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Boekhoud L, Schaap HMEA, Huizinga RL, Olgers TJ, Ter Maaten JC, Postma DF, Bouma HR. Predictive performance of NEWS and qSOFA in immunocompromised sepsis patients at the emergency department. Infection 2024:10.1007/s15010-024-02247-4. [PMID: 38607592 DOI: 10.1007/s15010-024-02247-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE Sepsis has a high incidence and a poor prognosis. Early recognition is important to facilitate timely initiation of adequate care. Sepsis screening tools, such as the (quick) Sequential Organ Failure Assessment ((q)SOFA) and National Early Warning Score (NEWS), could help recognize sepsis. These tools have been validated in a general immunocompetent population, while their performance in immunocompromised patients, who are particularly at risk of sepsis development, remains unknown. METHODS This study is a post hoc analysis of a prospective observational study performed at the emergency department. Inclusion criteria were age ≥ 18 years with a suspected infection, while ≥ two qSOFA and/or SOFA criteria were used to classify patients as having suspected sepsis. The primary outcome was in-hospital mortality. RESULTS 1516 patients, of which 40.5% used one or more immunosuppressives, were included. NEWS had a higher prognostic accuracy as compared to qSOFA for predicting poor outcome among immunocompromised sepsis patients. Of all tested immunosuppressives, high-dose glucocorticoid therapy was associated with a threefold increased risk of both in-hospital and 28-day mortality. CONCLUSION In contrast to NEWS, qSOFA underestimates the risk of adverse outcome in patients using high-dose glucocorticoids. As a clinical consequence, to adequately assess the severity of illness among immunocompromised patients, health care professionals should best use the NEWS.
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Affiliation(s)
- Lisanne Boekhoud
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, EB70, 9700 RB, Groningen, The Netherlands
| | - Helena M E A Schaap
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rick L Huizinga
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tycho J Olgers
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Douwe F Postma
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hjalmar R Bouma
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, EB70, 9700 RB, Groningen, The Netherlands.
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Dumusc A, Alromaih F, Perreau M, Hügle T, Zufferey P, Dan D. Real-life drug retention rate and safety of rituximab when treating rheumatic diseases: a single-centre Swiss retrospective cohort study. Arthritis Res Ther 2023; 25:91. [PMID: 37264414 DOI: 10.1186/s13075-023-03076-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/25/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND In Switzerland, rituximab (RTX) is licenced for the treatment of rheumatoid arthritis (RA) and ANCA-associated vasculitis (AAV) but is frequently used off-label to treat other auto-immune diseases (AID), especially connective tissue diseases (CTD). We aimed to characterise the use of RTX in AID in a real-life Swiss setting and compare RTX retention rates and safety outcomes between patients treated for RA, CTD and AAV. METHODS A retrospective cohort study of patients who started RTX in the Rheumatology Department for RA or AID. The RTX retention rate was analysed using Kaplan-Meier survival curves. Occurrences of serious adverse events (SAE), low IgG levels and anti-drug antibodies (ADA) were reported. RESULTS Two hundred three patients were treated with RTX: 51.7% had RA, 29.6% CTD, 9.9% vasculitis and 8.9% other AIDs. The total observation time was 665 patient-years. RTX retention probability at 2 years (95%CI) was similar for RA and CTD 0.65 (0.55 to 0.73), 0.60 (0.47 to 0.72) and lower for vasculitis 0.25 (0.09 to 0.45). Survival curves for RTX retention matched closely (p = 0.97) between RA and CTD patients but were lower for patients with vasculitis due to a higher percentage of induced remission. Patients with vasculitis (95%) and CTD (75%) had a higher rate of concomitant glucocorticoid use than RA (60%). Moderate to severe hypogammaglobulinaemia was observed more frequently in patients with vasculitis (35%) than with RA (13%) or CTD (9%) and was associated with an increased risk of presenting a first infectious SAE (HR 2.01, 95% CI 1.04 to 3.91). The incidence rate of SAE was 23.3 SAE/100 patient-years (36% were infectious). When searched, ADAs were observed in 18% of the patients and were detected in 63% of infusions-related SAE. 10 patients died during RTX treatment and up to 12 months after the last RTX infusion, 50% from infection. CONCLUSION RTX retention rates are similar for patients with RA and CTD but lower for those with vasculitis due to more frequent remission. Patients treated with RTX for vasculitis present more SAE and infectious SAE than patients with RA and CTD, potentially due to a higher use of concomitant glucocorticoids and the occurrence of hypogammaglobulinaemia.
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Affiliation(s)
- Alexandre Dumusc
- Department of Rheumatology, Lausanne University Hospital, 1005, Lausanne, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne, 1005, Lausanne, Switzerland.
| | - Fahad Alromaih
- Department of Rheumatology, Lausanne University Hospital, 1005, Lausanne, Switzerland
| | - Matthieu Perreau
- Faculty of Biology and Medicine, University of Lausanne, 1005, Lausanne, Switzerland
- Division of Immunology and Allergy, Lausanne University Hospital, 1005, Lausanne, Switzerland
| | - Thomas Hügle
- Department of Rheumatology, Lausanne University Hospital, 1005, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, 1005, Lausanne, Switzerland
| | - Pascal Zufferey
- Department of Rheumatology, Lausanne University Hospital, 1005, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, 1005, Lausanne, Switzerland
| | - Diana Dan
- Department of Rheumatology, Lausanne University Hospital, 1005, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, 1005, Lausanne, Switzerland
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Yayla ME, Yurteri EU, Torgutalp M, Eroğlu DŞ, Sezer S, Dinçer ABK, Gülöksüz EGA, Yüksel ML, Yılmaz R, Ateş A, Turgay TM, Kınıklı G. Causes of severe infections in patients with systemic sclerosis and associated factors. Turk J Med Sci 2022; 52:1881-1888. [PMID: 36945989 PMCID: PMC10390190 DOI: 10.55730/1300-0144.5535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 10/10/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a chronic systemic disease characterized by vascular damage, autoimmunity, and fibrosis in the skin and internal organs. In this study, we tried to determine the causes of severe infection in patients with SSc and to reveal the factors associated with severe infection. METHODS We retrospectively examined 214 SSc patients between January 2010 and August 2020. Forty-seven patients with at least one severe infection and 167 patients without severe infection were compared. RESULTS A total of 76 episodes of severe infections were detected in 47 (22%) patients. Common infections included pneumonia, infected digital ulcer, urinary tract infections, and osteomyelitis. Female patients had a higher frequency in the group without severe infection (91.6% vs. 80.9%, p = 0.035). Patients with severe infections had a higher frequency of digital ulcers (p < 0.001), cardiac (p = 0.002), and GIS involvement (p < 0.001). In multivariable analysis, digital ulcer presence (OR: 2.849 [1.356-5.898] (p = 0.006) and cardiac involvement (OR: 2.801 [1.248-6.285]) were associated with severe infection. Of the patients with severe infections, 34% had recurrent severe infections. There was no difference in demographic and clinical characteristics between patients with recurrent and nonrecurrent severe infections. DISCUSSION The presence of digital ulcer and cardiac involvement seem to be associated with a severe infection in patients with systemic sclerosis. In patients with cardiac involvement and digital ulcers, more careful attention may be required for the development of severe infections.
