, identified through national healthcare registers, were compared between individual b/tsDMARDs, adjusted for confounding by demographics, RA disease characteristics and comorbidity. RESULTS There were marked differences in treatment discontinuations due to adverse events (rates per 1000 person-years ranged from 18 on rituximab to 57 on tofacitinib), but few significant differences were observed for the serious adverse events under study. Neither cardiovascular events nor general serious infections were more frequent on baricitinib or tofacitinib versus bDMARDs, but JAKi were associated with higher rates of hospital-treated herpes zoster (HR vs etanercept, 3.82 (95% CI 2.05 to 7.09) and 4.00 (1.59 to 10.06)). Low number of events limited some comparisons, in particular for sarilumab and tofacitinib. CONCLUSION Data from ARTIS supports that the b/tsDMARDs currently used to treat RA have acceptable and largely similar safety profiles, but differences exist in particular concerning tolerability and specific infection risks.
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Affiliation(s)
- Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Hannah Bower
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Matilda Morin
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Uppsala University, Section of Rheumatology, Uppsala, Sweden
| | - Daniela Di Giuseppe
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Benedicte Delcoigne
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Nils Feltelius
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Helena Forsblad-d'Elia
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elisabet Lindqvist
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund University, Lund, Sweden
| | - Ulf Lindström
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
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Glintborg B, Di Giuseppe D, Wallman JK, Provan SA, Nordström D, Hokkanen AM, Österlund J, Kristianslund E, Kvien TK, Gudbjornsson B, Hetland ML, Michelsen B, Jacobsson L, Askling J, Lindström U. Is the risk of infection higher during treatment with secukinumab than with TNF inhibitors? An observational study from the Nordic countries. Rheumatology (Oxford) 2023; 62:647-658. [PMID: 35723604 PMCID: PMC9891432 DOI: 10.1093/rheumatology/keac358] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES The positioning of secukinumab in the treatment of axial SpA (axSpA) and PsA is debated, partly due to a limited understanding of the comparative safety of the available treatments. We aimed to assess the risk of the key safety outcome infections during treatment with secukinumab and TNF inhibitors (TNFi). METHODS Patients with SpA and PsA starting secukinumab or TNFi year 2015 through 2018 were identified in four Nordic rheumatology registers. The first hospitalized infection during the first year of treatment was identified through linkage to national registers. Incidence rates (IRs) with 95% CIs per 100 patient-years were calculated. Adjusted hazard ratios were estimated through Cox regression, with secukinumab as the reference. Several sensitivity analyses were performed to investigate confounding by indication. RESULTS Among 7708 patients with SpA and 5760 patients with PsA, we identified 16 229 treatment courses of TNFi (53% bionaïve) and 1948 with secukinumab (11% bionaïve). For secukinumab, the first-year risk of hospitalized infection was 3.5% (IR 5.0; 3.9-6.3), compared with 1.7% (IR 2.3; 1.7-3.0) during 3201 courses with adalimumab, with the IRs for other TNFi lying in between these values. The adjusted HR for adalimumab, compared with secukinumab, was 0.58 (0.39-0.85). In sensitivity analyses, the difference from secukinumab was somewhat attenuated and in some analyses no longer statistically significant. CONCLUSION When used according to clinical practice in the Nordic countries, the observed first-year absolute risk of hospitalized infection was doubled for secukinumab compared with adalimumab. This excess risk seemed largely explained by confounding by indication.
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Affiliation(s)
| | | | - Johan K Wallman
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Skane University Hospital, Lund, Sweden
| | - Sella A Provan
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Dan Nordström
- Department of Medicine and Rheumatology, Helsinki University and Helsinki University Hospital, Helsinki
| | | | - Jenny Österlund
- Division of Medicine, Helsinki University, Helsinki, Finland
| | | | - Tore K Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Glostrup
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Brigitte Michelsen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
- Division of Rheumatology, Department of Medicine, Hospital of Southern Norway Trust, Kristiansand, Norway
| | - Lennart Jacobsson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm
| | - Ulf Lindström
- Correspondence to: Ulf Lindström, Department of Rheumatology and Inflammation Research, University of Gothenburg, Box 115, Gothenburg, Sweden. E-mail:
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11
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Makimoto K, Konno R, Kinoshita A, Kanzaki H, Suto S. Incidence of severe infection in patients with rheumatoid arthritis taking biological agents: a systematic review. JBI Evid Synth 2023; 21:835-885. [PMID: 36630204 DOI: 10.11124/jbies-22-00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of this review was to estimate the population-based incidence of and determine the types of severe infection and deaths experienced by patients with rheumatoid arthritis taking biological agents. INTRODUCTION Since the late 1990s, various biological and synthetic drugs have been developed to treat rheumatoid arthritis. In recent years, the incidence of severe infection in patients with rheumatoid arthritis in Western nations has been determined by observational studies; however, no systematic review has been conducted on this topic. INCLUSION CRITERIA The following inclusion criteria were considered: i) observational studies on patients with rheumatoid arthritis treated with biological agents; ii) studies reporting the number of severe infections requiring hospitalization for treatment; iii) studies reporting person-years of observation data; and iv) studies based on rheumatoid arthritis registries, medical records from rheumatology centers, or insurance claim databases. METHODS PubMed, CINAHL, Embase, and Web of Science were searched to identify published studies. The reference lists of all studies selected for critical appraisal were screened for additional studies. Unpublished studies were searched on MedNar and OpenGrey databases. All the searches were updated on December 6, 2021. After removing the duplicates, 2 independent reviewers screened titles and abstracts against the inclusion criteria and then assessed full texts against the criteria. Two reviewers independently appraised the study and outcome levels for methodological quality using the critical appraisal instrument for cohort studies from JBI. Two reviewers extracted the relevant information related to severe infection and drugs. RESULTS Fifty-two studies from 21 countries reported severe infection rates associated with using 9 biologic agents. In total, 18,428 infections with 395,065 person-years of biologic drug exposure were included in the analysis. Thirty-five studies included infections in outpatients receiving intravenous antibiotic therapy. Fifteen studies reported the first episode of infection, and the remaining studies did not specify either the first or all of the episodes of infection. Inclusion of viral infection and/or opportunistic infection varied among studies. Fifteen studies reported the site of infection, and respiratory, skin/soft tissue, urinary tract infection, and sepsis/bacteremia were commonly reported. Ten studies reported the case fatality rates, ranging from 2.5% to 22.2%. Meta-analysis was conducted for 7 biologic agents and conventional disease-modifying antirheumatic drugs. The infection rate varied from 0.9 to 18.0/100 person-years. The meta-analysis revealed an infection rate of 4.2/100 person-years (95% CI 3.5-4.9) among patients receiving tumor necrosis factor inhibitors (heterogeneity 98.2%). The meta-analysis for the other 3 biologic agents revealed a point estimate of 5.5 to 8.7/100 person-years with high heterogeneity. Sensitivity analysis indicated that registry-based studies were less likely to have very low or very high infection rates compared with other data sources. The definition of infection, the patient composition of the cohorts, and the type of databases appeared to be the primary sources of clinical and methodological heterogeneity. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020175137. CONCLUSIONS Due to high statistical heterogeneity, the meta-analysis was not suited to estimating a summary measure of the infection rate. Developing standardized data collection is necessary to compare infection rates across studies.
