1
|
Isa M, Ramos MRR, Kamal S. Infection Risk in Biological Disease-Modifying Anti-rheumatic Drugs. Cureus 2025; 17:e80634. [PMID: 40236366 PMCID: PMC11998624 DOI: 10.7759/cureus.80634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2025] [Indexed: 04/17/2025] Open
Abstract
Rheumatology patients on biological disease-modifying anti-rheumatic drugs (bDMARDs) have been proposed to be at a higher risk of infections. Our review summarizes the current evidence behind this theory as well as explores which factors predispose patients to various infections, which agents are more likely to cause infections, and which infections are common in these patients. We also aim to explore updated guidelines on infection prevention in patients on bDMARDs.
Collapse
Affiliation(s)
- Mourushi Isa
- General Medicine, Northern Health, Melbourne, AUS
| | | | - Shahed Kamal
- General Medicine, Northern Health, Melbourne, AUS
| |
Collapse
|
2
|
Qwabe N, Paruk F, Mody GM. Low prevalence of methotrexate intolerance in rheumatoid arthritis: a South African study. Clin Rheumatol 2025; 44:1069-1079. [PMID: 39913009 PMCID: PMC11865189 DOI: 10.1007/s10067-025-07310-5] [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] [Received: 09/12/2024] [Revised: 11/07/2024] [Accepted: 12/31/2024] [Indexed: 02/07/2025]
Abstract
INTRODUCTION Methotrexate (MTX) is the first line therapy for rheumatoid arthritis (RA), and despite its widespread use, there is very little information about MTX intolerance in sub-Saharan Africa. The aim of this study was to assess the prevalence of MTX intolerance and other reasons for stopping MTX in RA in South Africa. METHODS A retrospective chart review of all RA patients seen at Inkosi Albert Luthuli Hospital in Durban from 2009 to 2019 was undertaken. We included patients who received MTX for at least three months. All patients received folic acid supplements. Patients who discontinued MTX were categorized as having either MTX related toxicity or other reasons. RESULTS A total of 695 patients were identified with a female to male ratio of 7:1. The mean age was 57.9 (± 13.3) years, and median duration of MTX use was 67.0 (39.0-106.0) months. Most of the patients were African Blacks (61.2%), and Indians (32.8%). There were 83 (11.9%) patients who stopped MTX, and it was successfully reintroduced in 25 of them. Thus, 58 (8.3%) patients discontinued therapy, 33 (4.7%) due to intolerance and 25 (3.6%) due to factors other than adverse effects. The commonest causes of MTX intolerance were respiratory, gastrointestinal and haematological. The other reasons for discontinuation included co-morbidities and pregnancy related concerns. CONCLUSIONS The low prevalence of MTX intolerance in a multiethnic population in this single centre study, confirms the value of MTX as anchor therapy, especially in resource constrained settings. Key Points • We report a low and similar prevalence of methotrexate intolerance in a large population of African Blacks and Indians with RA in sub-Saharan Africa. • Even though there was heterogeneity among other studies, our review indicates that MTX was tolerated better in our patients compared to patients in Europe and the United States of America.
Collapse
Affiliation(s)
- Namuhla Qwabe
- Department of Rheumatology, School of Clinical Medicine, College of Health Science, University of Kwa-Zulu Natal, Durban, South Africa.