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Affiliation(s)
- Müçteba Enes Yayla
- Department of Internal Medicine, Division of Rheumatology, , Ankara Training and Research Hospital, Ankara, Turkey ; Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Emine Uslu Yurteri
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Murat Torgutalp
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Didem Şahin Eroğlu
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Serdar Sezer
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Ayşe Bahar Keleşoğlu Dinçer
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Emine Gözde Aydemir Gülöksüz
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Mehmet Levent Yüksel
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Recep Yılmaz
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Aşkın Ateş
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Tahsin Murat Turgay
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Gülay Kınıklı
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
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Tanaka Y, Suzuki K. Infections associated with systemic lupus erythematosus: Tackling two devils in the deep blue sea. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_78_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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5
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Hanaoka H, Kikuchi J, Kaneko Y, Seki N, Tsujimoto H, Chiba K, Takeuchi T. Proton Pump Inhibitor and Tacrolimus Uses are Associated With Hypomagnesemia in Connective Tissue Disease: a Potential Link With Renal Dysfunction and Recurrent Infection. Front Pharmacol 2021; 12:616719. [PMID: 34093176 PMCID: PMC8173076 DOI: 10.3389/fphar.2021.616719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Low levels of serum magnesium perturb renal tubular cell function and lymphocytes, resulting in renal deterioration and an imbalance in mononuclear cells. This study investigated the mechanism and influence of hypomagnesemia in patients with connective tissue disease. Methods: We retrospectively evaluated patients with connective tissue disease and available serum magnesium data who visited Keio University Hospital in 2019. Patients were divided into two groups: those with (serum magnesium < 1.8 mg/dl) and those without hypomagnesemia; their rates of hospitalization for severe infection and cumulative renal deterioration were compared. Patients’ fractions of lymphocytes and natural killer and dendritic cell subsets, as measured by fluorescence-activated cell sorting (FACS) analysis, were also compared. Results: Among 284 patients, hypomagnesemia was detected in 63 (22.2%). Multivariate analysis revealed that the use of proton pump inhibitors [odds ratio (OR), 1.48; p = 0.01] and tacrolimus (OR, 6.14; p < 0.01) was independently associated with hypomagnesemia. In addition, the renal deterioration rate was significantly higher in tacrolimus and/or proton pump inhibitor users with hypomagnesemia (p = 0.01). The hospitalization rate for severe infection was also higher in patients with hypomagnesemia (p = 0.04). FACS analysis showed lower CD8+ T cell, CD19+ B cell, natural killer cell, and dendritic cell counts in patients with hypomagnesemia (p = 0.03, p = 0.02, p = 0.02, and p = 0.03, respectively). Conclusion: The use of tacrolimus and proton pump inhibitors may be associated with hypomagnesemia and lead to poor renal outcomes and severe infection in patients with connective tissue disease.
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Affiliation(s)
- Hironari Hanaoka
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Noriyasu Seki
- Mitsubishi Tanabe Pharma Corporation, Yokohama, Japan
| | | | - Kenji Chiba
- Mitsubishi Tanabe Pharma Corporation, Yokohama, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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6
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Stabler S, Giovannelli J, Launay D, Cotteau-Leroy A, Heusele M, Lefèvre G, Terriou L, Lambert M, Dubucquoi S, Hachulla E, Sobanski V. Serious Infectious Events and Immunoglobulin Replacement Therapy in Patients With Autoimmune Disease Receiving Rituximab: A Retrospective Cohort Study. Clin Infect Dis 2021; 72:727-737. [PMID: 32067031 DOI: 10.1093/cid/ciaa127] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 02/09/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Rituximab (RTX) is widely administered to patients with autoimmune disease (AID). This study aimed to estimate the incidence of serious infectious events (SIEs) after RTX initiation in patients with AID. We also described the characteristics and risk factors of SIEs, and immunoglobulin replacement therapy (IgRT) strategies. METHODS Patients treated between 2005 and 2016 were included in this retrospective monocentric cohort study. An RTX course was defined as the complete RTX treatment regimen received by a given patient for AID. SIEs and IgRT were right-censored at 24 months after RTX initiation. RESULTS Two hundred twenty-one patients were included (corresponding to 276 RTX courses). Reasons for RTX initiation included connective tissue disease (38%), systemic vasculitis (36%), and autoimmune cytopenia (22%). The 1- and 2-year incidences of SIEs were 17.3 (95% confidence interval [CI], 12.0-22.5) and 11.3 (95% CI, 8.1-14.5) per 100 person-years, respectively. Forty-seven SIEs were observed, mostly comprising pneumonias (45%) and bacteremias (21%). When documented, the microorganisms were bacterial (55%) and fungal (12%). Identified risk factors of SIEs were age, history of diabetes, history of cancer, concomitant steroid treatment, and low CD4 lymphocyte count at RTX initiation. IgRT was started in 22 RTX courses (8%). CONCLUSIONS In patients with AID treated with RTX, the 1- and 2-year incidence of SIE was 17.3 and 11.3 per 100 person-years, respectively. Reports of SIE characteristics, risk factors, and IgRT strategies highlight the need for an appropriate and individualized assessment prior to and following RTX to prevent SIEs, particularly in patients with comorbidities.
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Affiliation(s)
- Sarah Stabler
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France
| | - Jonathan Giovannelli
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | - David Launay
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | | | - Marion Heusele
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France
| | - Guillaume Lefèvre
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,CHU Lille, Institut d'Immunologie, Lille, France
| | - Louis Terriou
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France
| | - Marc Lambert
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | - Sylvain Dubucquoi
- Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France.,CHU Lille, Institut d'Immunologie, Lille, France
| | - Eric Hachulla
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | - Vincent Sobanski
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
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Avasarala J, Guduru Z, McLouth CJ, Wilburn A, Talbert J, Sutton P, Sokola BS. Use of anti-TNF-α therapy in Crohn's disease is associated with increased incidence of multiple sclerosis. Mult Scler Relat Disord 2021; 51:102942. [PMID: 33933908 DOI: 10.1016/j.msard.2021.102942] [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] [Received: 10/06/2020] [Revised: 01/11/2021] [Accepted: 04/02/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We investigated if anti-tumor necrosis factor-α (anti-TNF-α) drugs used in the treatment of inflammatory bowel disease (IBD) alter the incidence of MS and if so, to understand the magnitude of such an effect. METHODS This is a retrospective cohort study of data from Truven Health Market Scan administrative claims database. The patients included in the study had to be ≥ 18 years of age. The presence of IBD was based on at least 2 claims of International Classification of Diseases (ICD-9 or 10) diagnosis codes. The IBD diagnosis index date had to precede the MS diagnosis index date for inclusion in the study. The diagnosis of multiple sclerosis (MS) was defined as having at least 2 claims for the disease (ICD 9, 340 and ICD 10 codes, G35) and at least one prescription claim for any of the drugs that were defined as MS therapy. RESULTS Patients with IBD had 1.32 times the risk of MS incidence compared to healthy controls (adjusted incidence rate ratio (IRR): 1.32; 95% CI: 1.03 - 1.71; p = .0312). Patients with IBD exposed to anti-TNF-α therapies had a 43% increase in the incidence of MS compared to those with IBD without exposure (adjusted incidence rate: 1.43; 95% CI: .062 - 3.32; p = .3989). Among CD patients treated anti-TNF-α medications an increase in the incidence of MS, compared to CD patients not exposed to such medications was observed (IRR = 2.62; 95% CI: 1.00 to 6.83; p = 0.049), statistically significant. After adjusting for age/gender, patients with CD using anti-TNF-α agents had an increase of incidence in MS (adjusted IRR: 2.24; 95% CI: 0.85 - 5.94; p = .1035) but it was not statistically significant. CONCLUSIONS Use of anti-TNF-α drugs in CD was associated with a statistically significant increase in the incidence of MS but this effect was lost when controlled for age/gender.
