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Brehm TT, Reimann M, Köhler N, Lange C. (Re-)introduction of TNF antagonists and JAK inhibitors in patients with previous tuberculosis: a systematic review. Clin Microbiol Infect 2024:S1198-743X(24)00206-4. [PMID: 38663653 DOI: 10.1016/j.cmi.2024.04.011] [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: 01/29/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Tuberculosis (TB) is a common complication associated with treatment with tumour necrosis factor (TNF) antagonists and Janus kinase (JAK) inhibitors. However, there is uncertainty about the risk of TB relapse in patients with TB and comorbidities requiring treatment with these agents. OBJECTIVES To assess the risk of TB relapse in patients (re-)started on TNF antagonists or JAK inhibitors. METHODS Systematic review. DATA SOURCES PubMed and Cochrane Library databases until 11 December 2023. STUDY ELIGIBILITY CRITERIA Randomized control trials, prospective and retrospective cohort studies, case reports and case series. PARTICIPANTS Patients with current or previous TB who were (re-)started on TNF antagonists or JAK inhibitors. INTERVENTIONS (Re-)introduction of TNF antagonists and JAK inhibitors. ASSESSMENT OF RISK OF BIAS All studies meeting entry criteria were included regardless of quality. METHODS OF DATA SYNTHESIS Categorical data are presented as frequencies and percentages. For non-normally distributed aggregated data, we calculated the pooled weighted median with 95% CI. For individual patient data, the median and interquartile range (IQR) were calculated. RESULTS Of 5018 articles screened for eligibility, 67 publications reporting on 368 TB patients who (re-)initiated treatment with TNF antagonists for underlying diseases were included. The median age was 42.5 years (95% CI: 40.4-42.5) and the proportion of female patients was 36.6% (n = 74) of patients whose sex was reported. A total of 14 patients (3.8%, 95% CI: 2.1-6.3%) developed TB relapse after a median of 8.5 months (interquartile range, 6.8-14.8 months) following (re-)initiation of anti-TNF treatment. Furthermore, among 251 articles screened for eligibility, 11 reports on TB patients who were (re-)started on JAK inhibitors for underlying diseases were identified. The median age was 62 years (interquartile range, 48.5-68.5 years) and 45.5% (n = 5) were female. Only one patient (9.1%; 95% CI: 0.2-41.3%) had TB reactivation 10 months after starting treatment with ruxolitinib. In addition, 94 patients who were treated with TNF antagonists and two patients temporarily treated with JAK inhibitors for the prevention or treatment of paradoxical reactions were analysed. None of the publications reported microbiological failure or worsening of TB-related symptoms. CONCLUSIONS (Re-)initiation of TNF antagonists and JAK inhibitors may be relatively safe in patients with current or previous TB and the need for further treatment of underlying diseases.
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Affiliation(s)
- Thomas Theo Brehm
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.
| | - Maja Reimann
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | - Niklas Köhler
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
| | - Christoph Lange
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany; Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Baylor College of Medicine and Texas Children's Hospital, Global Tuberculosis Program, Houston, Texas, USA; Institute for Infection Research and Vaccine Development (IIRVD), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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2
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Gianarakis M, Gianarakis A, Ahmed S, Pueringer J, Ranasinghe U. Granulomas Galore: Concomitant Granulomatous Infections in a Patient With Crohn's Disease. Cureus 2024; 16:e54225. [PMID: 38496097 PMCID: PMC10943491 DOI: 10.7759/cureus.54225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
Tumor necrosis factor (TNF)-alpha inhibitors are effective biologics in the treatment of inflammatory bowel disease; however, they increase susceptibility to opportunistic infections. We report a case of a 74-year-old female with Crohn's disease who developed concomitant pulmonary tuberculosis (Mycobacterium tuberculosis [MTB]) and Histoplasmosis capsulatum infection while on adalimumab. Co-infection is rare in patients on TNF-alpha inhibitor therapy, and most cases have been reported in patients with human immunodeficiency virus (HIV). This was a challenging case for diagnosis and treatment due to indistinguishable presenting symptoms of both infections, similar laboratory and radiographical findings, and a clinical course complicated by drug-drug interactions and worsening of symptoms despite therapy.
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Affiliation(s)
| | | | - Safia Ahmed
- Family Medicine, Swedish Hospital, Chicago, USA
| | - John Pueringer
- Internal Medicine, University of Illinois at Chicago, Chicago, USA
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Fine S, Vecchio M, Filipe Goncalves Monteiro J, Vecchio E, Mao EJ. Overuse of Tuberculosis Surveillance Testing in Patients With Inflammatory Bowel Disease Compared to Non-IBD Patients on Biologic Therapy. CROHN'S & COLITIS 360 2021; 3:otab026. [PMID: 36776652 PMCID: PMC9802072 DOI: 10.1093/crocol/otab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Indexed: 12/29/2022] Open
Abstract
Background Biologic treatment for moderate to severe inflammatory bowel disease (IBD) places patients at risk for infectious complications. Tuberculosis (TB) infection and reactivation can lead to serious morbidity and mortality for immunosuppressed patients. As a result, guidelines recommend screening for TB before starting biologic treatment, but a paucity of data remains on the utility of surveillance testing. Methods We performed a retrospective chart review at a single academic center evaluating both IBD and non-IBD patients on biologic therapy. The primary outcome was to determine the number of subsequent surveillance tests performed after initial screening for latent TB in both patient groups. Results A total of 188 patients (147 IBD and 41 non-IBD patients) on biologic therapy were included. Screening for TB before biologic treatment was performed in 56% of non-IBD patients versus 83% for patients with IBD (P = 0.0003). Of the total cohort, 65% had at least 2 follow-up surveillance tests for TB. Three or more surveillance tests were performed in 40% of patients with IBD versus only 13% for non-IBD patients (P = 0.0132). A total of 7 patients (4%) had an abnormal surveillance test. No patients were confirmed to have a diagnosis of TB or underwent treatment. Conclusions Patients on biologic therapy unnecessarily undergo surveillance testing for TB. Patients with IBD on biologic therapy are screened annually for TB at a higher rate compared to non-IBD patients. Standardization of care among patients on biologic therapy is necessary to avoid excessive testing in areas with a low incidence of TB.