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Affiliation(s)
- Kiyoko Makimoto
- Osaka University, Suita, Osaka, Japan.,The Japan Centre for Evidence Based Practice: A JBI Centre of Excellence, Osaka University, Suita, Osaka, Japan
| | - Rie Konno
- Hyogo Medical University, Hypgo, Kobe, Japan
| | | | | | - Shunji Suto
- Nara Medical University, Kashihara, Nara, Japan
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12
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Schulze-Koops H, Skapenko A, Krause A, Krueger K, Lorenz HM, Sewerin P, Specker C, Wagner UG, Voormann A, Mueller-Ladner U, Voll RE. Correspondence to 'Risk factors for hospital admissions related to COVID-19 in patients with autoimmune inflammatory rheumatic diseases'. Ann Rheum Dis 2023; 82:e1. [PMID: 33127664 DOI: 10.1136/annrheumdis-2020-218997] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig Maximilians University of Munich, Munich, Germany
| | - Alla Skapenko
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig Maximilians University of Munich, Munich, Germany
| | - Andreas Krause
- Department of Rheumatology, Clinical Immunology and Osteology, Immanuel Hospital Berlin-Wannsee Branch, Berlin, Germany
| | | | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp Sewerin
- Department and Hiller-Research-Unit fpr Rheumatology, University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Christof Specker
- Klinik für Rheumatologie und Klinische Immunologie, Kliniken Essen-Mitte-KEM, Essen, Germany
| | - Ulf G Wagner
- Division of Rheumatology, Department for Endocrinology, Nephrology, Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Anna Voormann
- Deutsche Gesellschaft für Rheumatologie eV, Berlin, Germany
| | - Ulf Mueller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus-Liebig-University Giessen, Giessen, Germany
| | - Reinhard E Voll
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany.,Centre for Chronic Immunodeficiency, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
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13
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García-Fernández A, Morán-Álvarez P, Bachiller-Corral J, Vázquez-Díaz M. Low Positivity Rate of Anti-SARS-CoV-2 IgG in Unvaccinated Patients With Rheumatic Diseases Treated With Rituximab. J Clin Rheumatol 2022; 28:424-428. [PMID: 35696998 PMCID: PMC9722326 DOI: 10.1097/rhu.0000000000001876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Robinson JI, Md Yusof MY, Davies V, Wild D, Morgan M, Taylor JC, El-Sherbiny Y, Morris DL, Liu L, Rawstron AC, Buch MH, Plant D, Cordell HJ, Isaacs JD, Bruce IN, Emery P, Barton A, Vyse TJ, Barrett JH, Vital EM, Morgan AW. Comprehensive genetic and functional analyses of Fc gamma receptors influence on response to rituximab therapy for autoimmunity. EBioMedicine 2022; 86:104343. [PMID: 36371989 PMCID: PMC9663864 DOI: 10.1016/j.ebiom.2022.104343] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Rituximab is widely used to treat autoimmunity but clinical response varies. Efficacy is determined by the efficiency of B-cell depletion, which may depend on various Fc gamma receptor (FcγR)-dependent mechanisms. Study of FcγR is challenging due to the complexity of the FCGR genetic locus. We sought to assess the effect of FCGR variants on clinical response, B-cell depletion and NK-cell-mediated killing in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). METHODS A longitudinal cohort study was conducted in 835 patients [RA = 573; SLE = 262]. Clinical outcome measures were two-component disease activity score in 28-joints (2C-DAS28CRP) for RA and British Isles Lupus Assessment Group (BILAG)-2004 major clinical response (MCR) for SLE at 6 months. B-cells were evaluated by highly-sensitive flow cytometry. Single nucleotide polymorphism and copy number variation for genes encoding five FcγRs were measured using multiplex ligation-dependent probe amplification. Ex vivo studies assessed NK-cell antibody-dependent cellular cytotoxicity (ADCC) and FcγR expression. FINDINGS In RA, carriage of FCGR3A-158V and increased FCGR3A-158V copies were associated with greater 2C-DAS28CRP response (adjusted for baseline 2C-DAS28CRP). In SLE, MCR was associated with increased FCGR3A-158V, OR 1.64 (95% CI 1.12-2.41) and FCGR2C-ORF OR 1.93 (95% CI 1.09-3.40) copies. 236/413 (57%) patients with B-cell data achieved complete depletion. Homozygosity for FCGR3A-158V and increased FCGR3A-158V copies were associated with complete depletion in combined analyses. FCGR3A genotype was associated with rituximab-induced ADCC, and increased NK-cell FcγRIIIa expression was associated with improved clinical response and depletion in vivo. Furthermore, disease status and concomitant therapies impacted both NK-cell FcγRIIIa expression and ADCC. INTERPRETATION FcγRIIIa is the major low affinity FcγR associated with rituximab response. Increased copies of the FCGR3A-158V allele (higher affinity for IgG1), influences clinical and biological responses to rituximab in autoimmunity. Enhancing FcγR-effector functions could improve the next generation of CD20-depleting therapies and genotyping may stratify patients for optimal treatment protocols. FUNDING Medical Research Council, National Institute for Health and Care Research, Versus Arthritis.
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Affiliation(s)
- James I Robinson
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Md Yuzaiful Md Yusof
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Vinny Davies
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; School of Mathematics and Statistics, University of Glasgow, UK
| | - Dawn Wild
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Michael Morgan
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; Cancer Research UK Cambridge Institute, University of Cambridge, UK
| | - John C Taylor
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Yasser El-Sherbiny
- Department of Biosciences, School of Science and Technology, Nottingham Trent University, UK; Department of Clinical Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - David L Morris
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Lu Liu
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Andy C Rawstron
- Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals NHS Trust, UK
| | - Maya H Buch
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | - Darren Plant
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | | | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University and Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Ian N Bruce
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | - Paul Emery
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; NIHR Leeds Medtech and In vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, UK
| | - Anne Barton
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | - Timothy J Vyse
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Jennifer H Barrett
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Edward M Vital
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Ann W Morgan
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; NIHR Leeds Medtech and In vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, UK.
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15
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Kastrati K, Aletaha D, Burmester GR, Chwala E, Dejaco C, Dougados M, McInnes IB, Ravelli A, Sattar N, Stamm TA, Takeuchi T, Trauner M, van der Heijde D, Voshaar MJH, Winthrop K, Smolen JS, Kerschbaumer A. A systematic literature review informing the consensus statement on efficacy and safety of pharmacological treatment with interleukin-6 pathway inhibition with biological DMARDs in immune-mediated inflammatory diseases. RMD Open 2022; 8:rmdopen-2022-002359. [PMID: 36260501 PMCID: PMC9462104 DOI: 10.1136/rmdopen-2022-002359] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/30/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively targeting interleukin-6 (IL-6) pathway in the context of immune-mediated inflammatory diseases. Methods A systematic literature research of all publications on IL-6 axis inhibition with bDMARDs published between January 2012 and December 2020 was performed using MEDLINE, EMBASE and Cochrane CENTRAL databases. Efficacy and safety outcomes were assessed in clinical trials including their long-term extensions and observational studies. Meeting abstracts from ACR, EULAR conferences and results on clinicaltrials.gov were taken into consideration. Results 187 articles fulfilled the inclusion criteria. Evidence for positive effect of IL-6 inhibition was available in various inflammatory diseases such as rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still’s disease, cytokine release syndrome due to chimeric antigen receptor T cell therapy and systemic sclerosis-associated interstitial lung disease. Newcomers like satralizumab and anti-IL-6 ligand antibody siltuximab have expanded therapeutic approaches for Castleman’s disease and neuromyelitis optica, respectively. IL-6 inhibition did not provide therapeutic benefits in psoriatic arthritis, ankylosing spondylitis and certain connective tissue diseases. In COVID-19, tocilizumab (TCZ) has proven to be therapeutic in advanced disease. Safety outcomes did not differ from other bDMARDs, except higher risks of diverticulitis and lower gastrointestinal perforations. Inconsistent results were observed in several studies investigating the risk for infections when comparing TCZ to TNF-inhibitors. Conclusion IL-6 inhibition is effective for treatment of several inflammatory diseases with a safety profile that is widely comparable to other bDMARDs.
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Affiliation(s)
- Kastriot Kastrati
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Gerd R Burmester
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Eva Chwala
- University Library, Medical University of Vienna, Wien, Austria
| | - Christian Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria
- Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Maxime Dougados
- Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
| | - Iain B McInnes
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Angelo Ravelli
- UO Pediatria II-Reumatologia, Istituto Giannina Gaslini, Genova, Italy
| | - Naveed Sattar
- Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, UK
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna Department of Medicine III, Wien, Austria
| | | | - Marieke J H Voshaar
- Department of Pharmacy and Department of Research & Innovation, Sint Maartenskliniek, Ubbergen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kevin Winthrop
- Schools of Medicine and Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
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16
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de Queiroz MJ, de Castro CT, Albuquerque FC, Brandão CC, Gerlack LF, Pereira DCR, Barros SC, Andrade WW, Bastos EDA, Azevedo JDNB, Carreiro R, Barreto ML, Santos DB. Safety of biological therapy in patients with rheumatoid arthritis in administrative health databases: A systematic review and meta-analysis. Front Pharmacol 2022; 13:928471. [PMID: 36034855 PMCID: PMC9407686 DOI: 10.3389/fphar.2022.928471] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/11/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Rheumatoid arthritis (RA) is a systemic inflammatory disease that affects the synovial fluid of joints, tendons, and some extra-articular sites. Biologic agents have been highly effective and are comparable in reducing RA symptoms, slowing disease progression, and improving physical function; however, concerns have been raised about the risks of several potential adverse effects. Thus, this study aimed to assess the safety of biological therapy in patients with rheumatoid arthritis in observational studies using administrative health databases. Methods: PubMed, Embase, Lilacs, Ovid, Scopus, and Web of Science were searched from inception to 21 October 2021. The analysis was divided into five groups: tumor necrosis factor inhibitors (TNFi) versus non-TNFi; TNFi versus csDMARDs; bDMARDs versus csDMARDs; abatacept versus bDMARDs; and TNFi versus Janus kinase inhibitors (JAKi). The adverse events were cancer, cardiovascular events, infection, herpes zoster, tuberculosis, and death. The methodological quality of the studies was assessed by the Newcastle-Ottawa Scale. A random-effects model estimated risk ratios with 95% confidence intervals. Results: Thirty-one studies were eligible for inclusion in the present systematic review, published from 2014 to 2021. A total of 1,039,398 RA patients were assessed. The 31 studies evaluated eleven different biological drugs. No significant differences were found regarding safety between TNFi versus non-TNFi (RR 1.08; 95% CI 0.92–1.28; p < 0.01; I2 = 93.0%), TNFi versus csDMARDs (RR 0.91; 95% CI 0.75–1.10; p < 0.01; I2 = 87.0%), bDMARDs versus csDMARDs (RR 0.99; 95% CI 0.82–1.20; p < 0.01; I2 = 93.0%), abatacept versus bDMARDs (RR 0.80; 95% CI 0.54–1.18; p < 0.01; I2 = 90.0%), and TNFi versus JAKi (RR 3.54; 95% CI 0.30–42.09; p = 0.01; I2 = 81.0%). In the subgroup analysis, among studies comparing abatacept to TNFi, a lower risk of cardiovascular events was associated with abatacept (RR 0.37; 95% CI 0.24–0.55). Conclusion: Our results do not suggest an increased risk of adverse events associated with biological therapy in treating RA patients, indicating a lower risk of cardiovascular events with abatacept than TNFi. However, these findings must be interpreted with caution given the limitations of this study and the low/very low certainty of the evidence. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?, identifier [CRD42020190838].