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Affiliation(s)
- Jagannadha Avasarala
- Department of Neurology, University of Kentucky Medical Center, Kentucky Neuroscience Institute, 740 S Limestone Dr, Lexington, KY 40536, USA.
| | - Zain Guduru
- Department of Neurology, University of Kentucky Medical Center, Kentucky Neuroscience Institute, 740 S Limestone Dr, Lexington, KY 40536, USA
| | - Christopher J McLouth
- Department of Behavioral Science, University of Kentucky Medical Center, Medical Behavioral Science Building, Lexington, KY 40536, USA
| | - Amanda Wilburn
- University of Kentucky Health Sciences, 740 S Limestone Dr, Lexington, KY 40536, USA
| | - Jeffrey Talbert
- Department of Pharmacy Practice and Science and Biomedical Informatics, University of Kentucky College of Pharmacy, 185 Todd Building, 789 S Limestone St., Lexington KY 40536, USA
| | - Paige Sutton
- Department of Neurology, University of Kentucky Medical Center, Kentucky Neuroscience Institute, 740 S Limestone Dr, Lexington, KY 40536, USA
| | - Brent S Sokola
- University Hospitals Specialty Pharmacy, 4510 Richmond Road, Warrensville Heights, OH 44128, USA
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Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death. AREAS COVERED This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020. EXPERT OPINION Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.
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Affiliation(s)
- Megan R W Barber
- Division of Rheumatology, University of Calgary , Calgary, Alberta, Canada
| | - Ann E Clarke
- Division of Rheumatology, University of Calgary , Calgary, Alberta, Canada
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9
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Low Influenza, Pneumococcal and Diphtheria-Tetanus-Poliomyelitis Vaccine Coverage in Patients with Primary Sjögren's Syndrome: A Cross-Sectional Study. Vaccines (Basel) 2019; 8:vaccines8010003. [PMID: 31877764 PMCID: PMC7157651 DOI: 10.3390/vaccines8010003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 11/25/2022] Open
Abstract
Objective: To evaluate vaccination coverage and reasons for non-vaccination in patients with primary Sjögren’s syndrome (pSS). Method: A total of 111 patients fulfilling American–European Consensus Group criteria for pSS were interviewed by use of a standardized questionnaire between January 2016 and November 2017 in two French tertiary referral centers for auto-immune diseases. Results: Updated immunization coverage for influenza was 31.5% (n = 35), pneumococcus was 11.7% (n = 13), and diphtheria–tetanus–poliomyelitis (DTP) was 24.3% (n = 27). The main reasons for non-vaccination were fear of side effects from the influenza vaccine (40.3%) and a lack of proposal for the pneumococcal vaccine (72.3%). In vaccinated patients, vaccination was mainly proposed by general practitioners for the influenza vaccine (42.6%) and rheumatologists for the pneumococcal vaccine (41.2%). Probability of influenza vaccination was associated with age (odds ratio/year (OR) 1.04, 95% confidence interval (CI) 1.0–1.1; p = 0.016), history of severe infection (OR 15.9, 95% CI 1.35–186; p = 0.028), low EULAR Sjögren’s syndrome disease activity index (OR 0.85, 95% CI 0.75–0.96; p = 0.013), and comorbidities (OR 3.52, 95% CI 1.22–10.2; p = 0.02). Probability of vaccination against pneumococcus was associated with lung comorbidities (OR 3.83, 95% CI 1.11–13.12; p = 0.033) and up-to-date influenza vaccination (OR 3.71, 95% CI 1.08–12.8; p = 0.038). Conclusion: Influenza, pneumococcal, and DTP vaccine coverage was low in patients with pSS included in this study. These results underline the relevance of systematically screening vaccine status in pSS patients and educating patients and physicians on the need for vaccination to improve vaccine coverage in this population.
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Mortality of patients with systemic lupus erythematosus admitted to the intensive care unit - A retrospective single-center study. Best Pract Res Clin Rheumatol 2019; 32:701-709. [PMID: 31203928 DOI: 10.1016/j.berh.2019.01.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that results in increased morbidity and mortality. Under certain conditions, patients with SLE may be admitted to the intensive care unit (ICU) secondary to infectious disease flare-ups or other non-SLE disease conditions that are aggravated by SLE. The aim of our study was to investigate the causes and outcomes of ICU-admitted patients with SLE. This is a retrospective cohort study involving paitents with SLE that were admitted to the general ICU at Sheba Medical Center between 2002 and 2015. Outcome was measured by the 30-day mortality and the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Demographic, diagnostic, physiological, and laboratory variables of survivors and nonsurvivors were compared using univariate and multivariate Cox regression analyses. A receiver operating characteristic curve was plotted for significant variables to illustrate their diagnostic capabilities. Twenty-seven patients were admitted to the ICU (female: 21 [77%], mean age ± SD: 51.1 ± 15.4 years). The mean ± SD APACHE II score and 30-day mortality rate were 23.4 ± 8.3 and 29.6%, respectively. Infections, especially lower respiratory tract infections, were the cause of 66.7% of admissions and accounted for 87.5% of deaths. APACHE II scores, bacteremia, and gram-negative infections were significantly associated with mortality (p = 0.033, p = 0.022, and p = 0.01, respectively). An APACHE II score of 27 and above was the strongest predictor of mortality with a sensitivity and specificity of 83.3% and 84.2%, respectively (AUC = 0.82, p = 0.022). Patients with SLE that were admitted to the ICU with gram-negative infections, sepsis, or an APACHE II score of 27 and above have a higher mortality rate and thus should be promptly identified and treated accordingly.
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Incidence of infection other than tuberculosis in patients with autoimmune rheumatic diseases treated with bDMARDs: a real-time clinical experience from India. Rheumatol Int 2019; 39:497-507. [DOI: 10.1007/s00296-019-04245-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/21/2019] [Indexed: 12/15/2022]
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12
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Tummers M, van Hoorn R, Levering C, Booth A, van der Wilt GJ, Kievit W. Optimal search strategies for identifying moderators and predictors of treatment effects in PubMed. Health Info Libr J 2018; 36:318-340. [PMID: 30006959 DOI: 10.1111/hir.12230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/07/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment effects differ across patients. To guide selection of treatments for patients, it is essential to acknowledge these differences and identify moderators or predictors. Our aim was to generate optimal search strategies (commonly known as filters) for PubMed to retrieve papers identifying moderators and predictors of treatment effects. METHODS Six journals were hand-searched for articles on moderators or predictors. Selected articles were randomly allocated to a development and validation set. Search terms were extracted from the development set and tested for their performance. Search filters were created from combinations of these terms and tested in the validation set. RESULTS Of 4407 articles, 198 were considered to be relevant. The most sensitive filter in the development set '("Epidemiologic Methods" [MeSH] OR assign* OR control*[tiab] OR trial*[tiab]) AND therapy*[sh]' yielded in the validation set a sensitivity of 89% [88%-90%] and a specificity of 80% [79%-82%]. CONCLUSIONS The search filters created in this study can help to efficiently retrieve evidence on moderators and predictors of treatment effect. Testing of the filters in multiple domains should reveal robustness across disciplines. These filters can facilitate the retrieval of evidence on moderators and predictors of treatment effects, helping the implementation of stratified or personalised health care.
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Affiliation(s)
- Marcia Tummers
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ralph van Hoorn
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Charlotte Levering
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andrew Booth
- School of Health and Related Research (ScHARR), Health Economics and Decision Science (HEDS), University of Sheffield Regent Court, Sheffield, UK
| | - Gert Jan van der Wilt
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wietske Kievit
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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14
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Liu P, Tan HZ, Li H, Lim CC, Choo JCJ. Infections in hospitalized lupus nephritis patients: characteristics, risk factors, and outcomes. Lupus 2018; 27:1150-1158. [PMID: 29631512 DOI: 10.1177/0961203318768881] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background There are limited studies documenting infection epidemiology in lupus nephritis (LN) patients. We aimed to study infection incidences and risk characteristics and ascertain possible predictors of infective outcomes in a multiethnic Asian population. Methods This retrospective study from 2006 to 2012 included newly diagnosed LN patients. We collected admissions, immunosuppression, and infection data until end-stage renal failure, death, last follow-up, or the year 2015. The infection incidence rates were evaluated and a generalized linear latent and mixed models (GLLAMM) analysis was carried out to evaluate potential predictors of infection. Results Our cohort of 101 patients consisted of mainly Chinese (75.2%), females (78.2%), and a median age of 38 years (IQR 26-49). The median time of follow-up was 72.8 months (IQR 49.5-94.0). Six out of 14 patient deaths were infection related. Seventy-eight out of 200 admissions, with a total of 102 episodes of infection, occurred in 46 patients. The incidence of infection rates leading to admissions was 10.3 per 100 person-years and the incidence of infection episodes rates was 17.6 per 100 person-years. Cytomegalovirus (CMV) was the most common organism identified. Univariate GLLAMM analysis showed Malay compared to Chinese ethnicity (HR 2.833 (95% CI 1.088-7.373)), use of oral cyclophosphamide (HR 6.618 (95% CI 1.015-43.154)) and rituximab (HR 3.967 (95% CI 1.157-13.603)) as predictors of infection-related admissions. Malay ethnicity and rituximab remained significant in the multivariate GLLAMM analysis. Conclusions Our study highlights substantial infection incidences in patients with LN and its contribution to deaths.