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Affiliation(s)
- Sean Fine
- Department of Medicine, Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Address correspondence to: Sean Fine, MD, MS, Brown Physicians Inc. 375 Wampanoag Trail, Suite 202A, East Providence, RI 02915, USA ()
| | - Marc Vecchio
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Eric Vecchio
- Department of Gastroenterology and Hepatology at UConn Health, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Eric J Mao
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA, USA
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Yanarateş A, Budak E. Disseminated Tuberculosis and Saccular Aneurysm Findings on FDG PET/CT in a Patient With Polyarteritis Nodosa. J Clin Rheumatol 2021; 27:e67-e68. [PMID: 31764382 DOI: 10.1097/rhu.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ahmet Yanarateş
- From the Department of Nuclear Medicine, Izmir Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, Izmir, Turkey
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5
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Faleck DM, Shmidt E, Huang R, Katta LG, Narula N, Pinotti R, Suarez-Farinas M, Colombel JF. Effect of Concomitant Therapy With Steroids and Tumor Necrosis Factor Antagonists for Induction of Remission in Patients With Crohn's Disease: A Systematic Review and Pooled Meta-analysis. Clin Gastroenterol Hepatol 2021; 19:238-245.e4. [PMID: 32569749 PMCID: PMC8364422 DOI: 10.1016/j.cgh.2020.06.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS It is not clear whether concomitant therapy with corticosteroids and anti-tumor necrosis factor (TNF) agents is more effective at inducing remission in patients with Crohn's disease (CD) than anti-TNF monotherapy. We aimed to determine whether patients with active CD receiving corticosteroids during induction therapy with anti-TNF agents had higher rates of clinical improvement than patients not receiving corticosteroids during induction therapy. METHODS We systematically searched the MEDLINE, Embase, and CENTRAL databases, through January 20, 2016, for randomized trials of anti-TNF agents approved for treatment of CD and identified 14 trials (5 of adalimumab, 5 of certolizumab, and 4 of infliximab). We conducted a pooled meta-analysis of individual patient and aggregated data from these trials. We compared data from participants who continued oral corticosteroids during induction with anti-TNF therapy to those treated with anti-TNF agents alone. The endpoints were clinical remission (CD activity index [CDAI] scores <150) and clinical response (a decrease in CDAI of 100 points) at the end of induction (weeks 4-14 of treatment). RESULTS We included 4354 patients who received induction therapy with anti-TNF agents, including 1653 [38.0%] who were receiving corticosteroids. The combination of corticosteroids and an anti-TNF agent induced clinical remission in 32.0% of patients, whereas anti-TNF monotherapy induced clinical remission in 35.5% of patients (odds ratio [OR], 0.93; 95% CI, 0.74-1.17). The combination of corticosteroids and an anti-TNF agent induced a clinical response in 42.7% of patients, whereas anti-TNF monotherapy induced a clinical response in 46.8% (OR 0.84; 95% CI, 0.73-0.96). These findings did not change with adjustment for baseline CDAI scores and concurrent use of immunomodulators. CONCLUSIONS Based on a meta-analysis of data from randomized trials of anti-TNF therapies in patients with active CD, patients receiving corticosteroids during induction therapy with anti-TNF agents did not have higher rates of clinical improvement compared with patients not receiving corticosteroids during induction therapy. Given these findings and the risks of corticosteroid use, clinicians should consider early weaning of corticosteroids during induction therapy with anti-TNF agents for patients with corticosteroid-refractory CD.
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Affiliation(s)
- David M. Faleck
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Gastroenterology, Hepatology & Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eugenia Shmidt
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA,University of Minnesota, Division of Gastroenterology, Hepatology and Nutrition, Minneapolis, MN, USA
| | - Ruiqi Huang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leah G. Katta
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine and Farncombe, Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Rachel Pinotti
- Levy Library, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mayte Suarez-Farinas
- Department of Population Health Science and Policy, Department of Genetics and Genomics Science, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Rodríguez S, Muñoz A, Bustos RH, Jaimes D. Pharmacovigilance of Biopharmaceuticals in Rheumatic Diseases, Adverse Events, Evolution, and Perspective: An Overview. Biomedicines 2020; 8:E303. [PMID: 32842558 PMCID: PMC7555940 DOI: 10.3390/biomedicines8090303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/07/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023] Open
Abstract
Since we have gained an understanding of the immunological pathophysiology of rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus, treatment based on biological drugs has become a fundamental axis. These therapies are oriented towards the regulation of cytokines such as tumour necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-1, and the modulation of cell-mediated immunity (B cells and T cells) by anti CD20 or anti CTAL-4 agents, and can increase the risk of associated infections or adverse events (AE). In this context, the entry of biotherapeutics represented a challenge for pharmacovigilance, risk management and approval by the main global regulatory agencies regarding biosimilars, where efficacy and safety are based on comparability exercises without being an exact copy in terms of molecular structure. The objective of this review is divided into three fundamental aspects: (i) to illustrate the evolution and focus of pharmacovigilance at the biopharmaceutical level, (ii) to describe the different approved recommendations of biopharmaceuticals (biological and biosimilars) and their use in rheumatic diseases (RDs) such as rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE) and other less frequent RD like cryopyrin-associated autoinflammatory syndromes (CAPS), and (iii) to identify the main AE reported in the post-marketing phase of RD biopharmaceuticals.
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Affiliation(s)
| | | | - Rosa-Helena Bustos
- Evidence-Based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia; (S.R.); (A.M.); (D.J.)
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Abstract
Biologic drugs have revolutionized the treatment of certain hematologic, autoimmune, and malignant diseases, but they may place patients at risk for reactivation or acquisition of tuberculosis. This risk is highest with the tumor necrosis factor-alpha (TNF-α) inhibitors. Amongst this class of drugs, the monoclonal antibodies (infliximab, adalimumab, golimumab) and antibody fragment (certolizumab) carry an increased risk compared to the soluble receptor fusion molecule, etanercept. Treatment of latent TB is critical to decrease the risk of reactivation. Data continues to emerge regarding tuberculosis risk associated with novel biologics targeting cytokines involved in tuberculosis control.
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8
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Mayito J, Andia I, Belay M, Jolliffe DA, Kateete DP, Reece ST, Martineau AR. Anatomic and Cellular Niches for Mycobacterium tuberculosis in Latent Tuberculosis Infection. J Infect Dis 2019; 219:685-694. [PMID: 30376080 PMCID: PMC6376907 DOI: 10.1093/infdis/jiy579] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/25/2018] [Indexed: 12/25/2022] Open
Abstract
Latent tuberculosis has been recognized for over a century, but discovery of new niches, where Mycobacterium tuberculosis resides, continues. We evaluated literature on M.tuberculosis locations during latency, highlighting that mesenchymal and hematopoietic stem cells harbor organisms in sensitized asymptomatic individuals.
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Affiliation(s)
- Jonathan Mayito
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda.,Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Irene Andia
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mulugeta Belay
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - David A Jolliffe
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - David P Kateete
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Stephen T Reece
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Adrian R Martineau
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
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9
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Uzorka JW, Wallinga J, Kroft LJM, Ottenhoff THM, Arend SM. Radiological Signs of Latent Tuberculosis on Chest Radiography: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2019; 6:5541696. [PMID: 31363778 PMCID: PMC6667719 DOI: 10.1093/ofid/ofz313] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/08/2019] [Indexed: 01/15/2023] Open
Abstract
Objective Current guidelines recommend screening for latent tuberculosis infection (LTBI) with a tuberculin skin test (TST) or interferon gamma release assay (IGRA), or both. Many also recommend chest radiography (CXR), although its added value is uncertain. This systematic review assessed the prevalence of abnormalities suggestive of LTBI on CXR (LTBI-CXR lesions) and evaluated the strength of the association. Method We searched 4 databases up to September 2017 and systematically reviewed cross-sectional and cohort studies reporting LTBI-CXR lesions in individuals with a positive TST or IGRA, or both, result. Prevalence estimates were pooled using random effects models and odds ratios (ORs) were used to calculate risk estimates. Results In the 26 included studies, the pooled proportion of individuals with LTBI having LTBI-CXR lesions was 0.15 (95% confidence interval [CI], 0.12–0.18]. In 16 studies that reported on individuals with LTBI and uninfected controls, LTBI-CXR lesions were associated with a positive TST result ≥ 5 mm or ≥ 10 mm (OR, 2.45; 95% CI, 1.00–5.99; and OR, 2.06; 95% CI, 1.38–3.09, respectively) and with a positive QuantiFERON result (OR, 1.99; 95% CI, 1.17–3.39) compared to CXR in uninfected controls. Although few studies reported specified lesions, calcified nodules were most frequently reported in individuals with LTBI (proportion, 0.07; 95% CI, 0.02–0.11). Conclusions Lesions on CXR suggestive of previous infection with Mycobacterium tuberculosis were significantly associated with positive tests for LTBI, although the sensitivity was only 15%. This finding may have added value when detection of past LTBI is important but immunodiagnostic tests may be unreliable.