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Affiliation(s)
- Mariana Jorge de Queiroz
- Department of Pharmaceutical Assistance and Strategic Inputs, Ministry of Health, Brasília, Brazil
| | | | | | - Celmário Castro Brandão
- Department of Pharmaceutical Assistance and Strategic Inputs, Ministry of Health, Brasília, Brazil
| | - Leticia Farias Gerlack
- Department of Pharmaceutical Assistance and Strategic Inputs, Ministry of Health, Brasília, Brazil
| | | | - Sandra Castro Barros
- Department of Pharmaceutical Assistance and Strategic Inputs, Ministry of Health, Brasília, Brazil
| | - Wenderson Walla Andrade
- Department of Pharmaceutical Assistance and Strategic Inputs, Ministry of Health, Brasília, Brazil
| | - Ediane de Assis Bastos
- Department of Pharmaceutical Assistance and Strategic Inputs, Ministry of Health, Brasília, Brazil
| | | | - Roberto Carreiro
- Center of Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Brazil
| | - Mauricio Lima Barreto
- Center of Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Brazil
| | - Djanilson Barbosa Santos
- Center of Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Brazil
- Center for Health Sciences, Federal University of Recôncavo da Bahia, Santo Antônio de Jesus, Brazil
- *Correspondence: Djanilson Barbosa Santos,
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17
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Aletaha D, Kerschbaumer A, Kastrati K, Dejaco C, Dougados M, McInnes IB, Sattar N, Stamm TA, Takeuchi T, Trauner M, van der Heijde D, Voshaar M, Winthrop KL, Ravelli A, Betteridge N, Burmester GRR, Bijlsma JW, Bykerk V, Caporali R, Choy EH, Codreanu C, Combe B, Crow MK, de Wit M, Emery P, Fleischmann RM, Gabay C, Hetland ML, Hyrich KL, Iagnocco A, Isaacs JD, Kremer JM, Mariette X, Merkel PA, Mysler EF, Nash P, Nurmohamed MT, Pavelka K, Poor G, Rubbert-Roth A, Schulze-Koops H, Strangfeld A, Tanaka Y, Smolen JS. Consensus statement on blocking interleukin-6 receptor and interleukin-6 in inflammatory conditions: an update. Ann Rheum Dis 2022; 82:773-787. [PMID: 35953263 DOI: 10.1136/ard-2022-222784] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Targeting interleukin (IL)-6 has become a major therapeutic strategy in the treatment of immune-mediated inflammatory disease. Interference with the IL-6 pathway can be directed at the specific receptor using anti-IL-6Rα antibodies or by directly inhibiting the IL-6 cytokine. This paper is an update of a previous consensus document, based on most recent evidence and expert opinion, that aims to inform on the medical use of interfering with the IL-6 pathway. METHODS A systematic literature research was performed that focused on IL-6-pathway inhibitors in inflammatory diseases. Evidence was put in context by a large group of international experts and patients in a subsequent consensus process. All were involved in formulating the consensus statements, and in the preparation of this document. RESULTS The consensus process covered relevant aspects of dosing and populations for different indications of IL-6 pathway inhibitors that are approved across the world, including rheumatoid arthritis, polyarticular-course and systemic juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still's disease, Castleman's disease, chimeric antigen receptor-T-cell-induced cytokine release syndrome, neuromyelitis optica spectrum disorder and severe COVID-19. Also addressed were other clinical aspects of the use of IL-6 pathway inhibitors, including pretreatment screening, safety, contraindications and monitoring. CONCLUSIONS The document provides a comprehensive consensus on the use of IL-6 inhibition to treat inflammatory disorders to inform healthcare professionals (including researchers), patients, administrators and payers.
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Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | | | - Kastriot Kastrati
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | - Christian Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria.,Rheumatology, Brunico Hospital, Brunico, Italy
| | - Maxime Dougados
- Rheumatology, Universite Paris Descartes Faculte de Medecine Site Cochin, Paris, France
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Wien, Austria
| | - Désirée van der Heijde
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, Enschede, Netherlands and Stichting Tools Patient Empowerment, University of Twente, Enschede, The Netherlands
| | - Kevin L Winthrop
- Schools of Medicine and Public Health, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Angelo Ravelli
- UO Pediatria II-Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | | | - Johannes Wj Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vivian Bykerk
- Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, ASS G. Pini, University of Milan, Milano, Italy
| | - Ernest H Choy
- CREATE Centre, Section of Rheumatology, School of Medicine, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Catalin Codreanu
- Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Bernard Combe
- Immunorhumatologie, CHU Lapeyronie, Montpellier, France
| | - Mary K Crow
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York City, New York, USA
| | - Maarten de Wit
- Medical Humanities, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Paul Emery
- University of Leeds, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Roy M Fleischmann
- Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Cem Gabay
- Division of Rheumatology, Geneva University Hospitals, Geneve, Switzerland
| | - Merete Lund Hetland
- Department of Clinical Medicine, Copenhagen University Hospital, Kobenhavn, Denmark.,Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Annamaria Iagnocco
- Scienze Cliniche e Biologiche, Università degli Studi di Torino, Torino, Italy
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joel M Kremer
- Medicine Rheumatology, Albany Medical College, Albany, New York, USA
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris, Paris, France.,Center for Immunology of Viral Infections and Auto-immune Diseases, Université Paris-Sud, Gif-sur-Yvette, France
| | - Peter A Merkel
- Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eduardo F Mysler
- Organización Médica de Investigación SA, Buenos Aires, Argentina
| | - Peter Nash
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
| | | | - Karel Pavelka
- Rheumatology Department, Charles University, Praha, Czech Republic
| | - Gyula Poor
- National Institute of Rheumatology & Physiology, Semmelweis University, Budapest, Hungary
| | - Andrea Rubbert-Roth
- Division of Rheumatology, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Internal Medicine IV, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Anja Strangfeld
- Forschungsbereich Epidemiologie, Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Germany
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Josef S Smolen
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
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18
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Dieperink SS, Glintborg B, Oestergaard LB, Nørgaard M, Benfield T, Mehnert F, Petersen A, Torp-Pedersen C, Hetland ML. Risk of Staphylococcus aureus bacteraemia in patients with rheumatoid arthritis and the effect of orthopaedic implants on the risk: a nationwide observational cohort study. Scand J Rheumatol 2022; 52:250-258. [PMID: 35442139 DOI: 10.1080/03009742.2022.2049057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE It remains disputed how much the risk of Staphylococcus aureus bacteraemia (SAB) is increased in patients with rheumatoid arthritis (RA), and the extent to which orthopaedic implants explain the risk. We assessed SAB incidence rates (IRs) and incidence rate ratios (IRRs), comparing RA patients with a general population cohort (GPC) and individuals with versus without orthopaedic implants. METHOD Danish residents aged ≥ 18 years without prior RA or SAB (=GPC) were followed up for RA and microbiologically verified SAB events (1996-2017). IRRs were calculated by age- and sex-stratified Poisson regression adjusted for age, comorbidities, calendar year, and socioeconomic status. RESULTS The GPC comprised 5 398 690 individuals. We identified 33 567 incident RA patients (=RA cohort) (median follow-up 7.3 years, IQR 3.6-12.3). We observed 25 023 SAB events (n = 224 in the RA cohort). IRs per 100 000 person-years were 81.0 (RA cohort) and 29.9 (GPC). IRs increased with age. Adjusted IRRs in 18-59-year-old RA patients were 2.6 (95% confidence interval 1.8-3.7) for women and 1.8 (1.1-3.1) for men, compared with same sex and age group GPC. IRRs declined with age. Compared with the GPC without implants, IRRs for RA patients with implants ranged from 1.9 (1.3-2.8) (women ≥ 70 years) to 5.3 (2.2-12.8) (18-59-year-old men). CONCLUSION In this nationwide registry-based cohort study RA was a risk factor for SAB, and orthopaedic implants further increased the risk. Clinicians should be aware of potential SAB in patients with RA and orthopaedic implants.
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Affiliation(s)
- S S Dieperink
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B Glintborg
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - L B Oestergaard
- Cardiovascular Research Center, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - M Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - T Benfield
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - F Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - A Petersen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - C Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - M L Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
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19
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National reimbursement databases: use and limitations for rheumatologic studies. Joint Bone Spine 2022; 89:105369. [DOI: 10.1016/j.jbspin.2022.105369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/20/2022]
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20
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Bower H, Frisell T, Di Giuseppe D, Delcoigne B, Askling J. Influenza outcomes in patients with inflammatory joint diseases and DMARDs: how do they compare to those of COVID-19? Ann Rheum Dis 2022; 81:433-439. [PMID: 34810197 PMCID: PMC8610614 DOI: 10.1136/annrheumdis-2021-221461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To estimate absolute and relative risks for seasonal influenza outcomes in patients with inflammatory joint diseases (IJDs) and disease-modifying antirheumatic drugs (DMARDs). To contextualise recent findings on corresponding COVID-19 risks. METHODS Using Swedish nationwide registers for this cohort study, we followed 116 989 patients with IJD and matched population comparators across four influenza seasons (2015-2019). We quantified absolute risks of hospitalisation and death due to influenza, and compared IJD to comparators via Cox regression. We identified 71 556 patients with IJD on active treatment with conventional synthetic DMARDs and biological disease-modifying antirheumatic drugs (bDMARDs)/targeted synthetic disease-modifying antirheumatic drug (tsDMARDs) at the start of each influenza season, estimated risks for the same outcomes and compared these risks across DMARDs via Cox regression. RESULTS Per season, average risks for hospitalisation listing influenza were 0.25% in IJD and 0.1% in the general population, corresponding to a crude HR of 2.38 (95% CI 2.21 to 2.56) that decreased to 1.44 (95% CI 1.33 to 1.56) following adjustments for comorbidities. For death listing influenza, the corresponding numbers were 0.015% and 0.006% (HR=2.63, 95% CI 1.93 to 3.58, and HR=1.46, 95% CI 1.07 to 2.01). Absolute risks for influenza outcomes were half (hospitalisation) and one-tenth (death) of those for COVID-19, but relative estimates comparing IJD to the general population were similar. CONCLUSIONS In absolute terms, COVID-19 in IJD outnumbers that of average seasonal influenza, but IJD entails a 50%-100% increase in risk for hospitalisation and death for both types of infections, which is largely dependent on associated comorbidities. Overall, bDMARDs/tsDMARDs do not seem to confer additional risk for hospitalisation or death related to seasonal influenza.