| | - Farhanah Paruk
- Division of Internal Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Girish Mahasukhlal Mody
- Department of Rheumatology, School of Clinical Medicine, College of Health Science, University of Kwa-Zulu Natal, Durban, South Africa
| |
Collapse
|
3
|
Liu L, Ambe K, Onishi M, Yoshii Y, Makino T, Tohkin M. Comparison of the Efficacy and Safety of Disease-Modifying Antirheumatic Drugs Combination Therapies: A Systematic Review and Network Meta-Analysis. Clin Transl Sci 2025; 18:e70156. [PMID: 40033744 PMCID: PMC11876292 DOI: 10.1111/cts.70156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2024] [Revised: 01/19/2025] [Accepted: 01/24/2025] [Indexed: 03/05/2025] Open
Abstract
There are several disease-modifying antirheumatic drugs currently available to treat rheumatoid arthritis (RA). However, the optimal combination therapy with methotrexate for treating RA remains unclear. We aimed to identify combination therapies with high-efficacy and safety by employing the Bayesian method in a network meta-analysis. We systematically searched PubMed, Embase, CENTRAL, Ichushi web, and PMDA review reports and application materials through October 2020, and found 86 randomized controlled trials. The primary efficacy outcome was the 50% improvement rate according to the American College of Rheumatology criteria (ACR50), and the primary safety outcome was the incidence of serious adverse events. We calculated odds ratios (ORs) and its 95% credible intervals (CrIs) between each treatment, and the surface under the cumulative ranking curve (SUCRA) score for each treatment to rank disease-modifying antirheumatic drug combinations. Individually, most disease-modifying antirheumatic drugs combined with methotrexate are more likely to achieve ACR50 than methotrexate monotherapy, with significant differences (p < 0.05), whereas the incidence of serious adverse events was not significantly different compared with methotrexate monotherapy (p > 0.05). Infliximab combined with methotrexate had the highest efficacy ranking (OR = 10.53, 95% CrI: [3.20, 42.87], SUCRA score: 0.884), and etanercept combined with methotrexate had the highest safety ranking (OR = 0.29, 95% CrI: [0.03, 2.04], SUCRA score: 0.893). Comprehensive cluster analysis revealed that the combination of etanercept, an Fc-fusion protein targeting tumor necrosis factor α, with methotrexate demonstrated higher efficacy and safety. These findings could support the selection of combination therapies for the treatment of RA.
Collapse
Affiliation(s)
- Linfeng Liu
- Department of Regulatory Science, Graduate School of Pharmaceutical SciencesNagoya City UniversityNagoyaJapan
- Department of Pharmacognosy, Graduate School of Pharmaceutical SciencesNagoya City UniversityNagoyaJapan
| | - Kaori Ambe
- Department of Regulatory Science, Graduate School of Pharmaceutical SciencesNagoya City UniversityNagoyaJapan
| | - Mayu Onishi
- Department of Regulatory Science, Graduate School of Pharmaceutical SciencesNagoya City UniversityNagoyaJapan
| | - Yuka Yoshii
- Department of Regulatory Science, Graduate School of Pharmaceutical SciencesNagoya City UniversityNagoyaJapan
| | - Toshiaki Makino
- Department of Pharmacognosy, Graduate School of Pharmaceutical SciencesNagoya City UniversityNagoyaJapan
| | - Masahiro Tohkin
- Department of Regulatory Science, Graduate School of Pharmaceutical SciencesNagoya City UniversityNagoyaJapan
| |
Collapse
|
4
|
Balsa A, Díaz Del Campo Fontecha P, Silva Fernández L, Valencia Martín J, Nistal Martínez V, León Vázquez F, Hernández Hernández MV, Corominas H, Cáliz Cáliz R, Aguado García JM, Candelas Rodríguez G, Ibargoyen Roteta N, Martí Carvajal A, Plana Farras MN, Puñal Riobóo J, Park HS, Triñanes Pego Y, Villaverde García V. Recommendations by the Spanish Society of Rheumatology on risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2023; 19:533-548. [PMID: 38008602 DOI: 10.1016/j.reumae.2023.07.004] [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: 05/26/2023] [Accepted: 07/06/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE To present recommendations based on the available evidence and the consensus of experts, for risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. METHODS Clinical research questions relevant to the purpose of the document were identified. These questions were reformulated in PICO format (patient, intervention, comparison, outcome or outcome) by a panel of experts, selected based on their experience in the area. A systematic review of the evidence was carried out, grading according to the GRADE criteria (Grading of Recommendations Assessment, Development, and Evaluation). Specific recommendations were then formulated. RESULTS 6 PICO questions were proposed by the panel of experts based on their clinical relevance and the existence of recent information regarding the risk of occurrence of serious infections, the risk of reactivation of the hepatitis B virus, the risk of reactivation of the virus varicella-zoster, the risk of appearance of skin (melanoma and non-melanoma) or haematological cancer, the risk of appearance of thromboembolic disease and the risk of progression of the human papilloma virus. A total of 28 recommendations were formulated, structured by question, based on the evidence found and the consensus of the experts. CONCLUSIONS The SER recommendations on risk management of treatment with biologic therapies and JAK inhibitors in rheumatoid arthritis are presented.
