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D'Gama JD, Bermas BL. Safety of biologic agents for the management of rheumatic diseases during pregnancy. Curr Opin Rheumatol 2024; 36:184-190. [PMID: 38456470 DOI: 10.1097/bor.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW To discuss the current understanding regarding the use of biologic therapeutics in pregnancy. RECENT FINDINGS Our understanding of the mechanisms underlying the potential fetal and infant exposure to biologics as well as a growing body of empirical evidence from real world use of biologics in pregnancy have demonstrated that biologics are generally compatible preconception and during pregnancy. Long-term effects of exposure to biologic agents in utero are not known, but will be uncovered in time. Biosimilars, which are becoming more popular, may not always share the same safety profiles as their originators. SUMMARY Biologics have revolutionized the management of rheumatologic disease and ushered in a new era of clinical remission among patients. These agents, developed and introduced into clinical use at the beginning of the new millennium, are very potent, yet their efficacy in treating disease often in reproductive aged women, raises questions regarding their safety during pregnancy. These therapeutics can cause immunosuppression and can inhibit immunologic circuits that are not only involved in disease pathophysiology but hypothetically could impact the development of the fetal immune system. Reassuringly, biologics, typically antibodies or antibody-based proteins, are introduced to the fetus via the typical route of transplacental antibody transfer, and thus only begin to be transferred in appreciable amounts in the second trimester (after organogenesis). From theoretic and empirical standpoints, biologic use during pregnancy appears well tolerated for fetal development and to not substantially affect infant immune development.
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Affiliation(s)
- Jonathan D D'Gama
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Mills BS, Bermas BL. Pregnancy and the Autoimmune Patient. Curr Allergy Asthma Rep 2024:10.1007/s11882-024-01143-z. [PMID: 38563848 DOI: 10.1007/s11882-024-01143-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW This article will review the current understanding of the immunologic changes that occur during pregnancy. It will discuss the impact of pregnancy on the disease activity of autoimmune or inflammatory rheumatic diseases (AIRD). Lastly, it will highlight the most recent data on pre-conception and pregnancy management practices that can improve pregnancy outcomes in autoimmune patients. RECENT FINDINGS Pregnancy is an immunologically complex and dynamic state that may affect the activity of AIRDs, with more patients having active disease during pregnancy than previously thought. Uncontrolled inflammatory diseases are associated with poor pregnancy outcomes such as preeclampsia, small for gestational age infants, and prematurity. Pre-conception counseling and early pregnancy planning discussions can help ensure optimal disease control and medication management prior to attempting conception. Adequate control of AIRDs on pregnancy-compatible medications during the pre-conception, pregnancy, and postpartum periods is required for optimal pregnancy outcomes.
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Affiliation(s)
- Brooke S Mills
- University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas, TX, 75390, USA
| | - Bonnie L Bermas
- University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas, TX, 75390, USA.
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Tarter L, Bermas BL. Expert Perspective on a Clinical Challenge: Lupus and Pregnancy. Arthritis Rheumatol 2024; 76:321-331. [PMID: 37975160 DOI: 10.1002/art.42756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
Systemic lupus erythematosus (SLE), a multiorgan systemic inflammatory disorder, predominantly affects women during their reproductive years. In this review, we summarize the state of knowledge about preconception planning and management of SLE during pregnancy. Achieving remission or low disease activity for several months on medications compatible with pregnancy prior to conception is essential to decreasing the risk of disease flare and improving pregnancy outcomes, including pre-eclampsia, preterm birth, and intrauterine growth restriction. With close management and well-controlled disease before and during pregnancy, <10% of patients flare. All patients with SLE should remain on hydroxychloroquine unless contraindicated. Expectant mothers with a history of antiphospholipid syndrome should be treated with anticoagulant therapy during pregnancy. Women with anti-Ro/SSA or anti-La/SSB antibodies require additional monitoring because their offspring are at increased risk for congenital heart block. Patients with SLE should be offered low-dose aspirin starting at the end of the first trimester to reduce the risk of pre-eclampsia. Flares of SLE during pregnancy require escalation of therapy. The immunosuppressives azathioprine, tacrolimus, and cyclosporine are compatible with pregnancy, and biologic agents can also be considered. Glucocorticoid use in pregnancy should be limited to the lowest effective dose. Mycophenolate mofetil/mycophenolic acid, methotrexate, leflunomide, and cyclophosphamide are known to be teratogenic and are contraindicated in pregnancy. Distinguishing a flare of lupus nephritis during pregnancy from pre-eclampsia can be particularly challenging. Overall, outcomes in pregnancy for women with lupus are improving, but gaps in knowledge about optimal management strategies persist.