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Affiliation(s)
- Hannah Bower
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Daniela Di Giuseppe
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Bénédicte Delcoigne
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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21
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Moreno-Torres V, de Mendoza C, de la Fuente S, Sánchez E, Martínez-Urbistondo M, Herráiz J, Gutiérrez A, Gutiérrez Á, Hernández C, Callejas A, Maínez C, Royuela A, Cuervas-Mons V. Bacterial infections in patients hospitalized with COVID-19. Intern Emerg Med 2022; 17:431-438. [PMID: 34406633 PMCID: PMC8371593 DOI: 10.1007/s11739-021-02824-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/02/2021] [Indexed: 02/05/2023]
Abstract
Bacterial infections may complicate the course of COVID-19 patients. The rate and predictors of bacterial infections were examined in patients consecutively admitted with COVID-19 at one tertiary hospital in Madrid between March 1st and April 30th, 2020. Among 1594 hospitalized patients with COVID-19, 135 (8.5%) experienced bacterial infectious events, distributed as follows: urinary tract infections (32.6%), bacteremia (31.9%), pneumonia (31.8%), intra-abdominal infections (6.7%) and skin and soft tissue infections (6.7%). Independent predictors of bacterial infections were older age, neurological disease, prior immunosuppression and ICU admission (p < 0.05). Patients with bacterial infections who more frequently received steroids and tocilizumab, progressed to lower Sap02/FiO2 ratios, and experienced more severe ARDS (p < 0.001). The mortality rate was significantly higher in patients with bacterial infections as compared to the rest (25% vs 6.7%, respectively; p < 0.001). In multivariate analyses, older age, prior neurological or kidney disease, immunosuppression and ARDS severity were associated with an increased mortality (p < 0.05) while bacterial infections were not. Conversely, the use of steroids or steroids plus tocilizumab did not confer a higher risk of bacterial infections and improved survival rates. Bacterial infections occurred in 8.5% of patients hospitalized with COVID-19 during the first wave of the pandemic. They were not independently associated with increased mortality rates. Baseline COVID-19 severity rather than the incidence of bacterial infections seems to contribute to mortality. When indicated, the use of steroids or steroids plus tocilizumab might improve survival in this population.
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Affiliation(s)
- Víctor Moreno-Torres
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain.
| | - Carmen de Mendoza
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain.
- CEU-San Pablo, University, Madrid, Spain.
| | - Sara de la Fuente
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Enrique Sánchez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | - Jesús Herráiz
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Andrea Gutiérrez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Ángela Gutiérrez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Carlos Hernández
- Pharmacy Department, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Alejandro Callejas
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Carmen Maínez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Ana Royuela
- Clinical Biostatistics Unit, Health Research Institute Puerta de Hierro-Segovia de Arana, CIBERESP, Madrid, Spain
| | - Valentín Cuervas-Mons
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
- Universidad Autónoma de Madrid, Madrid, Spain
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22
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Malm E, Nielsen SM, Berg J, Ioannidis JPA, Furst D, Smolen JS, Taylor PC, Kristensen LE, Tarp S, Ellingsen T, Christensen R. Risk of harm in synthetic and biological intervention trials in patients with inflammatory arthritis: protocol for a metaepidemiological study focusing on contextual factors. BMJ Open 2021; 11:e049850. [PMID: 34489286 PMCID: PMC8422485 DOI: 10.1136/bmjopen-2021-049850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Inflammatory arthritis (IA) conditions, including rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis, are characterised by inflammatory infiltration of the joints. Biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs), respectively, reduce the effects of proinflammatory cytokines and immune cells to ameliorate disease. However, immunosuppression can be associated with high rates of serious adverse events (SAEs), including serious infections, and maybe an increased risk of malignancies and cardiovascular events. Currently, there is no empirical evidence on the extent to which contextual factors and risk of bias (RoB) domains may modify these harm signals in randomised trials. METHODS AND ANALYSIS We will search MEDLINE (via PubMed) for systematic reviews published since April 2015 and all Cochrane reviews. From these reviews, randomised trials will be eligible if they include patients with an IA condition with at least one group randomly allocated to bDMARD and/or tsDMARD treatments. A predefined form will be used for extracting data on population characteristics (eg, baseline characteristics or eligibility criteria, such as medication background) and specific harm outcome measures, such as number of withdrawals, numbers of patients discontinuing due to adverse events and number of patients having SAEs. RoB in individual trials will be assessed using a modified Cochrane RoB tool. We will estimate the potentially causal harm effects related to the experimental intervention compared with control comparator as risk ratios, and heterogeneity across randomised comparisons will be assessed statistically and evaluated as inconsistency using the I2 Index. Our metaregression analyses will designate population and trial characteristics and each RoB domain as independent variables, whereas the three harm domains will serve as dependent variables. ETHICS AND DISSEMINATION Ethics approval is not required for this study. Results will be disseminated through publication in international peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42020171124.
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Affiliation(s)
- Esben Malm
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Sabrina Mai Nielsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Johannes Berg
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - John P A Ioannidis
- 3Department of Medicine, Department of Epidemiology and Population Health, Department of Biomedical Data Science, Department of Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Daniel Furst
- Division of Rheumatology, Department of Medicine, University of California at Los Angeles, LA, CA, USA
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lars Erik Kristensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Simon Tarp
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Torkell Ellingsen
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
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23
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Bower H, Frisell T, Di Giuseppe D, Delcoigne B, Ahlenius GM, Baecklund E, Chatzidionysiou K, Feltelius N, Forsblad-d'Elia H, Kastbom A, Klareskog L, Lindqvist E, Lindström U, Turesson C, Sjöwall C, Askling J. Impact of the COVID-19 pandemic on morbidity and mortality in patients with inflammatory joint diseases and in the general population: a nationwide Swedish cohort study. Ann Rheum Dis 2021; 80:1086-1093. [PMID: 33622688 PMCID: PMC8206171 DOI: 10.1136/annrheumdis-2021-219845] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/10/2021] [Accepted: 02/10/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To estimate absolute and relative risks for all-cause mortality and for severe COVID-19 in inflammatory joint diseases (IJDs) and with antirheumatic therapies. METHODS Through Swedish nationwide multiregister linkages, we selected all adult patients with rheumatoid arthritis (RA, n=53 455 in March 2020), other IJDs (here: spondyloarthropathies, psoriatic arthritis and juvenile idiopathic arthritis, n=57 112), their antirheumatic drug use, and individually matched population referents. We compared annual all-cause mortality March-September 2015 through 2020 within and across cohorts, and assessed absolute and relative risks for hospitalisation, admission to intensive care and death due to COVID-19 March-September 2020, using Cox regression. RESULTS During March-September 2020, the absolute all-cause mortality in RA and in other IJDs was higher than 2015-2019, but relative risks versus the general population (around 2 and 1.5) remained similar during 2020 compared with 2015-2019. Among patients with IJD, the risks of hospitalisation (0.5% vs 0.3% in their population referents), admission to intensive care (0.04% vs 0.03%) and death (0.10% vs 0.07%) due to COVID-19 were low. Antirheumatic drugs were not associated with increased risk of serious COVID-19 outcomes, although for certain drugs, precision was limited. CONCLUSIONS Risks of severe COVID-19-related outcomes were increased among patients with IJDs, but risk increases were also seen for non-COVID-19 morbidity. Overall absolute and excess risks are low and the level of risk increases are largely proportionate to those in the general population, and explained by comorbidities. With possible exceptions, antirheumatic drugs do not have a major impact on these risks.
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Affiliation(s)
- Hannah Bower
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Gerd-Marie Ahlenius
- Rheumatology Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | | | - Helena Forsblad-d'Elia
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alf Kastbom
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lars Klareskog
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | | | - Ulf Lindström
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Christopher Sjöwall
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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24
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Abstract
Purpose of Review We reviewed the current data on infections associated with rituximab use published over the last 5 years. Recent Findings New literature was available on rates of serious infections, Hepatitis B reactivation and screening, and infection with Severe Acute Respiratory Syndrome Coronavirus 2. Summary Rates of infection varied by study and population, however, higher risk of infection in patients with underlying rheumatologic diseases was seen in those who required a therapy switch, had a smoking history, and those undergoing retreatment who had a serious infection with their first course of therapy. With regards to HBV, the proportion of patients screened continues to be inadequate. Despite the upfront cost, HBV screening and prophylaxis were found to be cost effective. There is still limited data regarding COVID-19 severity in the setting of rituximab, however, rituximab, especially in combination with steroids, may lead to more severe disease and higher mortality.
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25
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Chen HH, Lin CH, Wang CY, Chao WC. Association of Hospitalised Infection With Socioeconomic Status in Patients With Rheumatoid Arthritis Receiving Biologics or Tofacitinib: A Population-Based Cohort Study. Front Med (Lausanne) 2021; 8:696167. [PMID: 34322506 PMCID: PMC8311461 DOI: 10.3389/fmed.2021.696167] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Use of biologics or targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) is associated with infection in patients with rheumatoid arthritis (RA). Socioeconomic status is substantial in infectious diseases; however, the impact of socioeconomic status on risk for infection in patients with RA receiving b/tsDMARD remains unclear. Methods: We used the 2003-2017 Taiwanese National Health Insurance Research Database to identify patients with RA receiving b/tsDMARDs. A Cox regression analysis was used to estimate the associations of covariates with the risk of hospitalised infection shown as hazard ratios (HRs) with 95% confidence interval (CIs). Results: We identified 7,647 RA patients who started their first bDMARD/tsDMARD treatment. Log-rank analyses demonstrated the association between age (p < 0.001), urbanisation (p = 0.001), the insured amount (p = 0.021), and the hospitalisation. Cox proportional regression analyses showed that age was independently associated with hospitalised infection in a dose-response manner, whereas a high-income category had an inverse association (HR 0.48, 95% CI 0.23-0.96). Hospitalisation for infection within 5 years was a strong risk factor (HR 5.63, 95% CI 1.91-16.62), and living in a rural area tended to be a risk factor (HR 1.76, 95% CI 0.98-3.14) for incident hospitalised infection. Conclusions: This study showed the crucial impacts of age, socioeconomic status, and history of infection on hospitalised infection in patients with RA receiving b/tsDMARDs. These findings highlight the largely ignored role of socioeconomic status in risk stratification among patients receiving b/tsDMARDs for RA.