Collapse
Affiliation(s)
- Alejandro Balsa
- Servicio de Reumatología, Hospital Universitario La Paz, Madrid, Spain
| | | | - Lucía Silva Fernández
- Servicio de Reumatología, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - José Valencia Martín
- Unidad de Medicina Preventiva y Salud Pública, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Fernando León Vázquez
- Medicina de Familia, Centro de Salud San Juan de la Cruz, Pozuelo de Alarcón, Madrid, Spain
| | - M Vanesa Hernández Hernández
- Servicio de Reumatología, Complejo Hospitalario Universitario de Canarias, San Cristóbal de la Laguna, Santa Cruz de Tenerife, Spain
| | - Héctor Corominas
- Servicio de Reumatología, Hospital Universitari de la Santa Creu i Sant Pau & Hospital Dos de Maig, Barcelona, Spain
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre. CIBERINFEC, ISCIII. Departamento de Medicina, UCM, Madrid, Spain
| | | | - Nora Ibargoyen Roteta
- Servicio de Evaluación de Tecnologías Sanitarias del País Vasco (Osteba). BIOEF, Barakaldo, Vizcaya, Spain
| | - Arturo Martí Carvajal
- Cátedra Rectoral de Medicina basada en la Evidencia, Universidad de Carabobo, Venezuela; Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - M Nieves Plana Farras
- Unidad de Evaluación de Tecnologías Sanitarias, Hospital Ramón y Cajal, IRYCIS. CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Janet Puñal Riobóo
- Unidad de Asesoramiento Científico-técnico, Avalia-t, Agencia Gallega para la Gestión del Conocimiento en Salud, ACIS, Santiago de Compostela, A Coruña, Spain
| | - Hye Sang Park
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Yolanda Triñanes Pego
- Unidad de Asesoramiento Científico-técnico, Avalia-t, Agencia Gallega para la Gestión del Conocimiento en Salud, ACIS, Santiago de Compostela, A Coruña, Spain
| | | |
Collapse
|
5
|
Kamath C, Brenner EJ. The safe use of inflammatory bowel disease therapies during the COVID-19 pandemic. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100101. [PMID: 35496814 PMCID: PMC9040409 DOI: 10.1016/j.crphar.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/31/2022] [Accepted: 04/21/2022] [Indexed: 10/29/2022] Open
Abstract
Background Patients with inflammatory bowel disease (IBD) often require the use of immunosuppressant medications that increase infection risk, leading to concerns over the safe use of IBD medications during the Coronavirus 19 (COVID-19) pandemic. Objectives To summarize available evidence on the safety and appropriate use of IBD medications during the COVID-19 pandemic, particularly in regard to risk of severe COVID-19 outcomes such as hospitalization, respiratory failure, or death for patients on IBD therapeutics. Conclusions The majority of IBD medications are safe to continue during the COVID-19 pandemic, with a few notable exceptions. Patients with IBD who do not have COVID-19 should continue their prescribed IBD therapies, although steroids are associated with severe COVID-19 outcomes and should be weaned when possible. Corticosteroids should be tapered and discontinued when possible in patients with IBD who test positive for COVID-19 as well. Patients with IBD who test positive for COVID-19 should hold biologics, thiopurines, methotrexate, and tofacitinib for at least 2 weeks, and those who have symptoms should not restart these medications until symptom resolution. During the COVID-19 pandemic, all patients with IBD should continue to follow public health guidance including social distancing, masking, and COVID-19 vaccination recommendations.