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Affiliation(s)
- Laura Tarter
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Bonnie L Bermas
- University of Texas Southwestern Medical Center, Dallas, Texas
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Bermas BL, Blanco I, Ramsey-Goldman R, Blazer AD, Clowse MEB, Edens C, Donley G, Pierce L, Wright C, Birru Talabi M. The impact of US abortion policy on rheumatology clinical practice: a cross-sectional survey of rheumatologists. Arthritis Rheumatol 2024; 76:485-486. [PMID: 37706661 DOI: 10.1002/art.42699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Bonnie L Bermas
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Irene Blanco
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ashira D Blazer
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | - Cuoghi Edens
- University of Chicago Medicine, Chicago, Illinois
| | - Greer Donley
- University of Pittsburgh School of Law, Pittsburgh, Pennsylvania
| | - Leslie Pierce
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Catherine Wright
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Bermas BL, Gerber DE. The Joint Problem of Rheumatoid Arthritis and Lung Cancer. J Thorac Oncol 2024; 19:196-198. [PMID: 38325979 DOI: 10.1016/j.jtho.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 02/09/2024]
Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David E Gerber
- Division of Hematology-Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas; Peter O'Donnell, Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas.
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Bermas BL, Sammaritano LR. Complementing What We Know About Systemic Lupus Erythematosus Pregnancy. J Rheumatol 2023; 50:1203-1204. [PMID: 37582557 DOI: 10.3899/jrheum.2023-0432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Affiliation(s)
- Bonnie L Bermas
- B.L. Bermas, MD, Division of Rheumatic Diseases, UTSouthwestern Medical Center, Dallas, Texas;
| | - Lisa R Sammaritano
- L.R. Sammaritano, MD, Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical School, New York, New York, USA
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Mineo C, Shaul PW, Bermas BL. The pathogenesis of obstetric APS: a 2023 update. Clin Immunol 2023; 255:109745. [PMID: 37625670 DOI: 10.1016/j.clim.2023.109745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023]
Abstract
The antiphospholipid syndrome (APS) is an autoimmune disease characterized by the persistent presence of antibodies directed against phospholipids and phospholipid-binding proteins that are associated with thrombosis and pregnancy-related morbidity. The latter includes fetal deaths, premature birth and maternal complications. In the early 1990s, a distinct set of autoantibodies, termed collectively antiphospholipid antibodies (aPL), were identified as the causative agents of this disorder. Subsequently histological analyses of the placenta from APS pregnancies revealed various abnormalities, including inflammation at maternal-fetal interface and poor placentation manifested by reduced trophoblast invasion and limited uterine spiral artery remodeling. Further preclinical investigations identified the molecular targets of aPL and the downstream intracellular pathways of key placental cell types. While these discoveries suggest potential therapeutics for this disorder, definitive clinical trials have not been completed. This concise review focuses on the recent developments in the field of basic and translational research pursuing novel mechanisms underlying obstetric APS.