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Affiliation(s)
- P Liu
- 1 Department of Renal Medicine, 37581 Singapore General Hospital , Singapore
| | - H Z Tan
- 1 Department of Renal Medicine, 37581 Singapore General Hospital , Singapore
| | - H Li
- 2 Division of Research, 37581 Singapore General Hospital , Singapore
| | - C C Lim
- 1 Department of Renal Medicine, 37581 Singapore General Hospital , Singapore
| | - J C J Choo
- 1 Department of Renal Medicine, 37581 Singapore General Hospital , Singapore
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Mahmoud I, Jellouli M, Boukhris I, Charfi R, Ben Tekaya A, Saidane O, Ferjani M, Hammi Y, Trabelsi S, Khalfallah N, Tekaya R, Gargah T, Abdelmoula L. Efficacy and Safety of Rituximab in the Management of Pediatric Systemic Lupus Erythematosus: A Systematic Review. J Pediatr 2017; 187:213-219.e2. [PMID: 28602379 DOI: 10.1016/j.jpeds.2017.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/31/2017] [Accepted: 05/01/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of rituximab for treating pediatric systemic lupus erythematosus (pSLE). STUDY DESIGN We performed a systematic review to evaluate the efficacy and safety of rituximab in children with pSLE. Data from studies performed before July 2016 were collected from MEDLINE, the Cochrane Library, Scopus, and the International Rheumatic Disease Abstracts, with no language restrictions. Study eligibility criteria included clinical trials and observational studies with a minimal sample size of 5 patients, regarding treatment with rituximab in patients with refractory pSLE (aged <18 years at the time of diagnosis). Independent extraction of articles was performed by 2 investigators using predefined data fields. RESULTS Twelve case series met the criteria for data extraction for the systematic review with a good quality assessment according to an 18-criteria checklist using a modified Delphi method. Among them, 3 studies were multicenter and 3 were prospective. The total number of patients was 272. Studies collected patients with active disease refractory to steroids and immunosuppressant drugs. Refractory lupus nephritis was the most common indication (33%). Acceptable evidence suggested improvements in renal, neuropsychiatric and haematological manifestations, disease activity, complement and anti-double stranded Desoxy-Nucleo-Adenosine, with a steroid-sparing effect. However, there was poor evidence suggesting efficacy on arthralgia, photosensitivity, and mucocutaneous manifestations of SLE in children. An overall acceptable safety profile with few major adverse events was shown. CONCLUSION Rituximab exhibited a satisfactory profile regarding efficacy and safety indicating that this agent is a promising therapy for pSLE and should be further investigated.
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Affiliation(s)
- Ines Mahmoud
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia.
| | - Manel Jellouli
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Imen Boukhris
- Department of Internal Medicine, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Rim Charfi
- Department of Clinical Pharmacology, National Centre of Pharmacovigilance, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Aicha Ben Tekaya
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Olfa Saidane
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Maryem Ferjani
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Yousra Hammi
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Sameh Trabelsi
- Department of Clinical Pharmacology, National Centre of Pharmacovigilance, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Narjess Khalfallah
- Department of Internal Medicine, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Rawdha Tekaya
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Tahar Gargah
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Leila Abdelmoula
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
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16
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Li J, Zhang Q, Su B. Clinical characteristics and risk factors of severe infections in hospitalized adult patients with primary nephrotic syndrome. J Int Med Res 2017; 45:2139-2145. [PMID: 28661269 PMCID: PMC5805218 DOI: 10.1177/0300060517715339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective Infection is a common condition in patients with nephrotic syndrome. The
objective of the present study is to investigate the clinical
characteristics and risk factors of infections in adult patients with
primary nephrotic syndrome (PNS). Methods Medical charts of 138 consecutive patients with PNS and infections who were
admitted to hospital from April 2013 to April 2016 were systematically
reviewed. Results Patients were divided into three groups according to the degree of
infections: mild infection group (n = 45), moderate infection group
(n = 60), and severe infection group (n = 33). In the severe infection
group, most patients (96.9%) had pulmonary infections with opportunistic
pathogens. There were significant differences in cumulative prednisone dose,
immunosuppressor use, and CD4+ T cell count among the three groups. A lower
CD4+ T cell count (<300 cells/mm3) (odds ratio = 4.25 [95%
confidence interval 1.680–10.98]) and higher cumulative dose of prednisone
(odds ratio = 1.38 [95% confidence interval 1.05–3.26]) were risk factors
for severe infections in adult patients with PNS. Conclusions CD4+ T cell count (<300 cells/mm3) and a higher cumulative dose
of prednisone are important risk factors for severe infections in adult
patients with PNS.
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Affiliation(s)
- Jie Li
- 1 Department of Nephrology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui, Zhejiang, China
| | - Qiankun Zhang
- 1 Department of Nephrology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui, Zhejiang, China
| | - Bofeng Su
- 2 Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Abstract
Infection is a leading cause of morbidity and mortality among patients with systemic lupus erythematous (SLE). Dysfunction of the innate and adaptive immune systems increases the risk of infection in patients with SLE. Infectious agents have also been theorized to play a role in the pathogenesis of SLE. This article summarizes our current knowledge of the infectious risk SLE patients face as a result of their underlying disease including abnormal phagocytes and T cells as well as the increased risk of infection associated with immunosuppressive agents used to treat disease. Pathogens thought to play a role in the pathogenesis of disease including EBV, CMV, human endogenous retroviruses (HERVs), and tuberculosis will also be reviewed, as well as the pathologic potential of microbial amyloids and the microbiome.
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Affiliation(s)
- Sarah Doaty
- Division of Rheumatology, University of California Los Angeles (UCLA), 1000 Veteran Ave, Room 32-59, Los Angeles, CA, 90024, USA
| | - Harsh Agrawal
- Division of Cardiology, University of Missouri, One Hospital Drive, Columbia, MO, 65201, USA
| | - Erin Bauer
- Division of Rheumatology, University of California Los Angeles (UCLA), 1000 Veteran Ave, Room 32-59, Los Angeles, CA, 90024, USA
| | - Daniel E Furst
- Division of Rheumatology, University of California Los Angeles (UCLA), 1000 Veteran Ave, Room 32-59, Los Angeles, CA, 90024, USA. .,University of Washington, Seattle, WA, USA. .,University of Florence, Piazza di San Marco, 4, 50121, Firenze, Italy.
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18
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Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with variable clinical manifestations. While the clearest guidelines for the treatment of SLE exist in the context of lupus nephritis, patients with other lupus manifestations such as neuropsychiatric, hematologic, musculoskeletal, and severe cutaneous lupus frequently require immunosuppression and/or biologic therapy. Conventional immunosuppressive agents such as mycophenolate mofetil, azathioprine, and cyclophosphamide are widely used in the management of SLE with current more rationalized treatment regimens optimizing the use of these agents while minimizing potential toxicity. The advent of biologic therapies has advanced the treatment of SLE particularly in patients with refractory disease. The CD20 monoclonal antibody rituximab and the anti-BLyS agent belimumab are now widely in use in clinical practice. Several other biologic agents are in ongoing clinical trials. While immunosuppressive and biologic agents are the foundation of inflammatory disease control in SLE, the importance of managing comorbidities such as cardiovascular risk factors, bone health, and minimizing susceptibility to infection should not be neglected.