Collapse
Key Words
- 5-ASA, 5-aminosalicylates
- AGA, American Gastrointestinal Association
- CI, confidence interval
- COVID-19, coronavirus disease 2019
- IBD, Inflammatory Bowel Disease
- ICU, IL
- JAK, janus kinase inhibitor
- MTX, methotrexate
- SECURE-IBD, Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease
- TNF, tumor necrosis factor
- UC, Ulcerative Colitis
- aOR, adjusted odds ratio
- interleukin, intensive care unit
Collapse
Affiliation(s)
- Chethana Kamath
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Erica J Brenner
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
6
|
Tornero-Molina J, Alperi-López M, Castellví I, de Agustín-de Oro JJ, Escudero A, García-Vicuña R, González-Gay MÁ, Hidalgo C, Rubio E, Sanmartí R, Casamira N, Calvo-Alén J. Experts document on methotrexate use in combined therapy with biological or targeted synthetic disease modifying drugs in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2022; 18:33-41. [PMID: 35090610 DOI: 10.1016/j.reumae.2020.08.009] [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: 05/06/2020] [Accepted: 08/20/2020] [Indexed: 06/14/2023]
Abstract
OBJECTIVE We aimed to develop recommendations for the management of methotrexate (MTX) when considering the combination with biological (b) or targeted synthetic (ts) disease modifying drugs (DMARDs) in rheumatoid arthritis (RA). METHODS Eleven experts on RA were selected. Two coordinators formulated 13 questions about the combination therapy of MTX with bDMARDs or tsDMARDs. A systematic review was conducted to answer the questions. Inclusion and exclusion criteria were established as well as the search strategies (Medline, Embase and the Cochrane Library were searched up to January 2019). Two reviewers selected the articles and collected data. Simultaneously, EULAR and ACR meeting abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation was established using the Oxford Center for Evidence Based Medicine and the level of agreement with a Delphi. Agreement was established if at least 80% of the experts voted 'yes' (yes/no). RESULTS The systematic review retrieved 513 citations of which 61 were finally included. A total of 10 recommendations were generated, voted and accepted. The level of agreement was very high in all of them and it was achieved in the first Delphi round. Final recommendations cover aspects such as the optimal MTX dosage, tapering strategy or patients' risk management. CONCLUSIONS This document is intended to help clinicians solve usual clinical questions and facilitate decision making when treating RA patients with MTX in combination with bDMARDs or tsDMARDs.
Collapse
Affiliation(s)
| | | | - Ivan Castellví
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Alejandro Escudero
- Servicio de Reumatología, Hospital Universitario Reina Sofía, IMIBIC, Córdoba, Spain
| | | | | | - Cristina Hidalgo
- Servicio de Reumatología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Raimon Sanmartí
- Servicio de Reumatología, Hospital Universitari Clínic, Barcelona, Spain
| | - Núria Casamira
- Departamento Médico, Laboratorios Gebro Pharma, Barcelona, Spain
| | - Jaime Calvo-Alén
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
| |
Collapse
|
7
|
Ungaro RC, Brenner EJ, Agrawal M, Zhang X, Kappelman MD, Colombel JF. Impact of Medications on COVID-19 Outcomes in Inflammatory Bowel Disease: Analysis of More Than 6000 Patients From an International Registry. Gastroenterology 2022; 162:316-319.e5. [PMID: 34529987 PMCID: PMC8437703 DOI: 10.1053/j.gastro.2021.09.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Ryan C. Ungaro
- Correspondence Address correspondence to: Ryan C. Ungaro, MD, MS, The Feinstein Inflammatory Bowel Disease Clinical Center, The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, New York 10029
| | - Erica J Brenner
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Manasi Agrawal
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xian Zhang
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jean-Frederic Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | |
Collapse
|
8
|
Consani Fernández SA, Díaz Cuña CL, Fernández Rey L, Rostán Sellanes S, Maciel Oleggini G, Facal Castro JA. Infections in systemic autoimmune diseases. REUMATOLOGIA CLINICA 2021; 17:582-587. [PMID: 34823825 DOI: 10.1016/j.reumae.2020.06.011] [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: 03/28/2020] [Accepted: 06/30/2020] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Infections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received. MATERIAL AND METHODS An analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease. RESULTS 339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA. CONCLUSIONS Infections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.
Collapse
Affiliation(s)
| | - Carolina Laura Díaz Cuña
- Asistente de Clínica Médica «3», Hospital Maciel, Udelar, Asistente del Departamento Básico de Medicina, Montevideo, Uruguay
| | - Lucia Fernández Rey
- Asistente de Clínica Médica «3», Hospital Maciel, Udelar, Montevideo, Uruguay
| | | | | | | |
Collapse
|
9
|
Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| |
Collapse
|
10
|
Taylor PC, Atzeni F, Balsa A, Gossec L, Müller-Ladner U, Pope J. The Key Comorbidities in Patients with Rheumatoid Arthritis: A Narrative Review. J Clin Med 2021; 10:509. [PMID: 33535498 PMCID: PMC7867048 DOI: 10.3390/jcm10030509] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
Comorbidities in patients with rheumatoid arthritis (RA) are often associated with poor health outcomes and increased mortality. Treatment decisions should take into account these comorbidities due to known or suspected associations with certain drug classes. In clinical practice, it is critical to balance potential treatment benefit against the possible risks for comorbidities as well as the articular manifestations of RA. This review summarises the current literature relating to prevalence and risk factors for the important comorbidities of cardiovascular disease, infections, lymphomas and nonmelanoma skin cancers in patients with RA. The impact on patient outcomes and the interplay between these comorbidities and the therapeutic options currently available, including tumour necrosis factor inhibitors and newer biological therapies, are also explored. As newer RA therapies are developed, and patients gain wider and earlier access to advanced therapies, in part due to the emergence of biosimilars, it is important to consider the prevention or treatment of comorbidities as part of the overall management of RA.