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Affiliation(s)
- Jonathan W Uzorka
- Department of Infectious Diseases, Leiden University Medical Center, the Netherlands
| | - Jacco Wallinga
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, the Netherlands
| | - Sandra M Arend
- Department of Infectious Diseases, Leiden University Medical Center, the Netherlands
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Vortia E, Uko VE, Yen-Lieberman B, Frawley J, Worley SE, Danziger-Isakov L, Kaplan B, Mahajan L. Low Indeterminate Rates Associated With Use of the QuantiFERON-TB Gold In-Tube Test in Children With Inflammatory Bowel Disease on Long-term Infliximab. Inflamm Bowel Dis 2018; 24:877-882. [PMID: 29562270 DOI: 10.1093/ibd/izx077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Tumor necrosis factor alpha (TNF-α) inhibitors are linked with increased risk of reactivation of active tuberculosis. The QuantiFERON-TB Gold In-Tube test is approved for screening latent tuberculosis infection in children and adults. There are limited data on the test performance in children on long-term treatment with TNF-α inhibitors. The objective of this study was to assess the proportion of indeterminate results for the QuantiFERON-TB Gold In-Tube in children with inflammatory bowel disease (IBD) on long-term infliximab treatment and to evaluate the range of interferon-γ responses to mitogen. METHODS A single-center prospective study of children 5 to 19 years of age with IBD on long-term infliximab treatment (>3 months). Each child was assessed for tuberculosis exposure risk and had blood drawn for the QuantiFERON-TB Gold In-Tube. Data on the range of interferon-γ responses and final QuantiFERON-TB Gold In-Tube test results were collected. RESULTS Ninety-three children were included, with a median age of 16 years. The median total duration of infliximab therapy was 34 months (range, 3-119 months). The QuantiFERON-TB Gold In-Tube was indeterminate in 1 patient (1.1%), positive in 2 patients, and negative in 90 patients. The maximum interferon-γ response to mitogen (10 IU/mL) was observed in 82 patients (88%), with only 1 patient having an inadequate response. The proportion of indeterminate results was significantly lower than the prospectively hypothesized rate of 8%, based on prior studies in nonimmunosuppressed patients (P = 0.004). CONCLUSIONS Pediatric patients with IBD on long-term treatment with infliximab had an adequate interferon-γ response to mitogen and a low indeterminate rate when assessed with the QuantiFERON-TB Gold In-Tube test. This study demonstrates a robust interferon gamma response to phytohemagglutinin stimulation in a pediatric population on long-term therapy with infliximab. The QuantiFERON-TB Gold In-Tube test may therefore be useful as a periodic screening tactic for latent TB in children on long-term infliximab therapy.
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Affiliation(s)
- Eugene Vortia
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Victor E Uko
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jill Frawley
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sarah E Worley
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lara Danziger-Isakov
- Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Barbara Kaplan
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lori Mahajan
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
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11
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Torres-Castiblanco JL, Carrillo JA, Hincapié-Urrego D, Rojas-Villarraga A. [Tuberculosis in the era of anti-TNF-alpha therapy: Why does the risk still exist?]. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2018; 38:17-26. [PMID: 29668129 DOI: 10.7705/biomedica.v38i0.3458] [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: 07/25/2016] [Revised: 11/15/2016] [Accepted: 03/28/2017] [Indexed: 06/08/2023]
Abstract
Rheumatoid arthritis is an autoimmune systemic disease characterized mainly by inflammatory compromise of diarthrodial joints. Multiple drug therapies have been developed to control the activity of rheumatoid arthritis, among them, the first line of disease-modifying antirheumatic drugs (DMARD), and novel drug therapies such as the anti-TNF alpha therapy, with satisfactory clinical outcomes.Despite this positive fact, the use of this therapy implies the risk of producing negative effects due to its mechanism of action, which has been associated with multiple infections, especially tuberculosis, making it necessary to use screen tests before resorting to this kind of drugs.We present the case of a 58-year-old female patient, with a six-year history of rheumatoid arthritis.The patient developed disseminated tuberculosis with compatible radiological and histological findings after receiving treatment with infliximab (anti-TNF therapy). No test was performed to screen for latent tuberculosis infection prior to the administration of infliximab.The performance of routine screenings tests for tuberculosis prior to anti-TNF alpha therapy plays an essential role in the detection of asymptomatic patients with latent tuberculosis. This is the only way to identify those patients who would benefit from anti-tuberculosis drugs before the initiation of anti-TNF alpha therapy, which makes the difference in the search of a significant reduction in the incidence of tuberculosis and its associated morbidity and mortality.
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Affiliation(s)
- John-Leonardo Torres-Castiblanco
- Centro de Estudio de Enfermedades Autoinmunes (CREA), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, D.C., Colombia.