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Affiliation(s)
- Natasha Jordan
- Department of Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - David D'Cruz
- Louise Coote Lupus Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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19
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Low pre-treatment B-cell counts are not a risk factor of infection in patients treated with rituximab for autoimmune diseases: An observational study. Joint Bone Spine 2016; 83:191-7. [DOI: 10.1016/j.jbspin.2015.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/14/2015] [Indexed: 12/21/2022]
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Jordan N, Lutalo PM, D'Cruz DP. Progress with the use of monoclonal antibodies for the treatment of systemic lupus erythematosus. Immunotherapy 2016; 7:255-70. [PMID: 25804478 DOI: 10.2217/imt.14.118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In recent years, significant progress has been made in the use of monoclonal antibodies in the treatment of systemic lupus erythematosus (SLE). Advances in our understanding of the complexity of SLE immunopathogenesis have led to the testing of several biologic agents in clinical trials. Monoclonal therapies currently emerging or under development include B-cell depletion therapies, agents targeting B-cell survival factors, blockade of T-cell co-stimulation and anticytokine therapies. Issues remain, however, regarding clinical trial design and outcome measures in SLE which need to be addressed to optimize translation of these promising therapies into clinical practice.
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Affiliation(s)
- Natasha Jordan
- Louise Coote Lupus Unit St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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21
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Tirado-Sánchez A, de la Fuente-García V, Ponce-Olivera RM. Off-label uses of etanercept in dermatology. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2016. [DOI: 10.1016/j.hgmx.2015.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Jordan N, D'Cruz D. Key issues in the management of patients with systemic lupus erythematosus: latest developments and clinical implications. Ther Adv Musculoskelet Dis 2015; 7:234-46. [PMID: 26622325 DOI: 10.1177/1759720x15601805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Systemic lupus erythematous (SLE) is a chronic multisystem disease with significant associated morbidity and mortality. A deeper understanding of the pathogenesis of SLE has led to the development of biologic agents, primarily targeting B cells and others inhibiting costimulatory molecules, type I interferons and cytokines such as interleukin-6. Several of these agents have been studied in clinical trials; some have shown promise while others have yielded disappointing results. Economic and regulatory issues continue to hamper the availability of such therapies for SLE patients. With increasing recognition that recurrent flares of disease activity lead to long-term damage accrual, one of the most important recent developments in patient management has been the concept of treat-to-target in SLE while minimizing patient exposure to excessive corticosteroid and other immunosuppressive therapy. This article reviews these key issues in SLE management, outlining recent developments and clinical implications for patients.
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Affiliation(s)
- Natasha Jordan
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David D'Cruz
- Louise Coote Lupus Unit, Guys Hospital, London, SE1 9RT, UK
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Update on infections and vaccinations in systemic lupus erythematosus and Sjögren's syndrome. Curr Opin Rheumatol 2015; 26:528-37. [PMID: 25022358 DOI: 10.1097/bor.0000000000000084] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To provide an update on infections in systemic lupus erythematosus (SLE) and Sjögren's syndrome, particularly addressing their role as triggers of autoimmunity, their impact on mortality, the main microorganisms, the approaches to differential diagnosis with disease flares and recommendations for vaccination. RECENT FINDINGS New mechanisms for autoimmunity triggered by Epstein-Barr virus and human commensal microbiota have been described. The increased risk for tuberculosis was recently demonstrated for the first time in Sjögren's syndrome. C-reactive protein was reported to be a more sensitive and specific marker for bacterial infections in SLE than procalcitonin and phagocyte-specific S100A8/A9 protein. Inactivated vaccines are well tolerated and efficacy was demonstrated for influenza vaccine. Immunogenicity is generally reduced but adequate in SLE. Prednisone or immunosuppressants are associated with decreased vaccine serological response, whereas hydroxicloroquine seems to improve vaccine immunogenicity. Other infection-preventive measures for these diseases include antimalarials and prophylaxis for tuberculosis or Pneumocystis jirovecii. SUMMARY Advances in the role of infectious agents as triggers for SLE and Sjögren's syndrome have provided new insights into disease development. Knowledge on vaccine immunogenicity, safety and efficacy has improved with evidence of a generally reduced but adequate response for inactivated vaccines in SLE. Other preventive measures comprise infection prophylaxis and antimalarials.
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24
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Nakayamada S, Iwata S, Tanaka Y. Relevance of lymphocyte subsets to B cell-targeted therapy in systemic lupus erythematosus. Int J Rheum Dis 2015; 18:208-18. [DOI: 10.1111/1756-185x.12534] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Shingo Nakayamada
- The First Department of Internal Medicine; School of Medicine; University of Occupational and Environmental Health; Kitakyushu Japan
| | - Shigeru Iwata
- The First Department of Internal Medicine; School of Medicine; University of Occupational and Environmental Health; Kitakyushu Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine; School of Medicine; University of Occupational and Environmental Health; Kitakyushu Japan
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25
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Selmi C, Ceribelli A, Naguwa SM, Cantarini L, Shoenfeld Y. Safety issues and concerns of new immunomodulators in rheumatology. Expert Opin Drug Saf 2014; 14:389-99. [PMID: 25518908 DOI: 10.1517/14740338.2015.993605] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The development of biologic therapies has been an enormous leap in the management of patients with rheumatoid and psoriatic arthritis. Since the first anti-TNF-α therapies, numerous molecules have been identified as targets of immunomodulatory therapies, such as IL-1 (anakinra, canakinumab), IL-6 (tocilizumab), CD20(+) B cells (rituximab), CTLA4 (abatacept) and two additional anti-TNF-α therapies (certolizumab pegol, golimumab). AREAS COVERED In the present review, we will describe the safety issues related to the immunosuppressive action of these biologic drugs that are mainly represented by infection and malignancy. The risk of infection should be identified before initiating a biologic treatment and markers checked over time, in particular for tuberculosis and hepatitis B and C viruses. Other infections (bacterial, viral, parasitic; opportunistic; surgery-related) and safety issues may require temporary interruption of the treatment until complete resolution. No significantly increased risk of malignancy, both hematological and solid, has been associated with the use of biologic agents. In all cases, it is difficult to dissect the risks related to biologics from those related to baseline treatments. EXPERT OPINION Detailed medical history and laboratory screening should be performed before starting biologic therapies. Clinicians should be aware of the different safety profiles associated with different molecules and they should follow up data coming out of the existing registries for biologics in regard to new or old side effects.
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Affiliation(s)
- Carlo Selmi
- Humanitas Research Hospital, Division of Rheumatology and Clinical Immunology , Rozzano, Milan , Italy
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26
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Aringer M, Smolen JS. Safety of off-label biologicals in systemic lupus erythematosus. Expert Opin Drug Saf 2014; 14:243-51. [DOI: 10.1517/14740338.2015.986455] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Patients with autoimmune rheumatic diseases are more susceptible to infectious complications during the course of their disease. The introduction of biologics has been a major achievement in treating these diseases, but an increased risk of infection associated with these therapies has become evident. Some infections can be prevented by vaccination and it is clearly worthwhile considering which immunisations would be sensible and practicable for these patients. To date no formal specific recommendations for patients on biologics have been published. A search was made of Medline (via PubMed) from 1970 to January 2014 to provide results. This review aims to provide a systematic analysis of the data about vaccines and biologics and considers recommendations for vaccination in adult patients with autoimmune rheumatic diseases treated with biologics.