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Affiliation(s)
- Chieko Mineo
- Center for Pulmonary and Vascular Biology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Philip W Shaul
- Center for Pulmonary and Vascular Biology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
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8
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Schreiber K, Giles I, Costedoat-Chalumeau N, Nelson-Piercy C, Dolhain RJ, Mosca M, Förger F, Fischer-Betz R, Molto A, Tincani A, Pasquier E, Marin B, Elefant E, Salmon J, Bermas BL, Sammaritano L, Clowse MEB, Chambers C, Buyon J, Inoue SA, Agmon-Levin N, Aguilera S, Emadi SA, Andersen J, Andrade D, Antovic A, Arnaud L, Christiansen AA, Avcin T, Badreh-Wirström S, Bertsias G, Bini I, Bobirca A, Branch W, Brucato A, Bultink I, Capela S, Cecchi I, Cervera R, Chighizola C, Cobilinschi C, Cuadrado MJ, Dey D, Etomi O, Espinosa G, Flint J, Fonseca JE, Fritsch-Stork R, Gerosa M, Glintborg B, Skorpen CG, Goulden B, Graversgaard C, Gunnarsson I, Gupta L, Hetland M, Hodson K, Hunt BJ, Isenberg D, Jacobsen S, Khamashta M, Levy R, Linde L, Lykke J, Meissner Y, Moore L, Morand E, Navarra S, Opris-Belinski D, Østensen M, Ozawa H, Perez-Garcia LF, Petri M, Pons-Estel GJ, Radin M, Raio L, Rottenstreich A, Ruiz-Irastorza G, Tunjić SR, Rygg M, Sciascia S, Strangfeld A, Svenungsson E, Tektonidou M, Troldborg A, Vinet E, Vojinovic J, Voss A, Wallenius M, Andreoli L. Global comment on the use of hydroxychloroquine during the periconception period and pregnancy in women with autoimmune diseases. Lancet Rheumatol 2023; 5:e501-e506. [PMID: 38251494 DOI: 10.1016/s2665-9913(23)00215-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Karen Schreiber
- Danish Centre for Expertise in Rheumatology (CeViG), Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark (KS); Institute for Regional Health, Southern Danish University, Odense, Denmark.
| | - Ian Giles
- Centre for Rheumatology, UCL Division of Medicine, London, UK
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de Référence Maladies Auto-Immunes et Systémiques Rares, Paris, France; Université Paris Cité, Paris, France
| | - Catherine Nelson-Piercy
- Department of Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK (CN-P, OE)
| | - Radboud Jem Dolhain
- Erasmus MC, University Medical Centre, Department of Rheumatology, Rotterdam, Netherlands
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Frauke Förger
- Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
| | - Rebecca Fischer-Betz
- Department for Rheumatology and Hiller Research Institute, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Anna Molto
- Rheumatology Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili and University, Brescia, Italy
| | - Elisabeth Pasquier
- Département de Médecine Interne et Pneumologie, CHRU de Brest, Hôpital de la Cavale Blanche, Brest, France; INSERM, Centre d'Investigation Clinique 1412, CHRU de Brest, Brest, France
| | - Benoit Marin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Trousseau, Département de Santé Publique, Centre de Référence sur les Agents Tératogènes, F75012, Paris, France
| | - Elisabeth Elefant
- AP-HP, Sorbonne Université, Hôpital Trousseau, Département de Santé Publique, Centre de Référence sur les Agents Tératogènes, F75012, Paris, France
| | - Jane Salmon
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York, USA
| | | | - Lisa Sammaritano
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christina Chambers
- Department of Paediatrics, University of California, San Diego, La Jolla, CA, USA
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Saori Abe Inoue
- Department of Rheumatology, Institute of Medicine, University of Tsukuba, Japan
| | - Nancy Agmon-Levin
- The Zabludowicz Centre for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Danieli Andrade
- Rheumatology, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Aleksandra Antovic
- Department of Medicine, Division of Rheumatology Karolinska Institutet and Rheumatology, Karolinska University Hospital Stockholm, Sweden
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Centre National de Références Maladies Auto-Immunes, Strasbourg, France
| | - Alice Ashouri Christiansen
- Danish Center for Expertise in Rheumatology, Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sara Badreh-Wirström
- Senior European and Regulatory Affairs Project Manager, EULAR PARE, Brussels, Belgium
| | - George Bertsias
- Rheumatology, University of Crete School of Medicine, Iraklio, Greece; Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | | | - Anca Bobirca
- Department of Internal Medicine and Rheumatology, Dr I Cantacuzino Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ware Branch
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milano, Fatebenefratelli Hospital, Milano, Italy
| | - Irene Bultink
- Department of Rheumatology, Amsterdam Rheumatology and immunology Centre, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Susanna Capela
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte EPE, Faculty of Medicine, University of Lisbon, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Irene Cecchi
- Centre of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, San Giovanni Hospital, Turin, Italy
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Cecilia Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Paediatric Rheumatology Unit, ASST Pini, CTO, Milan, Italy
| | - Claudia Cobilinschi
- Department of Internal Medicine and Rheumatology Sânta Maria Clinical Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Dzifa Dey
- Rheumatology Unit, Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, University of Ghana Medical School, Accra, Ghana