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12
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Cagatay T, Bingol Z, Kıyan E, Yegin Z, Okumus G, Arseven O, Erkan F, Gulbaran Z, Erelel M, Ece T, Cagatay P, Kılıçaslan Z. Follow‐up of 1887 patients receiving tumor necrosis‐alpha antagonists: Tuberculin skin test conversion and tuberculosis risk. CLINICAL RESPIRATORY JOURNAL 2017; 12:1668-1675. [DOI: 10.1111/crj.12726] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/03/2017] [Accepted: 10/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Tulin Cagatay
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Zuleyha Bingol
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Esen Kıyan
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Zeynep Yegin
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Gulfer Okumus
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Orhan Arseven
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Feyza Erkan
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Ziya Gulbaran
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Mustafa Erelel
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Turhan Ece
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
| | - Penbe Cagatay
- High School of Health Care Professions Biostatistic, Istanbul UniversityIstanbul Turkey
| | - Zeki Kılıçaslan
- Department of Pulmonary, Istanbul Medical Faculty, Istanbul UniversityIstanbul Turkey
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13
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Garziera G, Morsch ALB, Otesbelgue F, Staub FL, Palominos PE, Brenol CV, Silva DR. Latent tuberculosis infection and tuberculosis in patients with rheumatic diseases treated with anti-tumor necrosis factor agents. Clin Rheumatol 2017; 36:1891-1896. [DOI: 10.1007/s10067-017-3714-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 02/05/2023]
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14
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Zhang Z, Fan W, Yang G, Xu Z, Wang J, Cheng Q, Yu M. Risk of tuberculosis in patients treated with TNF-α antagonists: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2017; 7:e012567. [PMID: 28336735 PMCID: PMC5372052 DOI: 10.1136/bmjopen-2016-012567] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES An increased risk of tuberculosis (TB) has been reported in patients treated with TNF-α antagonists, an issue that has been highlighted in a WHO black box warning. This review aimed to assess the risk of TB in patients undergoing TNF-α antagonists treatment. METHODS A systematic literature search for randomised controlled trials (RCTs) was performed in MEDLINE, Embase and Cochrane library and studies selected for inclusion according to predefined criteria. ORs with 95% CIs were calculated using the random-effect model. Subgroup analyses considered the effects of drug type, disease and TB endemicity. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS 29 RCTs involving 11 879 patients were included (14 for infliximab, 9 for adalimumab, 2 for golimumab, 1 for etanercept and 3 for certolizumab pegol). Of 7912 patients allocated to TNF-α antagonists, 45 (0.57%) developed TB, while only 3 cases occurred in 3967 patients allocated to control groups, resulting in an OR of 1.94 (95% CI 1.10 to 3.44, p=0.02). Subgroup analyses indicated that patients of rheumatoid arthritis (RA) had a higher increased risk of TB when treated with TNF-α antagonists (OR 2.29 (1.09 to 4.78), p=0.03). The level of the evidence was recommended as 'low' by the GRADE system. CONCLUSIONS Findings from our meta-analysis indicate that the risk of TB may be significantly increased in patients treated with TNF-α antagonists. However, further studies are needed to reveal the biological mechanism of the increased TB risk caused by TNF-α antagonists treatment.
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Affiliation(s)
- Zheng Zhang
- Department of Clinical Laboratory & Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Wei Fan
- Department of Clinical Laboratory & Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Pathology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Gui Yang
- Department of Clinical Laboratory, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zhigao Xu
- Department of Pathology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - June Wang
- Department of Clinical Laboratory & Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qingyuan Cheng
- Department of Clinical Laboratory & Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Mingxia Yu
- Department of Clinical Laboratory & Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Clinical Laboratory, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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Abstract
Infliximab is one of the TNF-α inhibitors, a class of medications that made a revolution in treatment of rheumatic diseases especially rheumatoid arthritis. The activation of tuberculosis and atypical mycobacterial infections has been described in the setting of TNF-α inhibitor therapy, but septic arthritis relating to this treatment has not yet been reported in previous literature. We describe a 50-year-old woman with dermatomyositis who developed Mycobacterium Avium Complex septic arthritis, while being treated with infliximab for active skin disease. This case highlights an important complication related to therapy with TNF-α inhibitors.
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Domingo-Gonzalez R, Prince O, Cooper A, Khader SA. Cytokines and Chemokines in Mycobacterium tuberculosis Infection. Microbiol Spectr 2016; 4:10.1128/microbiolspec.TBTB2-0018-2016. [PMID: 27763255 PMCID: PMC5205539 DOI: 10.1128/microbiolspec.tbtb2-0018-2016] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Indexed: 02/06/2023] Open
Abstract
Chemokines and cytokines are critical for initiating and coordinating the organized and sequential recruitment and activation of cells into Mycobacterium tuberculosis-infected lungs. Correct mononuclear cellular recruitment and localization are essential to ensure control of bacterial growth without the development of diffuse and damaging granulocytic inflammation. An important block to our understanding of TB pathogenesis lies in dissecting the critical aspects of the cytokine/chemokine interplay in light of the conditional role these molecules play throughout infection and disease development. Much of the data highlighted in this review appears at first glance to be contradictory, but it is the balance between the cytokines and chemokines that is critical, and the "goldilocks" (not too much and not too little) phenomenon is paramount in any discussion of the role of these molecules in TB. Determination of how the key chemokines/cytokines and their receptors are balanced and how the loss of that balance can promote disease is vital to understanding TB pathogenesis and to identifying novel therapies for effective eradication of this disease.
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Affiliation(s)
| | - Oliver Prince
- Department of Molecular Microbiology, Washington University in St. Louis, St. Louis, MO 63130
| | - Andrea Cooper
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester LE1 7RH, United Kingdom
| | - Shabaana A Khader
- Department of Molecular Microbiology, Washington University in St. Louis, St. Louis, MO 63130
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Andrisani G, Armuzzi A, Marzo M, Felice C, Pugliese D, Papa A, Guidi L. What is the best way to manage screening for infections and vaccination of inflammatory bowel disease patients? World J Gastrointest Pharmacol Ther 2016; 7:387-396. [PMID: 27602239 PMCID: PMC4986392 DOI: 10.4292/wjgpt.v7.i3.387] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 06/16/2016] [Indexed: 02/07/2023] Open
Abstract
The use of biological agents and immunomodulators for inflammatory bowel disease (IBD) is associated with an increased risk of opportunistic infections, in particular of viral or bacterial etiology. Despite the existence of international guidelines, many gastroenterologists have not adopted routine screening and vaccination in those patients with IBD, which are candidate for biologic therapy. Available strategies to screen, diagnose and prevent bacterial and viral infections in patients with IBD prior to start biological therapy are discussed in this review.
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Disseminated Tuberculosis in a Patient Taking Anti-TNF Therapy for Crohn's Disease. ACG Case Rep J 2015; 3:45-8. [PMID: 26504878 PMCID: PMC4612758 DOI: 10.14309/crj.2015.97] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/25/2015] [Indexed: 01/25/2023] Open
Abstract
A man in his sixth decade with Crohn's colitis and who had been taking infliximab for 18 months presented with fever and weight loss. Chest CT showed numerous nodules in both lungs, and sputum culture grew Mycobacterium tuberculosis. Colonoscopy showed circumferential ulcerations from the cecum to the descending colon, and biopsies showed extensive granulomas with central necrosis, positive for acid-fast bacteria. Brain MRI revealed a thalamic ring-enhanced mass with edema, consistent with tuberculoma. Clinicians should be aware of the appropriate screening and close monitoring of tuberculosis before and during anti-tumor necrosis factor (TNF) therapy.
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Low-dose Infliximab for Induction and Maintenance Treatment in Chinese Patients With Moderate to Severe Active Ulcerative Colitis. J Clin Gastroenterol 2015; 49:582-8. [PMID: 25844841 DOI: 10.1097/mcg.0000000000000319] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
GOAL To evaluate the efficacy of low-dose (3.5 mg/kg) infliximab for induction and maintenance treatment in Chinese patients with ulcerative colitis. BACKGROUND Treatment with 4 to 5 mg/kg of infliximab also proved to be effective in treating moderate to severe ulcerative colitis. At present there is no relevant study on the effectiveness of infliximab doses lower than 4 mg/kg in patients with ulcerative colitis. STUDY A prospective, randomized, double-blind, placebo-controlled, and single-centered study was designed. A total of 123 patients (from 17 provinces of China) with moderate to severe active ulcerative colitis despite treatment with concurrent drugs received placebo or low-dose (3.5 mg/kg) or standard-dose (5 mg/kg) infliximab intravenously at weeks 0, 2, and 6 and then every 8 weeks through week 22. Patients were followed up for 30 weeks. RESULTS Overall, 73% and 78% of patients who received low-dose (3.5 mg/kg) and standard-dose (5 mg/kg) infliximab, respectively, had clinical responses at week 8, as compared with 37% of patients who received placebo (P<0.01 for both comparisons with placebo). The number of patients who received low-dose (3.5 mg/kg) or standard-dose (5 mg/kg) infliximab with a clinical response at week 30 (63% and 66%, respectively) was more than the patients who received placebo (27%, P<0.01 for both comparisons). CONCLUSIONS Chinese patients with moderate to severe active ulcerative colitis treated with low-dose (3.5 mg/kg) or standard-dose (5 mg/kg) infliximab at weeks 0, 2, and 6 and every 8 weeks thereafter were more likely to have a clinical response at weeks 8 and 30 than those who received placebo.