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Affiliation(s)
- Hsin-Hua Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, Chung Hsing University, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan.,Big Data Center, Chung Hsing University, Taichung, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan.,Department of Healthcare Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.,Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Nursing, Hung Kuang University, Taichung, Taiwan
| | - Wen-Cheng Chao
- Big Data Center, Chung Hsing University, Taichung, Taiwan.,Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Computer Science, Tunghai University, Taichung, Taiwan.,Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan
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26
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Jeon HL, Kim SC, Park SH, Shin JY. The risk of serious infection in rheumatoid arthritis patients receiving tocilizumab compared with tumor necrosis factor inhibitors in Korea. Semin Arthritis Rheum 2021; 51:989-995. [PMID: 34403814 DOI: 10.1016/j.semarthrit.2021.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/24/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine the risk of serious infections (SIs) among patients with rheumatoid arthritis (RA) treated with tocilizumab compared with tumor necrosis factor inhibitor (TNFi) in Korea. METHODS We conducted a retrospective cohort study using the Korean National Health Insurance data. The study cohort included patients ≥18 years with RA who were initiated with tocilizumab or TNFi between January 2013 and June 2018. The primary outcome was a composite endpoint of SIs, defined as an infection resulting in intravenous antimicrobial therapy or hospitalization. Secondary outcomes were organ-specific SIs. To control for confounders, we used inverse probability of treatment weighting (IPTW) using propensity score. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using a multivariable Cox regression model. RESULTS A total of 8794 patients were identified: 1395 and 7399 patients initiated with tocilizumab and TNFi, respectively. The mean follow-up durations were 1.2 years for tocilizumab initiators and 1.0 year for TNFi initiators. After IPTW and adjustment, no increased risk of SIs was observed in tocilizumab versus TNFi (HR, 1.00; 95%CI, 0.90-1.11). In the secondary analysis, tocilizumab was associated with a higher risk of skin and subcutaneous tissue infections (HR, 1.26; 95%CI, 1.02-1.54) and a lower risk of urological and gynecological infections (HR, 0.65; 95%CI, 0.49-0.87) compared to TNFi. CONCLUSION In this population-based cohort of RA patients in Korea, tocilizumab was not associated with a higher risk of SI compared to TNFi. However, tocilizumab should be carefully used for patients at high risk for skin-related infections.
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Affiliation(s)
- Ha-Lim Jeon
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - So-Hee Park
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea; Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
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27
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Shoor S. Risk of Serious Infection Associated with Agents that Target T-Cell Activation and Interleukin-17 and Interleukin-23 Cytokines. Infect Dis Clin North Am 2021; 34:179-189. [PMID: 32444009 DOI: 10.1016/j.idc.2020.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Co-stimulatory T-cell inhibitors are used in the treatment of rheumatoid arthritis and to prevent rejection of renal transplants. Inhibitors of the intereukin (IL-17) cytokine are indicated for psoriasis, psoriatic arthritis and ankylosing spondylitis and anti- IL-23 drugs for psoriasis. Serious infections occur in 4.2% to 25.0% of co-stimulatory inhibitors and 1.0% to 2.0% with IL-17 or IL-23 inhibitors. Underlying disease, steroid dose greater than 7.5 to 10.0 mg, and comorbidities influence risk in individual patients. Opportunistic infections or reactivation of tuberculosis are rare.
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Affiliation(s)
- Stanford Shoor
- Stanford University, 1000 Welch Road Suite 203, Palo Alto, CA 94304, USA.
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28
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Chatzidionysiou K, Hetland ML, Frisell T, Di Giuseppe D, Hellgren K, Glintborg B, Nordström D, Peltomaa R, Aaltonen K, Trokovic N, Kristianslund EK, Kvien TK, Provan SA, Gudbjornsson B, Grondal G, Dreyer L, Kristensen LE, Jørgensen TS, Jacobsson LTH, Askling J. Effectiveness of a Second Biologic After Failure of a Non-tumor Necrosis Factor Inhibitor As First Biologic in Rheumatoid Arthritis. J Rheumatol 2021; 48:1512-1518. [PMID: 33649069 DOI: 10.3899/jrheum.201467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In rheumatoid arthritis (RA), evidence regarding the effectiveness of a second biologic disease-modifying antirheumatic drug (bDMARD) in patients whose first-ever bDMARD was a non-tumor necrosis factor inhibitor (TNFi) bDMARD is limited. The objective of this study was therefore to assess the outcome of a second bDMARD (non-TNFi: rituximab [RTX], abatacept [ABA], or tocilizumab [TCZ], separately; and TNFi) after failure of a non-TNFi bDMARD as first bDMARD. METHODS We identified patients with RA from the 5 Nordic biologics registers who started treatment with a non-TNFi as first-ever bDMARD but switched to a second bDMARD. For the second bDMARD, we assessed drug survival (at 6 and 12 months) and primary response (at 6 months). RESULTS We included 620 patients starting a second bDMARD (ABA 86, RTX 40, TCZ 67, and TNFi 427) following failure of a first non-TNFi bDMARD. At 6 and 12 months after start of their second bDMARD, approximately 70% and 60%, respectively, remained on treatment, and at 6 months, less than one-third of patients were still on their second bDMARD and had reached low disease activity or remission according to the Disease Activity Score in 28 joints. For those patients whose second bMDARD was a TNFi, the corresponding proportion was slightly higher (40%). CONCLUSION The drug survival and primary response of a second bDMARD in patients with RA switching due to failure of a non-TNFi bDMARD as first bDMARD is modest. Some patients may benefit from TNFi when used after failure of a non-TNFi as first bDMARD.
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Affiliation(s)
- Katerina Chatzidionysiou
- K. Chatzidionysiou, MD, PhD, Associate Professor, T. Frisell, PhD, Associate Professor, D. Di Giuseppe, PhD, K. Hellgren, MD, PhD, J. Askling, MD, PhD, Professor, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden;
| | - Merete Lund Hetland
- M.L. Hetland, MD, PhD, Professor, B. Glintborg, MD, PhD, Associate Professor, DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, on behalf of the DANBIO Registry, Copenhagen, Denmark
| | - Thomas Frisell
- K. Chatzidionysiou, MD, PhD, Associate Professor, T. Frisell, PhD, Associate Professor, D. Di Giuseppe, PhD, K. Hellgren, MD, PhD, J. Askling, MD, PhD, Professor, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Daniela Di Giuseppe
- K. Chatzidionysiou, MD, PhD, Associate Professor, T. Frisell, PhD, Associate Professor, D. Di Giuseppe, PhD, K. Hellgren, MD, PhD, J. Askling, MD, PhD, Professor, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Karin Hellgren
- K. Chatzidionysiou, MD, PhD, Associate Professor, T. Frisell, PhD, Associate Professor, D. Di Giuseppe, PhD, K. Hellgren, MD, PhD, J. Askling, MD, PhD, Professor, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Bente Glintborg
- M.L. Hetland, MD, PhD, Professor, B. Glintborg, MD, PhD, Associate Professor, DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, on behalf of the DANBIO Registry, Copenhagen, Denmark
| | - Dan Nordström
- D. Nordström, MD, PhD, Professor, R. Peltomaa, MD, PhD, N. Trokovic, MS, Helsinki University and Hospital (ROB-FIN), Departments of Medicine and Rheumatology, Helsinki, Finland
| | - Ritva Peltomaa
- D. Nordström, MD, PhD, Professor, R. Peltomaa, MD, PhD, N. Trokovic, MS, Helsinki University and Hospital (ROB-FIN), Departments of Medicine and Rheumatology, Helsinki, Finland
| | - Kalle Aaltonen
- K. Aaltonen, MD, PhD, Pharmaceuticals Pricing Board, Ministry of Social Affairs and Health, Helsinki, Finland
| | - Nina Trokovic
- D. Nordström, MD, PhD, Professor, R. Peltomaa, MD, PhD, N. Trokovic, MS, Helsinki University and Hospital (ROB-FIN), Departments of Medicine and Rheumatology, Helsinki, Finland
| | - Eirik K Kristianslund
- E.K. Kristianslund, MD, PhD, T.K. Kvien, MD, PhD, Professor, S.A. Provan, MD, PhD, Professor, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Tore K Kvien
- E.K. Kristianslund, MD, PhD, T.K. Kvien, MD, PhD, Professor, S.A. Provan, MD, PhD, Professor, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Sella A Provan
- E.K. Kristianslund, MD, PhD, T.K. Kvien, MD, PhD, Professor, S.A. Provan, MD, PhD, Professor, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Bjorn Gudbjornsson
- B. Gudbjornsson, MD, PhD, Professor, Centre for Rheumatology Research, University Hospital, and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Gerdur Grondal
- G. Grondal, MD, PhD, Professor, Department of Rheumatology and Centre for Rheumatology Research, University Hospital, Reykjavik, Iceland
| | - Lene Dreyer
- L. Dreyer, MD, PhD, Professor, Department of Rheumatology, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lars Erik Kristensen
- L.E. Kristensen, MD, PhD, Professor, T.S. Jørgensen, MD, PhD, The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Tanja Schjødt Jørgensen
- L.E. Kristensen, MD, PhD, Professor, T.S. Jørgensen, MD, PhD, The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Lennart T H Jacobsson
- L.T. Jacobsson, MD, PhD, Professor, Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Askling
- K. Chatzidionysiou, MD, PhD, Associate Professor, T. Frisell, PhD, Associate Professor, D. Di Giuseppe, PhD, K. Hellgren, MD, PhD, J. Askling, MD, PhD, Professor, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Psoas abscess during treatment with intravenous tocilizumab in a patient with rheumatoid arthritis: a case-based review. Rheumatol Int 2021; 41:819-825. [PMID: 33576887 PMCID: PMC7880036 DOI: 10.1007/s00296-021-04800-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/22/2021] [Indexed: 11/02/2022]
Abstract
Interleukin-6 receptor antagonist tocilizumab is a biologic drug used for treating patients with active rheumatoid arthritis (RA) who failed to respond to synthetic or other biologic disease-modifying antirheumatic drugs or where they were contraindicated. Interleukin-6 receptor blockade results in a decrease of disease activity but has some potential adverse effects, the most common being infections. We present a case of a 75-year-old female patient with long-lasting RA, several comorbidities and multiple prior therapies, who developed back pain and general malaise during tocilizumab intravenous treatment. The laboratory findings were typical of toxemia, and the imaging findings revealed large psoas muscle abscess. Surgical and antibiotic treatment was performed with a good outcome. To our knowledge, this has been the first case of a psoas abscess in a patient with RA treated with tocilizumab described in the literature so far. We also present a review of the literature regarding infection, and particularly abscess formation in patients treated with biological disease-modifying antirheumatic drugs, tocilizumab included.