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Affiliation(s)
- Isabel Ferreira
- Immuno-mediated Systemic Diseases Unit, Medicina 4, Hospital Prof. Doutor Fernando Fonseca, EPE, IC19, Amadora, Portugal
| | - David Isenberg
- Department of Medicine, Centre for Rheumatology, University College of London, London, UK
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Efficacy and safety of rituximab in the treatment of non-renal systemic lupus erythematosus: a systematic review. Semin Arthritis Rheum 2014; 44:175-85. [PMID: 24830791 DOI: 10.1016/j.semarthrit.2014.04.002] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 03/05/2014] [Accepted: 04/04/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To analyse the efficacy and safety of rituximab in the treatment of non-renal systemic lupus erythematosus (SLE). METHODS We systematically searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials up to June 2013. The following were the selection criteria: (1) adult patients with SLE, (2) rituximab treatment, (3) placebo or active comparator, (4) outcome measures assessing efficacy and/or (5) safety. Meta-analysis, systematic literature reviews, randomised control trials (RCT), open clinical trials and cohort studies were included. Independent extraction of articles by 2 authors using predefined data fields was performed. The quality of each study was graded using the Oxford Levels of Evidence and Jadad's scale. RESULTS A total of 26 articles met our inclusion criteria: one RCT and its exploratory analysis, 2 open studies and 22 cohort studies, which analysed 1,231 patients. Overall, patients had active disease refractory to steroids and/or immunosuppressant drugs. Acceptable evidence suggested improvements in disease activity, arthritis, thrombocytopaenia, complement and anti-dsDNA, with a steroid-sparing effect. But relapses of disease were demonstrated too. Weak evidence suggested a response in anaemia, cutaneous and neuropsychiatric manifestations. Available evidence revealed few major adverse events. Studies had medium methodological quality and in general were applicable to current practice. CONCLUSION Rituximab has been shown to be safe and effective in the treatment of non-renal SLE, especially in terms of disease activity, immunologic parameters and steroid-sparing effect. However, it can only be recommended for organ-specific manifestations such as arthritis and thrombocytopaenia. High-quality studies are needed in order to consider the long-term effects of re-treatment on different organ-specific manifestations.
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29
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Esposito S, Bosis S, Semino M, Rigante D. Infections and systemic lupus erythematosus. Eur J Clin Microbiol Infect Dis 2014; 33:1467-75. [PMID: 24715155 DOI: 10.1007/s10096-014-2098-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 03/20/2014] [Indexed: 12/25/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that presents a protean spectrum of clinical manifestations, and may affect any organ. The typical course of SLE is insidious, slow, and progressive, with potential exacerbations and remissions, and even dramatically acute and rapidly fatal outcomes. Recently, infections have been shown to be highly associated with the onset and/or exacerbations of SLE, and their possible causative and/or protective role has been largely emphasized in the medical literature. However, the etiopathogenesis of SLE is still obscure and far from being completely elucidated. Among infections, particularly Epstein-Barr virus (EBV), parvovirus B19, retrovirus, and cytomegalovirus (CMV) infections might play a pivotal pathogenetic role. The multifaceted interactions between infections and autoimmunity reveal many possibilities for either causative or protective associations. Indeed, some infections, primarily protozoan infections, might confer protection from autoimmune processes, depending on the unique interaction between the microorganism and host. Further studies are needed in order to demonstrate that infectious agents might, indeed, be causative of SLE, and to address the potential clinical sequelae of infections in the field of autoimmunity.
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Affiliation(s)
- S Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda n. 9, 20122, Milano, Italy,
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30
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Duraisingham SS, Buckland MS, Grigoriadou S, Longhurst HJ. Secondary antibody deficiency. Expert Rev Clin Immunol 2014; 10:583-91. [PMID: 24684706 DOI: 10.1586/1744666x.2014.902314] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Secondary antibody deficiencies are defined by a quantitative or qualitative decrease in antibodies that occur most commonly as a consequence of renal or gastrointestinal immunoglobulin loss, hematological malignancies and corticosteroid, immunosuppressive or anticonvulsant medications. Patients with hematological malignancies or requiring immunosuppressive medications are known to be at increased risk of infection, but few studies directly address this relationship in the context of antibody deficiency. Immunoglobulin replacement therapy has been shown to be effective in reducing infections in primary and some secondary antibody deficiencies. The commonly encountered causes of secondary antibody deficiencies and their association with infection-related morbidity and mortality are discussed. Recommendations are made for screening and clinical management of those at risk.
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Affiliation(s)
- Sai S Duraisingham
- Immunology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
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31
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Zarkali A, Karageorgopoulos DE, Rafailidis PI, Falagas ME. Frequency of the off-label use of monoclonal antibodies in clinical practice: a systematic review of the literature. Curr Med Res Opin 2014; 30:471-80. [PMID: 24127749 DOI: 10.1185/03007995.2013.855186] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The monoclonal antibodies represent novel therapeutic options for many clinical entities. This study aimed to study the frequency of the off-label use to total use of different monoclonal antibodies in clinical practice. METHODS This study systematically searched the PubMed and Scopus databases for relevant studies. RESULTS Fifteen studies were considered eligible for inclusion in this review. Eight of the included studies referred to the off-label use of anti-neoplastic monoclonal antibodies, three referred to immunosuppressive ones, and four to other types of monoclonal antibodies. The most studied anti-neoplastic monoclonal antibody was rituximab; which was prescribed off-label at a frequency varying between 16-75%, mostly for an unapproved diagnosis. Bevacizumab was prescribed off-label for age-related macular degeneration more often than ranibizumab, the approved monoclonal antibody for this condition. Of the immunosuppressive monoclonal antibodies, infliximab was used off-label in an average of 15.4% (range=2.8-25%) and adalimumab in 10.5% (range=0-15.4% in different years). CONCLUSION The frequency of off-label use of different types of monoclonal antibodies varies, but appears to be considerably high for specific monoclonal antibodies or indications. In certain examples, this might reflect implementation into clinical practice of relevant scientific data, albeit not of the strength or quality that suffices for receipt of regulatory approval. In others, it might relate to the sub-optimal effectiveness and considerable toxicity of the conventional therapies. Still, the clinician should bear in mind the potential costs and toxicity that can be associated with off-label use of monoclonal antibodies.
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Affiliation(s)
- Angeliki Zarkali
- Alfa Institute of Biomedical Sciences (AIBS) , Marousi, Athens , Greece
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Risk factors for severe bacterial infections in patients with systemic autoimmune diseases receiving rituximab. Clin Rheumatol 2014; 33:799-805. [PMID: 24487486 PMCID: PMC4058071 DOI: 10.1007/s10067-014-2509-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/12/2014] [Accepted: 01/19/2014] [Indexed: 11/14/2022]
Abstract
The risk of serious bacterial infectious events (SIEs) after an RTX course used in severe and refractory cases of systemic autoimmune diseases (SAID) is well known. Risk factors for SIEs merit investigation. For this case–control study, data were collected in a single centre of internal medicine and included all patients who received rituximab (RTX) for SAID between 2005 and 2011 (rheumatoid arthritis was excluded). Sixty-nine patients with SAID received a total of 87 RTX courses. Thirteen SIEs were reported in 12 patients leading to death in 5 patients. Patients with a history of SIE were significantly older (63.6 ± 18.8 vs 48.8 ± 16.7; p = 0.0091), suffered most frequently of diabetes mellitus (33.3 % vs 5.3 %, p = 0.015), had a lower CD19 count (1.0 ± 1.2/mm3 vs 3.9 ± 7.2/mm3) and had most frequently a prednisone dose >15 mg/day (91.7 % vs 47.7 %) at the start of the first RTX course. The SIE rate was 18.7 per 100 patient-years. At the initiation of the RTX course, risk factors for SIEs were lower IgG levels (OR = 0.87, 95%CI = 0.77–0.99, p = 0.03), lower CD19 count (OR = 0.85, 95%CI = 0.73–1.00) and creatinine clearance ≤ 45 ml/min (OR = 7.78, 95%CI = 1.36–44.38, p = 0.002). Conversely history of pneumococcal vaccination significantly decreased the risk of SIEs (OR = 0.11, 95%CI = 0.03–0.41, p = 0.0009). Concomitant treatment with prednisone at a dose >15 mg/day significantly increased the SIE risk (OR = 8.07, 95%CI = 1.94–33.59, p = 0.0004). SIEs are frequent in SAID treated with RTX, particularly in patients receiving high-dose corticosteroids, in patients with renal insufficiency and in patients with low IgG levels or a low CD19 count.