| | - Oseme Etomi
- Department of Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK (CN-P, OE)
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, University of Barcelona, Barcelona, Spain
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - João-Eurico Fonseca
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa and Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Ruth Fritsch-Stork
- Health Care Centre Mariahilf, ÖGK and Rheumatology Department at the Sigmund Freud Private University, Vienna, Austria
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, Research Centre for Adult and Paediatric Rheumatic Diseases, University of Milan, Milan, Italy; Clinical Rheumatology Unit, ASST G Pini and CTO, Milan, Italy
| | - Bente Glintborg
- DANBIO and Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Carina Gøtestam Skorpen
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway; Department of Rheumatology Ålesund, Helse More og Romsdal, Ålesund, Norway
| | - Bethan Goulden
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Centre for Rheumatology Research, UCL Division of Medicine, University College London, London; Women's Health, University College London Hospital, London, UK
| | - Christine Graversgaard
- Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark; Department of Rheumatology, Aarhus Universitetshospital, Aarhus, Denmark
| | - Iva Gunnarsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden; Solna and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Latika Gupta
- Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK; Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK; Department of Rheumatology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Merete Hetland
- DANBIO and Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ken Hodson
- UK Teratology Information Service, Newcastle upon Tyne, UK
| | - Beverley J Hunt
- Thrombosis and Haemophilia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Isenberg
- Centre for Rheumatology, UCL Division of Medicine, London, UK
| | - Søren Jacobsen
- Copenhagen Research Centre for Autoimmune Connective Tissue Diseases, COPEACT, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Louise Linde
- Copenhagen Research Centre for Autoimmune Connective Tissue Diseases, Lupus and Vasculitis Clinic, Copenhagen university hospital, Rigshospitalet, Denmark
| | - Jacob Lykke
- Department of Obstetrics, Copenhagen university hospital, Rigshospitalet, Denmark
| | - Yvette Meissner
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Germany
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Services, Harold's Cross, Dublin, Ireland
| | - Eric Morand
- Centre for Inflammatory Disease, Monash University, Melbourne, VIC, Australia
| | - Sandra Navarra
- Centre for Inflammatory Disease, Monash University, Melbourne, VIC, Australia
| | - Daniela Opris-Belinski
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines; Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Monika Østensen
- Department of Rheumatology, Sorlandet Hospital Kristiansand, Kristiansand, Norway (MØ)
| | - Hiroki Ozawa
- Immuno-Rheumatology Centre, St Luke's International Hospital, Tokyo, Japan
| | | | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Massimo Radin
- Centre of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, San Giovanni Hospital, Turin, Italy
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Amihai Rottenstreich
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra and Northwell, New York, NY, USA; Laboratory of Blood and Vascular Biology, Rockefeller University, New York, NY, USA; Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, University of the Basque Country, Bizkaia, Spain
| | | | - Marite Rygg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Pediatrics, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Savino Sciascia
- Centre of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, San Giovanni Hospital, Turin, Italy
| | - Anja Strangfeld
- Epidemiology and Health Care Research, German Rheumatism Research Center Berlin, Berlin, Germany
| | - Elisabet Svenungsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Tektonidou
- First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anne Troldborg
- Department of Rheumatology, Aarhus University Hospital, and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Evelyne Vinet
- McGill University, McGill University Health Centre, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jelena Vojinovic
- University of Nis, Faculty of Medicine, Clinic for Pediatrics University Clinical Center Nis, Nis, Serbia
| | - Anne Voss
- Department of Rheumatology C, Odense University Hospital, Odense, Denmark
| | - Marianne Wallenius
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, Trondheim University Hospital, St Olavs Hospital, Trondheim, Norway; Department of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology Unit, Spedali Civili and University of Brescia, Brescia, Italy
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Abstract
Family planning in women with vasculitis requires an interdisciplinary approach. This article summarizes recommendations and guidance for each phase of family planning in persons with vasculitis including preconception counseling, birth control, pregnancy, and breastfeeding. Pregnancy complications are presented by category of vasculitis with accompanying diagnostic and therapeutic recommendations. Birth control and assisted reproductive technology options are reviewed with special considerations for women who are high risk or have a history of blood clots. This article can be used as a clinical reference for reproductive discussions in all patients with vasculitis.