Collapse
Affiliation(s)
- Peter C. Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Alejandro Balsa
- Rheumatology Unit, Hospital Universitario La Paz, La Paz Institute for Health Research IdiPAZ, Universidad Autónoma de Madrid, Paseo de la Castellana, 261, 28046 Madrid, Spain;
| | - Laure Gossec
- Institut Pierre Louis d’Epidémiologie et de Santé Publique, Sorbonne Université, 75006 Paris, France;
- Rheumatology Department, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, 75013 Paris, France
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus Liebig University Gießen, Campus Kerckhoff, 61231 Bad Nauheim, Germany;
| | - Janet Pope
- St. Joseph’s Health Care, Schulich School of Medicine, University of Western Ontario, London, ON N6A 5C1, Canada;
| |
Collapse
|
11
|
Ruperto N, Brunner HI, Tzaribachev N, Vega-Cornejo G, Louw I, Cimaz R, Dare J, Espada G, Faugier E, Ferrandiz M, Gerloni V, Quartier P, Silva CA, Wagner-Weiner L, Gandhi Y, Passarell J, Nys M, Wong R, Martini A, Lovell DJ. Absence of Association Between Abatacept Exposure and Initial Infection in Patients With Juvenile Idiopathic Arthritis. J Rheumatol 2021; 48:1073-1081. [PMID: 33452173 DOI: 10.3899/jrheum.200154] [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] [Accepted: 12/18/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the relationship between infection risk and abatacept (ABA) exposure levels in patients with polyarticular-course juvenile idiopathic arthritis (pJIA) following treatment with subcutaneous (SC) and intravenous (IV) ABA. METHODS Data from 2 published studies (ClinicalTrials.gov: NCT01844518, NCT00095173) of ABA treatment in pediatric patients were analyzed. One study treated patients aged 2-17 years with SC ABA and the other treated patients aged 6-17 years with IV ABA. Association between serum ABA exposure measures and infection was evaluated using Kaplan-Meier plots of probability of first infection vs time on treatment by ABA exposure quartiles and log-rank tests. Number of infections by ABA exposure quartiles was investigated. RESULTS Overall, 343 patients were included in this analysis: 219 patients received SC ABA and 124 patients received IV ABA. Overall, 237/343 (69.1%) patients had ≥ 1 infection over 24 months. No significant difference in time to first infection across 4 quartiles of ABA exposure levels was observed in the pooled (P = 0.45), SC (2-5 yrs: P = 0.93; 6-17 yrs: P = 0.48), or IV (P = 0.50) analyses. Concomitant use of methotrexate and glucocorticoids (at baseline and throughout) with ABA did not increase infection risk across the ABA exposure quartiles. There was no evidence of association between number of infections and ABA exposure quartiles. No opportunistic infections related to ABA were reported. CONCLUSION In patients aged 2-17 years with pJIA, no evidence of association between higher levels of exposure to IV ABA or SC ABA and incidence of infection was observed.