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Serious infections in patients with rheumatoid arthritis and other immune-mediated connective tissue diseases exposed to anti-TNF or rituximab: data from the Spanish registry BIOBADASER 2.0. Rheumatol Int 2014; 34:953-61. [PMID: 24414744 DOI: 10.1007/s00296-014-2945-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 01/02/2014] [Indexed: 12/19/2022]
Abstract
Data on infections in patients exposed to biologic therapies are mainly focused on rheumatoid arthritis (RA). Little is known about the safety profile in other immune-mediated connective tissue diseases (ICTD). The purpose of this study was to describe and to compare the risk of serious infections (SI) in patients with RA and other ICTD on anti-TNF or rituximab and to identify predictors of SI. We analyzed RA or other ICTD patients on anti-TNF or rituximab included in the Spanish registry BIOBADASER 2.0 (2000-2011). For each disease group, incidence rate (IR), mortality rate (MR) and IR ratio (IRR) of SI with 95% CI were estimated. Risks were then standardized by age and sex to the general population. Risk factors for SI were assessed by Poisson regression models. A total of 3,301 patients on anti-TNF (n = 3,166) or rituximab (n = 135), of which 176 (5%) had ICTD other than RA, were analyzed. IR of SI was higher in non-RA ICTD than in RA, with an IRR of 3.15 (95% CI 1.86, 5.31) before adjustment and 1.96 (95% CI 1.06, 3.65) after adjustment for age, comorbidity and corticoid use. Mortality due to infections was higher in ICTD although it did not reach statistical significance. Age, disease duration, comorbidities, corticosteroids and ICTD different to RA were all independently associated with SI. Patients with ICTD other than RA are at a high risk of SI when prescribed anti-TNF or rituximab, partly due to the excess comorbidity and immunosuppressive co-treatment, but also to the inflammatory disease. When evaluating the risk/benefit ratio of off-label medications in ICTD patients, age, comorbidities and corticoid use should carefully be taken into account, applying adequate preventive measures.
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Costa-Reis P, Nativ S, Isgro J, Rodrigues T, Yildirim-Toruner C, Starr A, Saiman L, Imundo L, Eichenfield A. Major infections in a cohort of 120 patients with juvenile-onset systemic lupus erythematosus. Clin Immunol 2013; 149:442-9. [DOI: 10.1016/j.clim.2013.08.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 08/22/2013] [Accepted: 08/24/2013] [Indexed: 11/30/2022]
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Danza A, Ruiz-Irastorza G. Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus 2013; 22:1286-94. [DOI: 10.1177/0961203313493032] [Citation(s) in RCA: 224] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Infection is one of the leading causes of morbidity and mortality in systemic lupus erythematosus (SLE). Bacterial infections are most frequent, followed by viral and fungal infections. The impaired cellular and humoral immune functions seen in patients with SLE are predisposing conditions, whilst disease activity, prednisone doses over 7.5–10 mg/day, high doses of methylprednisolone or cyclophosphamide are well-recognised risk factors for infection. The first six months after rituximab treatment and the use of more than three courses are also associated with an increased susceptibility for infection. It has not been established whether belimumab, azathioprine and mycophenolate mofetil increase the risk of serious infections. Most vaccines are effective and safe in SLE patients, although vaccination should be avoided during periods of active disease. Live virus vaccines are contraindicated for immunosuppressed patients. Influenza and pneumococcal vaccines are universally recommended. Tuberculosis prophylaxis should be considered in selected cases. Therefore, it is advisable not to exceed doses of 5 mg/day of prednisone in chronic treatment. Methylprednisolone and cyclophosphamide should be used in low-dose regimens. Antimalarials have a well-known protective role against infection, in addition to other beneficial properties, thus, hydroxychloroquine is recommended for all SLE patients where no contraindication exists.
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Affiliation(s)
- A Danza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Spain
- Clinical Department of Medicine, Facultad de Medicina, Universidad de la República, Uruguay
| | - G Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Spain
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Alijotas-Reig J, Fernández-Figueras MT, Puig L. Inflammatory, immune-mediated adverse reactions related to soft tissue dermal fillers. Semin Arthritis Rheum 2013; 43:241-58. [DOI: 10.1016/j.semarthrit.2013.02.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 02/07/2013] [Accepted: 02/15/2013] [Indexed: 12/14/2022]
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Novel therapeutic agents in clinical development for systemic lupus erythematosus. BMC Med 2013; 11:120. [PMID: 23642011 PMCID: PMC3667088 DOI: 10.1186/1741-7015-11-120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 04/09/2013] [Indexed: 01/01/2023] Open
Abstract
Conventional immunosuppressive therapies have radically transformed patient survival in systemic lupus erythematosus (SLE), but their use is associated with considerable toxicity and a substantial proportion of patients remain refractory to treatment. A more comprehensive understanding of the complexity of SLE immunopathogenesis has evolved over the past decade and has led to the testing of several biologic agents in clinical trials. There is a clear need for new therapeutic agents that overcome these issues, and biologic agents offer exciting prospects as future SLE therapies.An array of promising new therapies are currently emerging or are under development including B-cell depletion therapies, agents targeting B-cell survival factors, blockade of T-cell co-stimulation and anti-cytokine therapies, such as monoclonal antibodies against interleukin-6 and interferon-α.
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Ikumi N, Matsukawa Y, Kuwana Y, Kodaira H, Tanaka T, Maruyama N, Nozawa S, Horikoshi A, Takeuchi J. Staphylococcus aureussepsis after etanercept induction in a hemodialysis patient. Hemodial Int 2012; 17:133-5. [DOI: 10.1111/j.1542-4758.2012.00723.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | | | | | | | - Noriaki Maruyama
- Division of Nephrology and Endocrinology; Department of Medicine; Nihon University School of Medicine; Oyaguchi-Kamimachi; Itabashi; Tokyo; Japan
| | - Sakiko Nozawa
- Department of Internal Medicine; Nihon University Nerima-Hikarigaoka Hospital; 2-11-1 Hikarigaoka, Nerima; Tokyo; Japan
| | | | - Jin Takeuchi
- Division of Hematology and Rheumatology; Itabashi; Tokyo; Japan
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Windt R, Glaeske G, Hoffmann F. [Prescription of TNF-alpha inhibitors and regional differences in 2010]. Z Rheumatol 2012; 70:874-81. [PMID: 21956828 DOI: 10.1007/s00393-011-0873-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tumor necrosis factor alpha (TNF-α) inhibitors are an important treatment option for rheumatoid arthritis and other chronic inflammatory diseases. However, attention should be paid to severe adverse drug reactions and very high costs of therapy. The objective of this study was to examine the prescription and costs of TNF-α inhibitors as well as regional differences at the district level in Germany. For this purpose, prescription claims data of a German health fund with 9.1 million insured persons from the year 2010 were analyzed. A total of 45,229 packs (0.1% of all prescribed drugs) and 3.15 million defined daily doses (DDD) of TNF-α inhibitors were prescribed. This leads to a total pharmacy revenue of 163.18 million Euro (share 4.1%) and 1 DDD costs on average 51.61 Euro. For 10,078 patients at least one TNF inhibitor was prescribed (prescription prevalence 111 per 100,000) with a higher proportion of women (125 vs. 92 per 100,000). The average revenue per insured person was often higher in districts of eastern Germany (>30 Euro) for reasons unknown. Provided that use is appropriate to indications there are only low saving potentials.