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20
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Brode SK, Jamieson FB, Ng R, Campitelli MA, Kwong JC, Paterson JM, Li P, Marchand-Austin A, Bombardier C, Marras TK. Risk of mycobacterial infections associated with rheumatoid arthritis in Ontario, Canada. Chest 2015; 146:563-572. [PMID: 24384637 DOI: 10.1378/chest.13-2058] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) are at increased risk of TB. Little is known about the risk of nontuberculous mycobacteria (NTM) disease in these patients. We sought to ascertain the rate of NTM infection and TB in all residents of Ontario, Canada, with and without RA. METHODS In a cohort study, all Ontarians aged ≥ 15 years in January 2001 were followed until December 2010. Individuals with RA were identified using a validated algorithm to search hospitalization and physician billing claims. We linked Public Health Ontario Laboratory data to identify all cases of laboratory-confirmed TB and NTM disease. Analysis was performed using Cox proportional hazards regression. RESULTS We identified 113,558 Ontarians with RA and 9,760,075 Ontarians without RA. Relative to the non-RA group, adjusted hazard ratios (HRs) and 95% CIs for TB (1.92, [1.50-2.47]) and NTM disease (2.07, [1.84-2.32]) demonstrated increased risks in the RA group. Among those with RA, per 100,000 person-years, NTM disease (HR, 41.6; 95% CI, 37.1-46.5) was more common than TB (HR, 8.5; 95% CI, 6.5-10.8). After full adjustment, people with RA who developed NTM disease were 1.81 times as likely to die than uninfected people with RA. CONCLUSIONS Mycobacterial infections are more common in Ontarians with RA, with NTM disease more likely than TB. NTM disease is associated with an increased risk of death in patients with RA. Given the rising rates of NTM disease worldwide, determining whether this risk is due to the use of immunosuppressive medications vs RA itself is an important objective for future research.
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Affiliation(s)
- Sarah K Brode
- Joint Division of Respirology, University Health Network, Mount Sinai Hospital, Toronto; Westpark Healthcare Centre, Toronto; Department of Medicine, Management and Evaluation, University of Toronto, Toronto
| | - Frances B Jamieson
- Department of Laboratory Medicine and Pathobiology, Management and Evaluation, University of Toronto, Toronto; Public Health Ontario, Toronto
| | - Ryan Ng
- Department of Medicine, Management and Evaluation, University of Toronto, Toronto
| | | | - Jeffrey C Kwong
- Department of Medicine and Toronto Western Family Health Team, University Health Network, Mount Sinai Hospital, Toronto; Department of Family and Community Medicine, Management and Evaluation, University of Toronto, Toronto; Public Health Ontario, Toronto; Institute for Clinical Evaluative Sciences, Toronto
| | - J Michael Paterson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Institute for Clinical Evaluative Sciences, Toronto; Department of Family Medicine, McMaster University, Hamilton
| | - Ping Li
- Institute for Clinical Evaluative Sciences, Toronto
| | | | - Claire Bombardier
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Theodore K Marras
- Joint Division of Respirology, University Health Network, Mount Sinai Hospital, Toronto; Department of Medicine, Management and Evaluation, University of Toronto, Toronto.
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Zaldívar-Orta EL, Rodríguez-García A. Importancia del escrutinio para tuberculosis previo a la administración de agentes anti-TNF-α en uveítis: a propósito de un caso clínico. REVISTA MEXICANA DE OFTALMOLOGÍA 2014. [DOI: 10.1016/j.mexoft.2014.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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22
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Hatzara C, Hadziyannis E, Kandili A, Koutsianas C, Makris A, Georgiopoulos G, Vassilopoulos D. Frequent conversion of tuberculosis screening tests during anti-tumour necrosis factor therapy in patients with rheumatic diseases. Ann Rheum Dis 2014; 74:1848-53. [DOI: 10.1136/annrheumdis-2014-205376] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 05/03/2014] [Indexed: 11/04/2022]
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23
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Abstract
The use of biological agents and immunomodulators for inflammatory bowel disease (IBD) has remarkably improved disease management in the current era but at the same time has increased the risk of infectious complications. Patients with IBD on corticosteroids, immunomodulators, and biological agents are considered immunocompromised and are at risk for opportunistic infections. These are infections caused by organisms that take advantage of a weakened immune system, and cause disease, when they ordinarily would cause mild illness or no disease in an immunocompetent host. Risk factors for opportunistic infections include malnutrition, older age, congenital immunodeficiency, HIV infection, chronic diseases, and use of corticosteroids, immunomodulators, and anti-tumor necrosis factor alpha therapy. Apart from immunosuppressive medications and older age, there is only indirect evidence for above risk factors contributing directly to opportunistic infection risk in patients with IBD. Opportunistic infections in patients with IBD include viral infections (herpes viruses, human papillomavirus, influenza virus, and JC virus), bacterial infections (tuberculosis, nocardiosis, Clostridium difficile infection, pneumococcal infection, legionellosis, and listeriosis), fungal infections (histoplasmosis, cryptococcosis, Pneumocystis jirovecii infection, aspergillosis, and candidiasis), and parasite infections (Strongyloides stercoralis). Although these infections lead to high morbidity and mortality, only a minority of patients with IBD develop opportunistic infections. Currently, we lack a test to accurately predict patients at risk of opportunistic infection, and future research needs to focus on biomarkers or predictive models for risk stratification. Until such a test is developed, we need to screen, prevent, diagnose, and treat opportunistic infections in all patients with IBD in a timely manner.