Collapse
Affiliation(s)
- Nicolino Ruperto
- N. Ruperto, MD, MPH, IRCCS Istituto G Gaslini, Clinica Pediatrica e Reumatologia-UOSID Centro Trial, Genoa, Italy;
| | - Hermine I Brunner
- H.I. Brunner, MD, MSc, MBA, D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nikolay Tzaribachev
- N. Tzaribachev, MD, Pediatric Rheumatology Research Institute, Bad Bramstedt, Germany
| | - Gabriel Vega-Cornejo
- G. Vega-Cornejo, MD, CREA Hospital México Americano, Guadalajara, Jalisco, Mexico
| | - Ingrid Louw
- I. Louw, MMED, MBChB, Panorama Medical Centre, Cape Town, South Africa
| | - Rolando Cimaz
- R. Cimaz, MD, University Hospital Meyer, Florence, Italy and Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Jason Dare
- J. Dare, MD, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Graciela Espada
- G. Espada, MD, Hospital de Niños Dr Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Enrique Faugier
- E. Faugier, MD, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Manuel Ferrandiz
- M. Ferrandiz, MD, Instituto Nacional de Salúd del Niño, Breña, Peru
| | - Valeria Gerloni
- V. Gerloni, MD, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Pierre Quartier
- P. Quartier, MD, Université de Paris, IMAGINE Institute, RAISE reference centre for rare diseases, Necker-Enfants Malades hospital, AP-HP, Paris, France
| | - Clovis Artur Silva
- C.A. Silva, MD, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Yash Gandhi
- Y. Gandhi, PhD, R. Wong, MD, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Julie Passarell
- J. Passarell, MA, Cognigen Corporation, Buffalo, New York, USA
| | - Marleen Nys
- M. Nys, MSc, Bristol Myers Squibb, Braine-L'Alleud, Belgium
| | - Robert Wong
- Y. Gandhi, PhD, R. Wong, MD, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Alberto Martini
- A. Martini, MD, IRCCS Istituto G Gaslini, Clinica Pediatrica e Reumatologia, Genoa, Italy and Università di Genova, Genoa, Italy
| | | | | |
Collapse
|
12
|
Tornero-Molina J, Alperi-López M, Castellví I, de Agustín-de Oro JJ, Escudero A, García-Vicuña R, González-Gay MÁ, Hidalgo C, Rubio E, Sanmartí R, Casamira N, Calvo-Alén J. Experts document on methotrexate use in combined therapy with biological or targeted synthetic disease modifying drugs in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2020; 18:S1699-258X(20)30200-X. [PMID: 33041228 DOI: 10.1016/j.reuma.2020.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/16/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We aimed to develop recommendations for the management of methotrexate (MTX) when considering the combination with biological (b) or targeted synthetic (ts) disease modifying drugs (DMARDs) in rheumatoid arthritis (RA). METHODS Eleven experts on RA were selected. Two coordinators formulated 13 questions about the combination therapy of MTX with bDMARDs or tsDMARDs. A systematic review was conducted to answer the questions. Inclusion and exclusion criteria were established as well as the search strategies (Medline, Embase and the Cochrane Library were searched up to January 2019). Two reviewers selected the articles and collected data. Simultaneously, EULAR and ACR meeting abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation was established using the Oxford Center for Evidence Based Medicine and the level of agreement with a Delphi. Agreement was established if at least 80% of the experts voted 'yes' (yes/no). RESULTS The systematic review retrieved 513 citations of which 61 were finally included. A total of 10 recommendations were generated, voted and accepted. The level of agreement was very high in all of them and it was achieved in the first Delphi round. Final recommendations cover aspects such as the optimal MTX dosage, tapering strategy or patients' risk management. CONCLUSIONS This document is intended to help clinicians solve usual clinical questions and facilitate decision making when treating RA patients with MTX in combination with bDMARDs or tsDMARDs.
Collapse
Affiliation(s)
| | | | - Ivan Castellví
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Alejandro Escudero
- Servicio de Reumatología, Hospital Universitario Reina Sofía, IMIBIC, Córdoba, Spain
| | | | | | - Cristina Hidalgo
- Servicio de Reumatología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Raimon Sanmartí
- Servicio de Reumatología, Hospital Universitari Clínic, Barcelona, Spain
| | - Núria Casamira
- Departamento Médico, Laboratorios Gebro Pharma, Barcelona, Spain
| | - Jaime Calvo-Alén
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
| |
Collapse
|
13
|
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: 83] [Impact Index Per Article: 16.6] [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.
Collapse
Affiliation(s)
- Ennio G Favalli
- Department of Rheumatology, ASST Gaetano Pini-CTO Institute, University of Milan, Milan, Italy.
| |
Collapse
|
14
|
Nair N, Sudharshan S, Ram Prakash M, Khetan V, Rao C. Tubercular subretinal abscess in a pediatric intermediate uveitis patient on methotrexate. Indian J Ophthalmol 2020; 68:2043-2045. [PMID: 32823474 PMCID: PMC7690549 DOI: 10.4103/ijo.ijo_362_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Pediatric intermediate uveitis (IU), usually idiopathic, can also be associated with tuberculosis (TB) and sarcoidosis. A 14-year-old girl was diagnosed with idiopathic IU after ruling out TB and sarcoid. She was treated with oral steroids and methotrexate (MTX) with good inflammation control. One year later, she presented with subretinal (SR) abscess. Lab tests were still negative but aqueous polymerase chain reaction confirmed TB. With antituberculosis treatment, complete resolution of the lesion was noted. The likelihood of a change in phenotype of ocular TB, from an IU to TB SR abscess or a possible reactivation of latent TB due to MTX are discussed.