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Affiliation(s)
- R Windt
- Zentrum für Sozialpolitik, Abteilung Gesundheitsökonomie, Gesundheitspolitik und Versorgungsforschung, Universität Bremen, Mary-Somerville-Str. 5, 28359, Bremen, Deutschland.
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Ramos-Casals M, Sanz I, Bosch X, Stone JH, Khamashta MA. B-cell-depleting therapy in systemic lupus erythematosus. Am J Med 2012; 125:327-36. [PMID: 22444096 PMCID: PMC3925418 DOI: 10.1016/j.amjmed.2011.09.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 09/14/2011] [Accepted: 09/21/2011] [Indexed: 01/10/2023]
Abstract
The emergence of a new class of agents (B-cell-depleting therapies) has opened a new era in the therapeutic approach to systemic lupus erythematosus, with belimumab being the first drug licensed for use in systemic lupus erythematosus in more than 50 years. Four agents deserve specific mention: rituximab, ocrelizumab, epratuzumab, and belimumab. Controlled trials have shown negative results for rituximab, promising results for epratuzumab, and positive results for belimumab. Despite these negative results, rituximab is the most-used agent in patients who do not respond or are intolerant to standard therapy and those with life-threatening presentations. B-cell-depleting agents should not be used in patients with mild disease and should be tailored according to individual patient characteristics, including ethnicity, organ involvement, and the immunological profile. Forthcoming studies of B-cell-directed strategies, particularly data from investigations of off-label rituximab use and postmarketing studies of belimumab, will provide new insights into the utility of these treatments in the routine management of patients with systemic lupus erythematosus.
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Affiliation(s)
- Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS, Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Iñaki Sanz
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, NY
| | - Xavier Bosch
- Department of Internal Medicine, ICMiD, Hospital Clínic, Barcelona, Spain
| | - John H. Stone
- Rheumatology Unit, Massachusetts General Hospital, Boston
| | - Munther A. Khamashta
- Lupus Research Unit, The Rayne Institute, St. Thomas’ Hospital, King’s College, London, UK
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Xie WL, Li ZL, Xu Z, Qu HR, Xue L, Su X, Wei QH, Wang H, Li MY, Zhao FT, Jiang LD, Zhang J, Wan WG, Dai M, Yang CD, Guan JL, Su L, Zhao DB, He DY, Xu HJ, Zou HJ, Bao CD. The risk factors for nosocomial infection in chinese patients with active rheumatoid arthritis in shanghai. ISRN RHEUMATOLOGY 2012; 2012:215692. [PMID: 22548187 PMCID: PMC3328155 DOI: 10.5402/2012/215692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 01/15/2012] [Indexed: 01/03/2023]
Abstract
Objective. To analyse the potential risk factors of nosocomial infections in patients with active rheumatoid arthritis (RA). Methods. A total of 2452 active RA patients at Hospitals in Shanghai between January 2009 and February 2011 were analyzed. Their demographic and clinical characteristics were compared with those without infection, and the potential risk factors were determined by logistic regression analysis. Results. Multivariate analysis indicated the gender (OR = 0.70, 95% CI 0.53–0.92), duration in hospital (OR = 1.03
, 95%CI 1.01–1.05), number of organs involved (OR = 0.82,
95%CI 0.72–0.92), number of disease-modifying antirheumatic drugs ((DMARDs) (OR = 1.22,
95%CI 1.061–1.40)), corticosteroid therapy (OR = 1.02, 95%CI 1.01–1.03), peripheral white blood cell counts ((WBC) (OR = 1.04,
95%CI 1.00–1.08)), levels of serum albumin (OR = 0.98, 95%CI 0.97–0.99), and C-reactive protein ((CRP) (OR = 1.03
, 95%CI 1.01–1.04)) that were significantly associated with the risk of infections. Conclusion. The female patients, longer hospital stay, more organs involved, more DMARDs, corticosteroid usage, high counts of WBC, lower serum albumin, and higher serum CRP were independent risk factors of infections in active RA patients.
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Affiliation(s)
- Wei-Lin Xie
- Department of Rheumatology and Immunology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
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Pneumocystis jirovecii pneumonia in non-HIV-infected patients: new risks and diagnostic tools. Curr Opin Infect Dis 2012; 24:534-44. [PMID: 21986616 DOI: 10.1097/qco.0b013e32834cac17] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Non-HIV-infected populations are increasingly identified as being at risk for developing Pneumocystis jirovecii pneumonia (PJP). These patients typically present with severe disease and poorly tolerate invasive diagnostic procedures. This review examines recently reported risks for PJP in non-HIV populations and summarizes new diagnostic techniques. RECENT FINDINGS PJP is associated with immunomodulatory drug therapies, including monoclonal antibody therapies such as tumour necrosis factor α antagonists, and calcineurin inhibitors. Underlying disease states include solid-organ transplantation, connective tissue and rheumatologic disorders, inflammatory bowel disease, haematological malignancies, and solid tumours. Modern diagnostic techniques [conventional PCR, quantitative PCR, (1→3)-β-D-glucan assays, and PET] are reviewed with respect to predictive value and clinical utility. In particular, current literature regarding validation and specificity of molecular diagnostic techniques is summarized, including application to minimally invasive specimens. SUMMARY HIV-negative populations at risk for PJP can be identified. Conventional PCR increases diagnostic sensitivity but may detect asymptomatic colonization. Quantitative PCR demonstrates potential for distinguishing colonization from infection, but clinical validation is required. Serum (1→3)-β-D-glucan may be elevated in PJP, although standardized cut-off values for clinical infection have not been determined. Further validation of serum markers and molecular diagnostic methods is necessary for early and accurate diagnosis in non-HIV populations.
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Abstract
The role of B cells in autoimmune diseases involves different cellular functions, including the well-established secretion of autoantibodies, autoantigen presentation and ensuing reciprocal interactions with T cells, secretion of inflammatory cytokines, and the generation of ectopic germinal centers. Through these mechanisms B cells are involved both in autoimmune diseases that are traditionally viewed as antibody mediated and also in autoimmune diseases that are commonly classified as T cell mediated. This new understanding of the role of B cells opened up novel therapeutic options for the treatment of autoimmune diseases. This paper includes an overview of the different functions of B cells in autoimmunity; the involvement of B cells in systemic lupus erythematosus, rheumatoid arthritis, and type 1 diabetes; and current B-cell-based therapeutic treatments. We conclude with a discussion of novel therapies aimed at the selective targeting of pathogenic B cells.
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Affiliation(s)
- Christiane S. Hampe
- Department of Medicine, University of Washington, SLU-276, 850 Republican, Seattle, WA 98109, USA
- *Christiane S. Hampe:
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Focosi D, Maggi F, Pistello M, Boggi U, Scatena F. Immunosuppressive monoclonal antibodies: current and next generation. Clin Microbiol Infect 2011; 17:1759-68. [PMID: 21995285 DOI: 10.1111/j.1469-0691.2011.03677.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Monoclonal antibodies (mAbs) are well-established therapeutics, as evidenced by the large number of Food and Drug Administration-approved mAbs for the treatment of cancers, and inflammatory or autoimmune diseases, and for the prevention and treatment of solid organ transplant rejection. Although, in many cases, mAbs have improved patient survival, they are also associated with an increased incidence of opportunistic infections. We review here the current and next generation of mAbs and the risks that infectious disease specialists should be aware of.
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Affiliation(s)
- D Focosi
- U.O. Immuoematologia SSN, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
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Winthrop KL, Smolen JS. Therapy: Off-label biologics use and infection risk-the great unknown. Nat Rev Rheumatol 2011; 7:685-6. [PMID: 21989283 DOI: 10.1038/nrrheum.2011.154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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