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Cardoso IP, de Almeida NP, Gotardo DR, Cardeal M, Santana GO. Tuberculin skin testing in inflammatory bowel disease patients from an endemic area of Brazil. Braz J Infect Dis 2013; 18:60-4. [PMID: 24055308 PMCID: PMC9425264 DOI: 10.1016/j.bjid.2013.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/02/2013] [Accepted: 05/13/2013] [Indexed: 11/20/2022] Open
Abstract
Objective Inflammatory bowel disease (IBD) is a chronic disorder involving the gastrointestinal tract. Immunosuppressive drugs are usually prescribed to treat IBD patients, and this treatment can lead to tuberculosis reactivation. This paper aimed to analyze tuberculin skin test (TST) results in IBD patients at a reference center in Brazil. Methods We evaluated TST results in IBD patients using a cross-sectional study. We also analyzed the medical records of patients treated at a reference IBD outpatient unit where TST is routinely performed. Results We reviewed 119 medical records of 57 (47.9%) Crohn's disease (CD), 57 (47.9%) ulcerative colitis (UC) and 5 (4.2%) indeterminate colitis (IC) patients. The mean (SD) age was 43.5 (13.7) years old. TST was positive in 24 (20.2%) of the patients. TST was positive in 16/57 (28.1%) UC and 6/57 (10.5%) CD patients (prevalence ratio [PR] 2.7). Forty-one patients (34.5%) were taking immunosuppressive drugs (azathioprine or prednisone) at the time of the TST, and six of these patients (14.6%) had positive test results. Two patients using infliximab had negative TST results. Thirty-five of the 41 patients (85.4%) on immunosuppressive treatment were anergic compared with 73.1% (57/78) of the untreated patients (PR 1.2). Conclusions Patients with IBD have TST results similar to the general Brazilian population. Within the IBD population, CD patients have a lower frequency of TST positivity than UC patients.
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Affiliation(s)
- Ingrid Puig Cardoso
- Gastroenterology Unit, Roberto Santos General Hospital, Salvador, BA, Brazil; Bahia School of Medicine and Public Health, Salvador, BA, Brazil
| | | | - Daniela Rosa Gotardo
- Gastroenterology Unit, Roberto Santos General Hospital, Salvador, BA, Brazil; Bahia School of Medicine and Public Health, Salvador, BA, Brazil
| | | | - Genoile Oliveira Santana
- Gastroenterology Unit, Roberto Santos General Hospital, Salvador, BA, Brazil; Universidade Federal da Bahia (UFBA), Salvador, BA, Brazil
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Gin A, Dolianitis C. Multidrug resistant miliary tuberculosis during infliximab therapy despite tuberculosis screening. Australas J Dermatol 2013; 55:140-1. [DOI: 10.1111/ajd.12053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 03/07/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander Gin
- Department of Royal Melbourne Hospital; Melbourne Victoria Australia
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26
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Gao J, Jiang XL. Low-dose infliximab for corticosteroid-refractory ulcerative colitis: Impact of number of infusions on efficacy and safety. Shijie Huaren Xiaohua Zazhi 2013; 21:1453-1457. [DOI: 10.11569/wcjd.v21.i15.1453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the impact of number of infusions on efficacy and safety of low-dose infliximab in management of corticosteroid-refractory ulcerative colitis.
METHODS: Forty-one patients with corticosteroid-refractory ulcerative colitis were randomized into two groups: A (n = 20) and B (n = 21). The baseline characteristics of patients were similar between the two groups. Group A was treated with infliximab (3.5 mg/kg) at weeks 0 and 2, while group B was treated at weeks 0, 2 and 6. The mean duration was 4 wk. Corticosteroids and 5-aminosalicylates were maintained and gradually stopped after infliximab treatment. Clinical effect [clinical response, clinical remission, colonoscopic remission, Mayo score, erythrocyte sedimentation rate (ESR), C-Reactive protein (CRP), stool frequency] and safety were observed at 8 wk.
RESULTS: The clinical response rate, clinical remission rate and colonoscopic remission rate showed no significant differences between the two groups (70% vs 76%, 50% vs 52%, 55% vs 57%, all P < 0.05). The Mayo score, ESR, CRP and stool frequency decreased in both groups at 8 wk (all P < 0.05). Clinical response, clinical remission and colonoscopic remission were achieved in 30 (73%), 21 (51%), and 23 (56%) cases. Sixteen patients discontinued corticosteroid, and 14 patients were decreasing the dose of corticosteroid. Only 1 patient developed infusion reaction in the third therapy.
CONCLUSION: Low-dose infliximab (3.5 mg/kg) is effective and safe in management of Chinese patients with corticosteroid-refractory ulcerative colitis. The clinical response and remission rate are similar at 8 wk after the second therapy or the third therapy.
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Intestinal tuberculosis mimicking Crohn disease in infliximab-treated rheumatoid arthritis. J Clin Rheumatol 2013; 18:324. [PMID: 22955489 DOI: 10.1097/rhu.0b013e3182685ce3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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García-López A, Burgueño-Montañés C. Importance of tuberculosis screening before inhibiting tumour necrosis factor-alpha therapy. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2013; 88:36-39. [PMID: 23414947 DOI: 10.1016/j.oftal.2011.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 10/04/2011] [Accepted: 10/20/2011] [Indexed: 06/01/2023]
Abstract
INTRODUCTION There has been an increase in the incidence of tuberculosis infection in recent years, due to the increasing use of drugs inhibiting tumour necrosis factor-alpha (anti-TNFα) in the treatment of inflammatory diseases. CASE REPORT We report the case of a male patient being treated with infliximab (anti-TNFα) who developed disseminated tuberculosis with ocular involvement. CONCLUSION It is very important to conduct a proper screening to detect patients at risk for tuberculosis before starting treatment with these drugs. For this purpose, the QuantiFERON®-TB Gold in Tube (Interferon Gamma Release Assay, IGRA) is presented as an alternative screening test with high sensitivity and specificity.
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Affiliation(s)
- A García-López
- Servicio de Oftamología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
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29
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Sánchez-Moya A, García-Doval I, Carretero G, Sánchez-Carazo J, Ferrandiz C, Herrera Ceballos E, Alsina M, Ferrán M, López-Estebaranz JL, Gómez-García F, De la Cueva Dobao P, Carrascosa JM, Vanaclocha F, Belinchón I, Peral F, Dauden E. Latent tuberculosis infection and active tuberculosis in patients with psoriasis: a study on the incidence of tuberculosis and the prevalence of latent tuberculosis disease in patients with moderate-severe psoriasis in Spain. BIOBADADERM registry. J Eur Acad Dermatol Venereol 2012; 27:1366-74. [DOI: 10.1111/jdv.12011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Pneumonia Due to Legionella pneumophila in Patients Treated With Tumor Necrosis Factor-α Antagonists. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e31821bc8f9] [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]
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Picard C. [The lungs and immunosuppressants: practical problems]. REVUE DE PNEUMOLOGIE CLINIQUE 2011; 67:226-232. [PMID: 21920282 DOI: 10.1016/j.pneumo.2011.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 03/29/2011] [Indexed: 05/31/2023]
Abstract
With a growing number of patients receiving immunosuppressive drugs, lung specialists are faced with new problems. This review addresses: 1: specific interactions between some pre-existing respiratory diseases (asthma, bronchiectasis, infiltrative lung disease, repeated pneumonia, etc) and immunosuppressants; 2: some particular issues in the care of respiratory complications (infections, thoracic surgery, neoplasia, thromboembolism, etc) in patients undergoing immunosuppressive treatment.