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30
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Riley TR, George MD. Risk for infections with glucocorticoids and DMARDs in patients with rheumatoid arthritis. RMD Open 2021; 7:e001235. [PMID: 33597206 PMCID: PMC7893655 DOI: 10.1136/rmdopen-2020-001235] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 12/15/2022] Open
Abstract
Immunomodulatory therapy for rheumatoid arthritis (RA) carries risk for infectious complications. Understanding the risks of different therapeutic options is essential for making treatment decisions and appropriately monitoring patients. This review examines data on the risks for serious infections and other key infections of interest for the major classes of agents in use for RA: glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), biologics and Janus kinase (JAK) inhibitors. Conventional synthetic DMARDs have an excellent safety profile with recent data available supporting the relative safety of methotrexate. Tumour necrosis factor (TNF) inhibitors are associated with an increase in the risk of serious infections. Risk with other biological agents and with JAK inhibitors varies somewhat but overall appears similar to that of TNF inhibitors, with JAK inhibitors also associated with a greater risk of herpes zoster. Glucocorticoids have a dose-dependent effect on serious infection risk-at higher doses risk of infection with glucocorticoids is substantially greater than with other immunomodulatory therapies, and even low-dose therapy carries a risk of infection that appears to be similar to that of biological therapies.
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Affiliation(s)
- Thomas R Riley
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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31
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Grøn KL, Glintborg B, Nørgaard M, Mehnert F, Østergaard M, Dreyer L, Krogh NS, Hetland ML. Overall infection risk in rheumatoid arthritis during treatment with abatacept, rituximab and tocilizumab; an observational cohort study. Rheumatology (Oxford) 2021; 59:1949-1956. [PMID: 31764977 DOI: 10.1093/rheumatology/kez530] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/01/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Most infections in patients with RA are treated in primary care with antibiotics. A small fraction require hospitalization. Only a few studies exist regarding the overall risk of infection (i.e. prescription of antibiotics or hospitalization due to infection) in patients initiating non-TNF-inhibitor therapy. In Danish RA patients initiating abatacept, rituximab and tocilizumab treatment in routine care, the aims were to compare adjusted incidence rates (IR) of infections and to estimate relative risk of infections across the drugs during 0-12 and 0-24 months. METHODS This was an observational cohort study including all RA patients in the DANBIO registry starting a non-TNF-inhibitor from 2010 to 2017. Infections were defined as a prescription of antibiotics or hospitalization due to infection. Prescriptions, comorbidities and infections were captured through linkage to national registries. IRs of infections (age, gender adjusted) and rate ratios (as estimates of RR (relative risk)), adjusted for additional covariates) (Poisson regression) were calculated. RESULTS We identified 3696 treatment episodes (abatacept 1115, rituximab 1017, tocilizumab 1564). At baseline, rituximab users were older and had more previous cancer. During 0-12 months, 1747 infections occurred. Age and gender-adjusted IRs per 100 person-years were as follows: abatacept: 76 (95% CI: 69, 84); rituximab: 87 (95% CI: 79, 96); tocilizumab: 77 (95% CI: 71, 84). Adjusted RRs were 0.94 (95% CI: 0.81, 1.08) for abatacept and 0.94 (95% CI: 0.81, 1.03) for tocilizumab compared with rituximab and 1.00 (95% CI: 0.88, 1.14) for abatacept compared with tocilizumab. RRs around 1 were observed after 24 months. Switchers and ever smokers had higher risk compared with biologic-naïve and never smokers, respectively. CONCLUSION Overall infections were common in non-TNF-inhibitor-treated RA patients, with a tendency towards rituximab having the highest risk, but CIs were wide in all analyses. Confounding by indication may at least partly explain any differences.
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Affiliation(s)
- Kathrine L Grøn
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus
| | - Mikkel Østergaard
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Lene Dreyer
- Departments of Clinical Medicine and Rheumatology, Aalborg University and Aalborg University Hospital, Aalborg
| | | | - Merete L Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
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32
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Kimura Y, Yoshida S. Successful abatacept treatment for Felty's syndrome in a patient with rheumatoid arthritis. Mod Rheumatol Case Rep 2020; 4:168-170. [PMID: 33086993 DOI: 10.1080/24725625.2020.1717740] [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: 10/25/2022]
Abstract
We report the case of a 69-year-old man with a 38-year history of rheumatoid arthritis (RA), who developed Felty's syndrome, successful treatment with abatacept (ABT). He was treated with etanercept 50 mg/w and methotrexate 8 mg/w for the past 5 years. He was suffered from febrile neutropenia 6 months ago. Etanercept and methotrexate was discontinued 3 months ago, however, neutrophil count was not changed. Abdominal ultrasound showed splenomegaly, the diagnosis of Felty's syndrome was made. Granulocyte colony-stimulating factor therapy showed no effect on neutropenia, he was treated with ABT. After ABT therapy, absolute neutrophil count was elevated 234/μL to 1840/μL.
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Affiliation(s)
- Yuko Kimura
- Department of Immuno-Rheumatology Center, Arisawa General Hospital, Hirakata, Osaka, Japan
| | - Shuzo Yoshida
- Department of Immuno-Rheumatology Center, Arisawa General Hospital, Hirakata, Osaka, Japan
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Holmøy T, Høglund RA, Illes Z, Myhr KM, Torkildsen Ø. Recent progress in maintenance treatment of neuromyelitis optica spectrum disorder. J Neurol 2020; 268:4522-4536. [PMID: 33011853 PMCID: PMC8563615 DOI: 10.1007/s00415-020-10235-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
Background Treatment of neuromyelitis optica spectrum disorder (NMOSD) has so far been based on retrospective case series. The results of six randomized clinical trials including five different monoclonal antibodies targeting four molecules and three distinct pathophysiological pathways have recently been published. Methods Literature search on clinical trials and case studies in NMOSD up to July 10. 2020. Results We review mechanism of action, efficacy and side effects, and consequences for reproductive health from traditional immunosuppressants and monoclonal antibodies including rituximab, inebilizumab, eculizumab, tocilizumab and satralizumab. Conclusion In NMOSD patients with antibodies against aquaporin 4, monoclonal antibodies that deplete B cells (rituximab and inebilizumab) or interfere with interleukin 6 signaling (tocilizumab and satralizumab) or complement activation (eculizumab) have superior efficacy compared to placebo. Tocilizumab and rituximab were also superior to azathioprine in head-to-head studies. Rituximab, tocilizumab and to some extent eculizumab have well-known safety profiles for other inflammatory diseases, and rituximab and azathioprine may be safe during pregnancy.
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Affiliation(s)
- Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Rune Alexander Høglund
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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High rates of severe disease and death due to SARS-CoV-2 infection in rheumatic disease patients treated with rituximab: a descriptive study. Rheumatol Int 2020; 40:2015-2021. [PMID: 32945944 PMCID: PMC7499013 DOI: 10.1007/s00296-020-04699-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/31/2020] [Indexed: 12/02/2022]
Abstract
The objective of this study is to describe the characteristics and outcomes of rheumatic and musculoskeletal disease (RMD) patients who were treated with rituximab and had suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this descriptive study, RMD patients who were treated with rituximab in the last 12 months at the Rheumatology Department of our hospital were screened for SARS-CoV-2 infection via telephone interview and a comprehensive review of clinical health records (01/02/2020–26/05/2020). Those with probable or confirmed SARS-CoV-2 infection were included. In total, 76 patients were screened. Of these, 13 (17.1%) had suspected or confirmed SARS-CoV-2 infection. With regard to these 13 patients, the median age at coronavirus disease (COVID-19) diagnosis was 68 years (range 28–76 years) and 8 (61.5%) were female. Five patients had rheumatoid arthritis, three had systemic vasculitis, two had Sjögren syndrome, and two had systemic lupus erythematosus. Additionally, seven patients (53.8%) had pulmonary involvement secondary to RMD. Eight patients (61.5%) developed severe disease leading to hospitalization, and seven developed bilateral pneumonia and respiratory insufficiency. Of the eight hospitalized patients, five (62.5%) fulfilled the acute respiratory distress syndrome criteria and three developed a critical disease and died. Our cohort had a high rate of severe disease requiring hospitalization (61.5%), with bilateral pneumonia and hyperinflammation leading to a high mortality rate (23.1%). Treatment with rituximab should be considered a possible risk factor for unfavorable outcomes in COVID-19 patients with RMD. However, further study is required to confirm this association.