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Affiliation(s)
- Catherine A Sims
- Division of Rheumatology, Duke University, 1021 Red Hat Lane, Durham, NC 27713, USA.
| | - Bonnie L Bermas
- University of Texas Southwestern, 2001 Inwood Road, Dallas, TX 75235, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University, 40 Duke Medicine Circle Clinic 1J, Durham, NC 27713, USA
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Abstract
PURPOSE OF REVIEW Immune check point inhibitors (ICIs) are a unique class of cancer treatments that harness the body's innate antitumor response. Although these medications have transformed oncology care, they also lead to generalized immune activation that can result in toxicities across a spectrum of organ systems called immune-related adverse events. This article reviews the most common rheumatologic immune-related adverse events and their management. RECENT FINDINGS Inflammatory arthritis, polymyalgia rheumatic, sicca symptoms, systemic sclerosis, myositis, and vasculitis have all been reported as ICI adverse events. Treatment includes nonsteroidal anti-inflammatory drugs, glucocorticoids, traditional DMARDs, and biologics. SUMMARY Rheumatologists have an important role in the management of patients with rheumatologic immune-related adverse events. Working with our oncology colleagues, we can help manage rheumatologic immune-related adverse events while optimally preserving ICI's antitumor effects.
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Affiliation(s)
- Melissa Defoe
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Bermas BL, Feldman CH. Assessing Systemic Lupus Erythematosus Care: Myopic Evaluations and the Elephant in the Room. Arthritis Care Res (Hoboken) 2022; 75:1194-1195. [PMID: 36576028 DOI: 10.1002/acr.25079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Affiliation(s)
| | - Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Bermas BL. The Unintended Consequence of the Overturn of Roe v Wade: Restrictions on Methotrexate Use. J Rheumatol 2022; 49:1284-1285. [DOI: 10.3899/jrheum.220782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bermas BL, Blanco I, Blazer AD, Clowse ME, Edens C, Ramsey-Goldman R, Birru Talabi M. Overturning Roe v. Wade: Toppling the Practice of Rheumatology. Arthritis Rheumatol 2022; 74:1865-1867. [PMID: 36128693 DOI: 10.1002/art.42336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Ashira D Blazer
- Weill Cornell Medicine, Hospital for Special Surgery, New York, NY
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Walker AM, Bermas BL, Jacobe HT. Morphea disease activity during pregnancy: A case series. J Dermatol 2022; 49:1278-1283. [DOI: 10.1111/1346-8138.16572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/29/2022] [Accepted: 08/21/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Amanda M. Walker
- Department of Dermatology University of Texas Southwestern Medical Center Dallas Texas USA
| | - Bonnie L. Bermas
- Department of Rheumatology University of Texas Southwestern Medical Center Dallas Texas USA
| | - Heidi T. Jacobe
- Department of Dermatology University of Texas Southwestern Medical Center Dallas Texas USA
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15
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Ciosek AL, Makris UE, Kramer J, Bermas BL, Solow EB, Wright T, Bitencourt N. Health Literacy and Patient Activation in the Pediatric to Adult Transition in Systemic Lupus Erythematosus: Patient and Health Care Team Perspectives. ACR Open Rheumatol 2022; 4:782-793. [PMID: 35716025 PMCID: PMC9469480 DOI: 10.1002/acr2.11474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/01/2022] [Accepted: 05/19/2022] [Indexed: 11/05/2022] Open
Abstract
Objective Methods Results Conclusion
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Affiliation(s)
| | - Una E. Makris
- University of Texas Southwestern Medical Center and Veterans Administration North Texas Health Care System Dallas
| | | | | | | | - Tracey Wright
- University of Texas Southwestern Medical Center, Texas Scottish Rite Hospital for Children, and Children's Health Dallas Dallas Texas
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16
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Solow EB, Bermas BL. Hydroxychloroquine: Heart-Throb No More? J Am Coll Cardiol 2022; 80:47-49. [PMID: 35772916 DOI: 10.1016/j.jacc.2022.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- E Blair Solow
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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17