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Affiliation(s)
- C Picard
- Service de Pneumologie et Transplantation Pulmonaire, Hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
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32
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Lioté H, Lioté F. Role for interferon-gamma release assays in latent tuberculosis screening before TNF-α antagonist therapy. Joint Bone Spine 2011; 78:352-7. [DOI: 10.1016/j.jbspin.2010.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2010] [Indexed: 01/10/2023]
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Orcau À, Caylà JA, Martínez JA. Present epidemiology of tuberculosis. Prevention and control programs. Enferm Infecc Microbiol Clin 2011; 29 Suppl 1:2-7. [DOI: 10.1016/s0213-005x(11)70011-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lioté H, Lioté F. Place des tests à l’interféron (IGRAs) dans le dépistage de la tuberculose latente (TBL) avant prescription d’agents anti-TNF : le point. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.rhum.2010.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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35
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Haroon M, Martin U, Devlin J. High incidence of intolerance to tuberculosis chemoprophylaxis. Rheumatol Int 2010; 32:33-7. [DOI: 10.1007/s00296-010-1571-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 07/11/2010] [Indexed: 10/19/2022]
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Maignen F, Hauben M, Tsintis P. Modelling the time to onset of adverse reactions with parametric survival distributions: a potential approach to signal detection and evaluation. Drug Saf 2010; 33:417-34. [PMID: 20397741 DOI: 10.2165/11532850-000000000-00000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND It has been postulated that the time to onset of adverse drug reactions is connected to the underlying pharmacological (or toxic) mechanism of adverse drug reactions whether the reaction is time dependent or not. OBJECTIVE We have conducted a preliminary study using the parametric modelling of the time to onset of adverse reactions as an approach to signal detection on spontaneous reporting system databases. METHODS We performed a parametric modelling of the reported time to onset of adverse drug reactions for which the underlying toxic mechanism is characterized. For the purpose of our study, we have used the reported liver injuries associated with bosentan, and the infections associated with the use of the tumour necrosis factor (TNF) inhibitors, adalimumab, etanercept and infliximab, which are used in Crohn's disease and rheumatoid arthritis, reported to EudraVigilance between December 2001 and September 2006. RESULTS The main results reflect the fact that the reported time to onset is a surrogate of the true time to onset of the reaction and combines three hazards (occurrence, diagnosis and reporting) that cannot be disentangled. Consequently, the modelling of the time to onset of reactions reported with TNF inhibitors showed differences that could reflect different pharmacological activities, indications, monitoring of the patients or different reporting patterns. These variations could also limit the interpretation of the parametric modelling. CONCLUSIONS Some consistency that was found between the occurrences of the infections with the TNF inhibitors suggests a causal association. There are statistical issues that are important to keep in mind when interpreting the results (the impact of the data quality on the fit of the distributions and the absence of a test of hypothesis linked to the absence of a relevant comparator). The study suggests that the modelling of the reported time to onset of adverse reactions could be a useful adjunct to other signal detection methods.
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Affiliation(s)
- François Maignen
- Pharmacovigilance and Risk Management Sector, European Medicines Agency, London, UK.
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Cerebral tuberculoma in a patient receiving anti-TNF alpha (adalimumab) treatment. Clin Rheumatol 2010; 29:1201-4. [PMID: 20419463 DOI: 10.1007/s10067-010-1466-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 04/07/2010] [Indexed: 12/18/2022]
Abstract
We report a case of a cerebral tuberculoma in a 60-year-old woman with rheumatoid arthritis while receiving the anti-tumor necrosis factor alpha monoclonal antibody, adalimumab (Humira), for active disease. MR brain imaging for dyspraxia revealed a left parietal ring-enhancing lesion, which on resection was shown to be a necrotizing granuloma. There were no associated pulmonary lesions, and the patient was systemically well. Sputum and urine cultures were negative for tuberculosis. The patient was treated with anti-tuberculous medications and made an excellent recovery. We consider this to be the first documented case of tuberculosis involving the central nervous system occurring in the setting of adalimumab treatment.
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Tuberculosis pulmonar en relación con adalimumab: estudio de 3 casos. Arch Bronconeumol 2010; 46:203-5. [DOI: 10.1016/j.arbres.2009.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 07/20/2009] [Accepted: 07/24/2009] [Indexed: 11/20/2022]
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Cappello M, Randazzo C, Rizzuto G, Bonura C, Di Vita G, Galia M. Splenic tuberculosis in a patient with Crohn's disease on infliximab: case report. Inflamm Bowel Dis 2010; 16:368-70. [PMID: 19591134 DOI: 10.1002/ibd.20998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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40
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Seow CH, de Silva S, Kaplan GG, Devlin SM, Ghosh S, Panaccione R. Managing the risks of IBD therapy. Curr Gastroenterol Rep 2010; 11:509-17. [PMID: 19903428 DOI: 10.1007/s11894-009-0077-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Successful management of the patient with inflammatory bowel disease (IBD) involves not only the induction and maintenance of remission, but also the optimization of the benefit-to-risk equation to achieve the greatest gain in quality of life. These risks range from intolerance to prescribed medications to potentially life-threatening sequelae (eg, sepsis) of immune suppression. A proper awareness of risk on the part of the physician and education of the patient can lead to early detection and institution of an appropriate management plan, including risk management and, optimally, primary prevention (eg, prophylactic vaccination). One should take the opportunity regularly to reassess the utility and efficacy of existing therapy, with the provision of ineffective therapies mandating urgent review. Overall, optimal management of the patient with IBD requires open dialogue between clinician and patient so that both are cognizant of the goals, benefits, and potential risks of therapy.
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Affiliation(s)
- Cynthia H Seow
- University of Calgary, TRW Building, Room 6D18, Calgary, Canada.
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42
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PARK JEONGHA, SEO GAYOUNG, LEE JINSOOK, KIM TAEHWAN, YOO DAEHYUN. Positive Conversion of Tuberculin Skin Test and Performance of Interferon Release Assay to Detect Hidden Tuberculosis Infection During Anti-Tumor Necrosis Factor Agent Trial. J Rheumatol 2009; 36:2158-63. [DOI: 10.3899/jrheum.090150] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objectives.To evaluate tuberculin skin tests (TST) and interferon-γ (IFN-γ) assay in the detection of latent tuberculosis (TB) infection during tumor necrosis factor (TNF) antagonist treatment in Korean patients with initial negative TST result.Methods.Eighty-six patients with rheumatic diseases who had received anti-TNF agents for over one year were investigated. Clinical data were obtained from medical records. All patients received followup TST, and IFN-γ assay was performed in 64.Results.The study population consisted of 40 rheumatoid arthritis (RA), 34 ankylosing spondylitis (AS), 9 juvenile rheumatoid arthritis (JRA), and 3 other patients. The TST converted to positive in 28 (32.6%) patients. There was no significant variation between TST conversion rate and all risk factors. Although there was no statistical significance, the odds of the TST conversion rate tended to increase with the duration of TNF antagonist administration. Nine (14.1%) of 64 patients who performed an IFN-γ assay had positive results. Among 28 TST positive conversion cases, 4 patients with AS and 1 with psoriatic arthritis had positive IFN-γ assay results, and one of them developed miliary TB. However, none of the 4 RA patients with positive IFN-γ assay showed TST conversion. There was 68.6% agreement (kappa = 0.29, p = 0.02) between TST and IFN-γ assay results.Conclusion.Serial TST with IFN-γ assay may be useful to identify false-negative response to cases of latent Mycobacterium tuberculosis infection and new TB infections in patients with immune mediated inflammatory diseases during longterm anti-TNF therapy, especially in areas with intermediate TB burden.