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Favalli EG. Understanding the Role of Interleukin-6 (IL-6) in the Joint and Beyond: A Comprehensive Review of IL-6 Inhibition for the Management of Rheumatoid Arthritis. Rheumatol Ther 2020; 7:473-516. [PMID: 32734482 PMCID: PMC7410942 DOI: 10.1007/s40744-020-00219-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, debilitating autoimmune disorder involving inflammation and progressive destruction of the joints, affecting up to 1% of the population. The majority of patients with RA have one or more comorbid conditions, the most common being cardiovascular disease, osteoporosis, and depression, the presence of which are associated with poorer clinical outcomes and lower health-related quality of life. RA pathogenesis is driven by a complex network of proinflammatory cells and cytokines, and of these, interleukin-6 (IL-6) plays a key role in the chronic inflammation associated with RA. Through cell signaling that can be initiated by both membrane-bound and soluble forms of its receptor, IL-6 acts both locally to promote joint inflammation and destruction, and in the circulation to mediate extra-articular manifestations of RA, including pain, fatigue, morning stiffness, anemia, and weight loss. This narrative review describes the role of IL-6 in the pathogenesis of RA, its comorbidities, and extra-articular systemic manifestations, and examines the effects of the IL-6 receptor inhibitors sarilumab and tocilizumab on clinical endpoints of RA, patient-reported outcomes, and common comorbidities and extra-articular manifestations.
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Affiliation(s)
- Ennio G Favalli
- Department of Rheumatology, ASST Gaetano Pini-CTO Institute, University of Milan, Milan, Italy.
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36
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Michaut A, Varin S. [Biotherapies in elderly patients]. Rev Med Interne 2020; 41:591-597. [PMID: 32674900 DOI: 10.1016/j.revmed.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/27/2020] [Accepted: 04/09/2020] [Indexed: 11/29/2022]
Abstract
The ageing of the population leads health professionals to question the tolerance and the effectiveness of the different biotherapies used in autoimmune diseases. Due to the exponential increase of biotherapies and their indications, several studies have been carried out to evaluate their impact on elderly patients suffering from autoimmune disease. However, these studies are still too few to take into account all the different specificities of elderly patients and their comorbidities; prescribers are therefore hesitant with their introduction after 75 years or even 65. More than the age of patients, it is necessary to evaluate the comorbidities before introducing this kind of treatments. Every biotherapy has different indications and contraindications, which must be known to adapt each treatment to each patient. This focus aims to remind of the adaptations and contraindications of the different biological disease-modifying anti-rheumatic drugs for geriatric population, and improve their uses since the treatments for these patients are sometimes not enough. Here we resume the methods allowing supervisors to identify errors of clinical reasoning in medical students and interns and we explain remediation techniques adapted to the types of error identified. Access to short illustrative videos of a MOOC (Massive Open On line Course) devoted to the supervision of clinical reasoning constitutes practical help for supervisors who are not expert in the complexity of medical pedagogy at the bedside.
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Affiliation(s)
- A Michaut
- Service de Rhumatologie, Centre Hospitalier Départemental de Vendée, Boulevard Stéphane Moreau, 85000 La Roche-sur-Yon, France.
| | - S Varin
- Service de Rhumatologie, Centre Hospitalier Départemental de Vendée, Boulevard Stéphane Moreau, 85000 La Roche-sur-Yon, France
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Chao WC, Wang CY, Hsu BC, Lin CH, Huang WN, Chen YH, Wu CL, Chen HH. Factors associated with sepsis risk in immune-mediated inflammatory diseases receiving tumor necrosis factor inhibitors: a nationwide study. Ther Adv Musculoskelet Dis 2020; 12:1759720X20929208. [PMID: 32595776 PMCID: PMC7298427 DOI: 10.1177/1759720x20929208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/30/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Risk factors for sepsis have not been assessed in patients receiving tumor
necrosis factor-alpha inhibitors (TNFi) for immune-mediated inflammatory
diseases (IMIDs) who are vulnerable to serious/hospitalized infections. Methods: Data from 2003–2017 were obtained from Taiwan’s National Health Insurance
Research Database to identify patients receiving TNFi, including etanercept,
adalimumab, and golimumab, for IMIDs including rheumatoid arthritis (RA),
ankylosing spondylitis (AS), psoriasis (PsO), psoriatic arthritis (PsA),
Crohn’s disease (CD), and ulcerative colitis (UC). To investigate risk
factors for sepsis, we used the Sepsis-3 definition and calculated hazard
ratios (HRs) with 95% confidence intervals (CIs) using Cox regression
analysis. Results: There were 17,764 patients (mean age 49.3 ± 14.3 years; females, 57.6%)
receiving TNFi for IMIDs, including RA (58.6%), AS (19.1%), PsO (15.1%), PsA
(2.5%), CD (3.0%), and UC (1.7%). The overall incidence rate of sepsis was
1088 per 100,000 person-years. After adjustment for potential confounders,
recent sepsis within 3 months before TNFi initiation (HR, 2.35; 95% CI,
1.73–3.20), CD (HR, 3.36; 95% CI 2.11–5.34; reference group: AS) and
glucocorticoid use (prednisolone-equivalent dose, mg/day HR, 1.05; 95% CI,
1.05–1.06) were associated with the risk of sepsis. Intriguingly, golimumab
users appeared to have a lower risk of sepsis compared with etanercept users
(HR, 0.56; 95% CI, 0.38–0.83). In addition, socioeconomic status, including
urbanization level and insured amount, was associated with sepsis in a
dose-response manner. Conclusions: Recent sepsis, CD, concomitant glucocorticoid use, and low socioeconomic
status, which were associated with an increased risk of sepsis, are crucial
for individualized risk management plans.
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Affiliation(s)
- Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, ROC
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung
| | - Bo-Chueh Hsu
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung
| | - Wen-Nan Huang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung
| | - Hsin-Hua Chen
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, ROC
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Abstract
In 1973, IL-6 was identified as a soluble factor that is secreted by T cells and is important for antibody production by B cells. Since its discovery more than 40 years ago, the IL-6 pathway has emerged as a pivotal pathway involved in immune regulation in health and dysregulation in many diseases. Targeting of the IL-6 pathway has led to innovative therapeutic approaches for various rheumatic diseases, such as rheumatoid arthritis, juvenile idiopathic arthritis, adult-onset Still’s disease, giant cell arteritis and Takayasu arteritis, as well as other conditions such as Castleman disease and cytokine release syndrome. Targeting this pathway has also identified avenues for potential expansion into several other indications, such as uveitis, neuromyelitis optica and, most recently, COVID-19 pneumonia. To mark the tenth anniversary of anti-IL-6 receptor therapy worldwide, we discuss the history of research into IL-6 biology and the development of therapies that target IL-6 signalling, including the successes and challenges and with an emphasis on rheumatic diseases. In this Perspective article, the authors recount the earliest stages of translational research into IL-6 biology and the subsequent development of therapeutic IL-6 pathway inhibitors for the treatment of autoimmune rheumatic diseases and potentially numerous other indications.
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Castellví I, Elhai M, Bruni C, Airò P, Jordan S, Beretta L, Codullo V, Montecucco CM, Bokarewa M, Iannonne F, Balbir A, Hsu VM, Distler O, Matucci-Cerinic M, Allanore Y. Safety and effectiveness of abatacept in systemic sclerosis: The EUSTAR experience. Semin Arthritis Rheum 2020; 50:1489-1493. [PMID: 32165035 DOI: 10.1016/j.semarthrit.2019.12.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/11/2019] [Accepted: 12/30/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To analyze the safety and effectiveness of abatacept (ABA) given in routine care to patients with systemic sclerosis (SSc). METHODS Retrospective multicenter observational study that enrolled patients with SSc treated with ABA. We collected epidemiological data and clinical outcomes. First, we analyzed the frequency of adverse effects. Secondly, we compared the evolution of different organ manifestations during ABA treatment. We collected data from 6 months before start of therapy to the last follow-up the following parameters: modified Rodnan Skin Score (mRSS), joints, lung and gastrointestinal involvement, concomitant medications, and laboratory tests. RESULTS Data on twenty-seven patients with SSc were collected (93% females; 67% limited SSc). Rheumatoid arthritis was the most frequent concomitant autoimmune disease. ILD was present in 15 patients. Anti-Scl 70 antibodies were present in 13 patients and rheumatoid factor and ACPA antibodies were present in eight and seven patients respectively. The main indication to use abatacept was joint involvement (59%) followed by myositis (26%). A total of 16 adverse effects were reported in 28 months of abatacept treatment including five that required hospitalization. Most of them occurred in the first 3 months after starting abatacept. After 12 months, the number of tender and swollen joints decreased compared to baseline (p<0.03 and p<0.02 respectively). Moreover, a beneficial effect of abatacept on HAQ-DI at 3 and 6 months (p<0.05) and on morning stiffness at 6 and 12 months (p<0.03) was observed. We also observed a decrease in the modified Rodnan skin score (p<0.05). No changes in lung or gastrointestinal involvement were found. CONCLUSIONS ABA demonstrated a good safety profile and seems to have some effectiveness on joint involvement and related disability in SSc patients treated in routine care.