Collapse
Affiliation(s)
- Nivedita Nair
- Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - S Sudharshan
- Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | | | - Vikas Khetan
- Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Chetan Rao
- Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| |
Collapse
|
15
|
Consani Fernández SA, Díaz Cuña CL, Fernández Rey L, Rostán Sellanes S, Maciel Oleggini G, Facal Castro JA. Infections in systemic autoimmune diseases. REUMATOLOGIA CLINICA 2020; 17:S1699-258X(20)30162-5. [PMID: 32843319 DOI: 10.1016/j.reuma.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/05/2020] [Accepted: 06/30/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Infections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received. MATERIAL AND METHODS An analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease. RESULTS 339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA. CONCLUSIONS Infections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.
Collapse
Affiliation(s)
| | - Carolina Laura Díaz Cuña
- Asistente de Clínica Médica «3». Hospital Maciel. Udelar. Asistente del Departamento Básico de Medicina. Montevideo. Uruguay
| | - Lucía Fernández Rey
- Asistente de Clínica Médica «3». Hospital Maciel. Udelar. Montevideo. Uruguay
| | | | | | | |
Collapse
|
16
|
[Infections]. Z Rheumatol 2019; 78:236-242. [PMID: 30659358 DOI: 10.1007/s00393-018-0586-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The individual risk assessment concerning infections in patients with rheumatic diseases is based on the detailed personalized documentation of relevant risk factors, such as the underlying disease itself, the intensity of immunosuppressive therapy and the severity of any comorbidities. From the perspective of infectiology, the history of repeated and severe infections as well as previous illnesses, such as (latent) tuberculosis and chronic hepatitis B or C need to be considered. In some instances prophylactic antibiotic therapy might be required, which should otherwise be avoided in order to prevent selection of resistant pathogens. Furthermore, vaccinations are particularly suitable to specifically minimize the risk for frequent infectious diseases.
Collapse
|
17
|
Cantini F, Niccoli L, Capone A, Petrone L, Goletti D. Risk of tuberculosis reactivation associated with traditional disease modifying anti-rheumatic drugs and non-anti-tumor necrosis factor biologics in patients with rheumatic disorders and suggestion for clinical practice. Expert Opin Drug Saf 2019; 18:415-425. [PMID: 31066297 DOI: 10.1080/14740338.2019.1612872] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Two classes of biologics, anti-tumor necrosis factor (TNF) and non-anti-TNF targeted, are currently available for the treatment of rheumatic diseases. AREAS COVERED Discussion on the need for LTBI diagnosis in rheumatic patients treated csDMARDs and non-anti-TNFs through a review of the literature. The literature, updated to 15 April 2019, on tuberculosis (TB) reactivation risk in patients exposed to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and non-anti-TNF biologics was reviewed. EXPERT OPINION An increased risk of TB reactivation in patients receiving csDMARDs (except sulphasalazine) resulted, while a review of clinical trials, and Periodic Safety Update Reports from pharmaceutical Companies evidenced a very low or absent risk for non-anti-TNF biologics. Hence, a contradiction emerges considering that latent TB infection (LTBI) screening is recommended for non-anti-TNF candidates but not for csDMARDs. Concerning the low TB incidence countries, several actions could be undertaken, including to screen all patients independently on the treatment, to omit the procedure in non-anti-TNF candidates, or to perform the LTBI investigations only in high-risk patients. According to WHO guidelines, LTBI screening in low TB risk countries seems unnecessary, except in high TB risk subjects.
Collapse
Affiliation(s)
- Fabrizio Cantini
- a Department of Rheumatology , Hospital of Prato , Prato , Italy
| | - Laura Niccoli
- a Department of Rheumatology , Hospital of Prato , Prato , Italy
| | - Alessandro Capone
- b Clinical Department , National Institute for Infectious Diseases L. Spallanzani-IRCCS , Rome , Italy
| | - Linda Petrone
- c Translational Research Unit, Department of Epidemiology and Preclinical Research , "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS , Rome , Italy
| | - Delia Goletti
- c Translational Research Unit, Department of Epidemiology and Preclinical Research , "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS , Rome , Italy
| |
Collapse
|