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Raychaudhuri SP, Nguyen CT, Raychaudhuri SK, Gershwin ME. Incidence and nature of infectious disease in patients treated with anti-TNF agents. Autoimmun Rev 2009; 9:67-81. [PMID: 19716440 DOI: 10.1016/j.autrev.2009.08.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2009] [Indexed: 12/19/2022]
Abstract
Tumor necrosis factor alpha (TNF-alpha) inhibitors offer a targeted therapeutic strategy that contrasts with the nonspecific immunosuppressive agents traditionally used to treat most inflammatory diseases. These biologic agents have had a significant impact in ameliorating the signs and symptoms of inflammatory rheumatoid disease and improving patient function. From the onset of clinical trials, a central concern of cytokine blockade has been a potential increase in susceptibility to infections. Not surprisingly, a variety of infections have been reported in association with the use of TNF-alpha inhibitor agents. In particular, there is evidence suggesting an increased rate of granulomatous infections in patients treated with monoclonal TNF-alpha inhibitors. This review provides the incidence and nature of infections in patients treated with TNF-alpha inhibitor agents and reminds the clinician of the required vigilance in monitoring patients.
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Silva LCR, Silveira GG, Arnone M, Romiti R, Geluk A, Franken KCLM, Duarte AJDS, Takahashi MDF, Benard G. Decrease in Mycobacterium tuberculosis specific immune responses in patients with untreated psoriasis living in a tuberculosis endemic area. Arch Dermatol Res 2009; 302:255-62. [DOI: 10.1007/s00403-009-0982-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 04/24/2009] [Accepted: 07/01/2009] [Indexed: 11/28/2022]
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Diel R, Hauer B, Loddenkemper R, Manger B, Krüger K. Empfehlungen für das Tuberkulose-Screening vor Gabe von TNF-α-Inhibitoren bei rheumatischen Erkrankungen. Z Rheumatol 2009; 68:411-6. [PMID: 19513727 DOI: 10.1007/s00393-009-0475-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- R Diel
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin
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Papa A, Mocci G, Bonizzi M, Felice C, Andrisani G, De Vitis I, Guidi L, Gasbarrini A. Use of infliximab in particular clinical settings: management based on current evidence. Am J Gastroenterol 2009; 104:1575-86. [PMID: 19491875 DOI: 10.1038/ajg.2009.162] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the increasingly widespread use of the anti-tumor necrosis factor-alpha agent infliximab for the treatment of Crohn's disease and ulcerative colitis, there have been some concerns raised about the potential consequences of such therapy in particular clinical settings. In this review, we report the current strategies for optimizing treatment outcomes and minimizing the risks of some of the most serious events attributable to infliximab therapy. In particular, an up-to-date overview is provided on how to treat patients with inflammatory bowel disease using infliximab therapy, with regard to the diagnosis and management of latent tuberculosis infection and the risk of reactivation of hepatitis B and C infections. Furthermore, based on the available evidence, we evaluate the possibility of using infliximab during pregnancy. Finally, we evaluate whether patients with malignancies or pre-neoplastic lesions could be candidates for infliximab therapy. Overall, this review will provide physicians who use infliximab for the treatment of inflammatory bowel disease with several practical recommendations for the management of some complex situations that may occur in daily clinical practice.
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Affiliation(s)
- Alfredo Papa
- Gastroenterology Unit, Department of Internal Medicine, Catholic University of Rome, Largo A. Gemelli 8, Rome, Italy.
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Hoentjen F, van Bodegraven AA. Safety of anti-tumor necrosis factor therapy in inflammatory bowel disease. World J Gastroenterol 2009; 15:2067-73. [PMID: 19418577 PMCID: PMC2678575 DOI: 10.3748/wjg.15.2067] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD), in particular Crohn’s disease refractory to conventional therapy, fistulizing Crohn’s disease and chronic active ulcerative colitis, generally respond well to anti-tumor necrosis factor (TNF) therapy. However, serious side effects do occur, necessitating careful monitoring of therapy. Potential side effects of anti-TNF therapy include opportunistic infections, which show a higher incidence when concomitant immunosuppression is used. Furthermore, antibody formation against anti-TNF is associated with decreased efficacy and an increased frequency of infusion reactions. The hypothesis of a slightly increased risk of lymphomas in IBD patients treated with anti TNF-therapy is debatable, since most studies lack the specific design to properly address this issue. Alarmingly, the occurrence of hepatosplenic T-cell lymphomas coincides with combined immunosuppressive therapy. Despite the potential serious side effects, anti-TNF therapy is an effective and relatively safe treatment option for refractory IBD. Future research is needed to answer important questions, such as the long-term risk of malignancies, safety during pregnancy, when to discontinue and when to switch anti-TNF therapy, as well as to determine the balance between therapeutic and toxic effects.
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Abstract
With the changing epidemiology of Crohn's disease (CD) and intestinal tuberculosis (ITB), we are in an era where the difficulty facing physicians in discriminating between the two diseases has increased, and the morbidity and mortality resulting from a delayed diagnosis or misdiagnosis is considerably high. In this article, we examine the changing trends in the epidemiology of CD and ITB, in addition to clinical features that aid in the differentiation of both diseases. The value of various laboratory, serological, and the tuberculin skin tests are reviewed as well. The use of an interferon-gamma-release assay, QuantiFERON-TB Gold, in the workup of these patients and its value in populations where the bacillus Calmette-Guérin vaccine is still administered is discussed. Different radiological, endoscopic, and pathological similarities and features that can aid the clinician in reaching a rapid diagnosis are reviewed as well. The association between mycobacteria and CD, the concerns with the practice of antituberculosis medication trials in areas where tuberculosis (TB) is endemic, as well as extrapulmonary TB induced by the use of antitumor necrosis factor-alpha agents are delineated in this article. Furthermore, we propose an algorithm for the investigation of patients in whom the differential diagnosis encompasses CD and ITB.
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Lioté H. Tuberculose, agents anti-TNF et autres immunosuppresseurs : évolution des stratégies de prévention. Rev Mal Respir 2008; 25:1237-49. [DOI: 10.1016/s0761-8425(08)75089-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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50
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Abstract
Psoriasis is a chronic, immune mediated inflammatory disease characterized by increased cell signalling via cytokines and chemokines on a background of up-regulated gene expression. There is substantial evidence that psoriasis should be regarded as more than a cutaneous disease; major psychological morbidity and increased mortality from cardiovascular disease and cancer are increasingly recognized. Improved understanding of the genetic and immunological mechanisms underpinning psoriasis has occurred concurrently with the development of targeted biological therapies including infliximab. These newer therapeutic approaches can be very effective but their long term safety profile is not yet fully determined.
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Affiliation(s)
- JA Leman
- Alan Lyell Centre for Dermatology, Western Infirmary, Glasgow, UK
| | - AD Burden
- Alan Lyell Centre for Dermatology, Western Infirmary, Glasgow, UK
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