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Affiliation(s)
- Ivan Castellví
- Universitat Autònoma de Barcelona, Division of Rheumatology and Autoimmune Systemic Diseases, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain.
| | - Muriel Elhai
- Paris Descartes University, INSERM U1016, Sorbone Paris Cité, Rheumatology A Department, Cochin Hospital, Paris, France
| | - Cosimo Bruni
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Paolo Airò
- UO Reumatologia ed Immunologia Clinica Spedali Civili Brescia, Brescia, Italy
| | - Suzana Jordan
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Lorenzo Beretta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Veronica Codullo
- Unita Operativa e Cattedra di Reumatologia. Policlinico Sant Matteo, Pavia, Italy
| | | | - Maria Bokarewa
- Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Hospital, University of Gothenburg. Gothenburg, Sweden
| | | | - Alexandra Balbir
- B. Shine Rheumatology Unit, Rambam Health Care Campus and Rappaport Faculty of Medicine, Haifa, Israel
| | - Vivien M Hsu
- Rutgers- Robert Wood Johnson Medical School Scleroderma Program, New Brunswick, United States
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Yannick Allanore
- Paris Descartes University, INSERM U1016, Sorbone Paris Cité, Rheumatology A Department, Cochin Hospital, Paris, France
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Luna G, Alping P, Burman J, Fink K, Fogdell-Hahn A, Gunnarsson M, Hillert J, Langer-Gould A, Lycke J, Nilsson P, Salzer J, Svenningsson A, Vrethem M, Olsson T, Piehl F, Frisell T. Infection Risks Among Patients With Multiple Sclerosis Treated With Fingolimod, Natalizumab, Rituximab, and Injectable Therapies. JAMA Neurol 2020; 77:184-191. [PMID: 31589278 PMCID: PMC6784753 DOI: 10.1001/jamaneurol.2019.3365] [Citation(s) in RCA: 315] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/16/2019] [Indexed: 12/25/2022]
Abstract
Importance Although highly effective disease-modifying therapies for multiple sclerosis (MS) have been associated with an increased risk of infections vs injectable therapies interferon beta and glatiramer acetate (GA), the magnitude of potential risk increase is not well established in real-world populations. Even less is known about infection risk associated with rituximab, which is extensively used off-label to treat MS in Sweden. Objective To examine the risk of serious infections associated with disease-modifying treatments for MS. Design, Setting, and Participants This nationwide register-based cohort study was conducted in Sweden from January 1, 2011, to December 31, 2017. National registers with prospective data collection from the public health care system were used. All Swedish patients with relapsing-remitting MS whose data were recorded in the Swedish MS register as initiating treatment with rituximab, natalizumab, fingolimod, or interferon beta and GA and an age-matched and sex-matched general population comparator cohort were included. Exposures Treatment with rituximab, natalizumab, fingolimod, and interferon beta and GA. Main Outcomes and Measures Serious infections were defined as all infections resulting in hospitalization. Additional outcomes included outpatient treatment with antibiotic or herpes antiviral medications. Adjusted hazard ratios (HRs) were estimated in Cox regressions. Results A total of 6421 patients (3260 taking rituximab, 1588 taking natalizumab, 1535 taking fingolimod, and 2217 taking interferon beta/GA) were included, plus a comparator cohort of 42 645 individuals. Among 6421 patients with 8600 treatment episodes, the mean (SD) age at treatment start ranged from 35.0 (10.1) years to 40.4 (10.6) years; 6186 patients were female. The crude rate of infections was higher in patients with MS taking interferon beta and GA than the general population (incidence rate, 8.9 [95% CI, 6.4-12.1] vs 5.2 [95% CI, 4.8-5.5] per 1000 person-years), and higher still in patients taking fingolimod (incidence rate, 14.3 [95% CI, 10.8-18.5] per 1000 person-years), natalizumab (incidence rate, 11.4 [95% CI, 8.3-15.3] per 1000 person-years), and rituximab (incidence rate, 19.7 [95% CI, 16.4-23.5] per 1000 person-years). After confounder adjustment, the rate remained significantly higher for rituximab (HR, 1.70 [95% CI, 1.11-2.61]) but not fingolimod (HR, 1.30 [95% CI, 0.84-2.03]) or natalizumab (HR, 1.12 [95% CI, 0.71-1.77]) compared with interferon beta and GA. In contrast, use of herpes antiviral drugs during rituximab treatment was similar to that of interferon beta and GA and lower than that of natalizumab (HR, 1.82 [1.34-2.46]) and fingolimod (HR, 1.71 [95% CI, 1.27-2.32]). Conclusions and Relevance Patients with MS are at a generally increased risk of infections, and this differs by treatment. The rate of infections was lowest with interferon beta and GA; among newer treatments, off-label use of rituximab was associated with the highest rate of serious infections. The different risk profiles should inform the risk-benefit assessments of these treatments.
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Affiliation(s)
- Gustavo Luna
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Peter Alping
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Fogdell-Hahn
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Martin Gunnarsson
- Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annette Langer-Gould
- Clinical and Translational Neuroscience, Southern California Permanente Medical Group, Kaiser Permanente, Pasadena
| | - Jan Lycke
- Department of Clinical Neuroscience and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
| | - Petra Nilsson
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Jonatan Salzer
- Department of Pharmacology and Clinical Neuroscience, Umea University, Umea, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Vrethem
- Department of Clinical and Experimental Medicine, Linkoping University, Linkoping, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Tavakolpour S, Alesaeidi S, Darvishi M, GhasemiAdl M, Darabi-Monadi S, Akhlaghdoust M, Elikaei Behjati S, Jafarieh A. A comprehensive review of rituximab therapy in rheumatoid arthritis patients. Clin Rheumatol 2019; 38:2977-2994. [PMID: 31367943 DOI: 10.1007/s10067-019-04699-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022]
Abstract
Rituximab (RTX) is an approved treatment for rheumatoid arthritis (RA) patients that do not respond adequately to disease-modifying antirheumatic drugs. However, different new concerns, such as efficacy, optimum dose, safety issues, prediction of response to RTX, and pregnancy outcomes have attracted a lot of attention. The PubMed database was systematically reviewed for the last published articles, new findings, and controversial issues regarding RTX therapy in RA using "Rheumatoid arthritis" AND "rituximab" keywords, last updated on June 18, 2019. From 1812 initial recorders, 162 studies met the criteria. Regarding the optimum dose, low-dose RTX therapy (2 × 500 mg) seems as effective as standard dose (2 × 1000 mg), safer, and more cost-effective. The most common reported safety challenges included de novo infections, false negative serologic tests of viral infections, reactivation of chronic infections, interfering with vaccination outcome, and development of de novo psoriasis. Other less reported side effects are infusion reactions, nervous system disorders, and gastrointestinal disorders. Lower exposure to other biologics, presence of some serological markers (e.g., anti-RF, anti-CCP, IL-33, ESR), specific variations in FCGR3A, FCGR2A, TGFβ1, IL6, IRF5, BAFF genes, and also EBV-positivity could be used to predict response to RTX. Although there is no evidence of the teratogenic effect of RTX, it is recommended that women do not expose themselves to RTX at least 6 months before the conception. Only a reversible reduction of B cell-count in the offspring may be the pregnancy-related outcome. Although RTX is an effective therapeutic option for RA, more studies on optimum doses, prevention of RTX-related side effects, prediction of RTX response, and safety during the pregnancy are required.
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Affiliation(s)
- Soheil Tavakolpour
- Pharmaceutical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Samira Alesaeidi
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), department of aerospace and subaquatic medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Mojtaba GhasemiAdl
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Meisam Akhlaghdoust
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Arash Jafarieh
- Amir'Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Impact of Adverse Events Associated With Medications in the Treatment and Prevention of Rheumatoid Arthritis. Clin Ther 2019; 41:1376-1396. [DOI: 10.1016/j.clinthera.2019.04.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/28/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
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Xiong Y, Mi BB, Liu MF, Xue H, Wu QP, Liu GH. Bioinformatics Analysis and Identification of Genes and Molecular Pathways Involved in Synovial Inflammation in Rheumatoid Arthritis. Med Sci Monit 2019; 25:2246-2256. [PMID: 30916045 PMCID: PMC6448456 DOI: 10.12659/msm.915451] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) has a high prevalence in the elderly population. The genes and pathways in the inflamed synovium in patients with RA are poorly understood. This study aimed to identify differentially expressed genes (DEGs) linked to the progression of synovial inflammation in RA using bioinformatics analysis. MATERIAL AND METHODS Gene expression profiles of datasets GSE55235 and GSE55457 were acquired from the Gene Expression Omnibus (GEO) database. DEGs were identified using Morpheus software, and co-expressed DEGs were identified with Venn diagrams. Protein-protein interaction (PPI) networks were assembled with Cytoscape software and separated into subnetworks using the Molecular Complex Detection (MCODE) algorithm. The functions of the top module were assessed using the Database for Annotation, Visualization, and Integrated Discovery (DAVID). The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis were performed. RESULTS DEGs that were upregulated were significantly enhanced in protein binding, the cell cytosol, organization of the extracellular matrix (ECM), regulation of RNA transcription, and cell adhesion. DEGs that were downregulated were associated with control of the immune response, B-cell and T-cell receptor signaling pathway regulation. KEGG pathway analysis showed that upregulated DEGs enhanced pathways associated with the cell adherens junction, osteoclast differentiation, and hereditary cardiomyopathies. Downregulated DEGs were enriched in primary immunodeficiency, cell adhesion molecules (CAMs), cytokine-cytokine receptor interaction, and hematopoietic cell lineages. CONCLUSIONS The findings from this bioinformatics network analysis study identified molecular mechanisms and the key hub genes that may contribute to synovial inflammation in patients with RA.
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Affiliation(s)
- Yuan Xiong
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Bo-Bin Mi
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Meng-Fei Liu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Hang Xue
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Qi-Peng Wu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Guo-Hui Liu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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