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Saez C, Nassi L, Wright T, Makris UE, Kramer J, Bermas BL, Solow EB, Bitencourt N. Therapeutic recreation camps for youth with childhood-onset systemic lupus erythematosus: perceived psychosocial benefits. Pediatr Rheumatol Online J 2022; 20:39. [PMID: 35672791 PMCID: PMC9171737 DOI: 10.1186/s12969-022-00702-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/02/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The psychosocial burden of having a chronic disease can be substantial for adolescents with childhood-onset systemic lupus erythematosus (cSLE). Current literature is scarce on interventions that can improve psychosocial outcomes for this population. Therapeutic recreation camps have been proposed as a beneficial experience for chronically ill pediatric populations. However, their effective components have not been well characterized in patients with cSLE. In this study, we sought to understand the various components of the camp experience for adolescents with cSLE from both the patient and parent perspective. METHODS We recruited patients with cSLE who had participated in one or more annual, weekend-long recreational lupus camp(s) near Dallas, Texas. Semi-structured in-depth telephone interviews were conducted from March-June 2020 with both the patients and parents. Questions focused on overall patient experience, psychosocial impact of camp participation, coping skills gained, and opportunities to prepare for the transition from pediatric to adult care. Interviews were coded and analyzed using inductive thematic analysis. RESULTS We interviewed 9 current and former campers (ages 16-24), including a current camp counselor, and 3 of their parents separately. Reported benefits included a positive impact on social support through peer bonding, opportunities to develop coping mechanisms through structured activities and peer/medical staff interactions, opportunities for education about the cSLE disease experience, improved adherence through peer modeling, overall increase in self-efficacy, and better parental insight into the patient experience. Participants also provided suggestions for expansion and improvement in program development to optimize educational opportunities for both campers and parents. In addition, they advocated for longitudinal social support and community building. CONCLUSIONS In this qualitative study, in which cSLE patients and their parents reflected on their experiences with therapeutic recreation camps, we found several perceived benefits impacting the patient and parent experience. Participants expressed a desire for more educational opportunities that could contribute to their successful transition from pediatric to adult care. Further studies are needed to demonstrate the effects of therapeutic recreation camps on the psychosocial health of this population.
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Affiliation(s)
- Cristina Saez
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - Lorien Nassi
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA ,grid.416991.20000 0000 8680 5133Texas Scottish Rite Hospital for Children, Dallas, Texas USA
| | - Tracey Wright
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA ,grid.416991.20000 0000 8680 5133Texas Scottish Rite Hospital for Children, Dallas, Texas USA
| | - Una E. Makris
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA ,grid.422201.70000 0004 0420 5441Veterans Administration North Texas Health Care System, Dallas, Texas USA
| | - Justin Kramer
- grid.264756.40000 0004 4687 2082Texas A&M University, College Station, Texas USA
| | - Bonnie L. Bermas
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - E. Blair Solow
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - Nicole Bitencourt
- Loma Linda University Medical Center, 11175 Campus Street, Coleman Pavilion, Loma Linda, CA, 92354, USA.
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18
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Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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19
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Pryor KP, Albert B, Desai S, Ritter SY, Tarter L, Coblyn J, Bermas BL, Santacroce LM, Dutton C, Braaten KP, Pace LE, Rexrode K, Janiak E, Feldman CH. Pregnancy Intention Screening in Patients With Systemic Rheumatic Diseases: Pilot Testing a Standardized Assessment Tool. ACR Open Rheumatol 2022; 4:682-688. [PMID: 35639495 PMCID: PMC9374050 DOI: 10.1002/acr2.11449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/26/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Systemic rheumatic conditions affect reproductive-aged patients and often require potentially teratogenic medications. We assessed the feasibility and impact of a standardized pregnancy intention screening question (One Key Question [OKQ]) in a large academic rheumatology practice. METHODS This 6-month pilot quality improvement initiative prompted rheumatologists to ask female patients aged 18 to 49 years about their pregnancy intentions using OKQ. We administered surveys to assess rheumatologists' barriers to and comfort with reproductive health issues. We performed chart reviews to assess uptake and impact on documentation, comparing charts with OKQ documented with 100 randomly selected charts eligible for pregnancy intention screening but without OKQ documented. RESULTS When we compared 32 of 43 preimplementation responses with 29 of 41 postimplementation responses, the proportion of rheumatologists who reported they were very comfortable with assessing their patients' reproductive goals increased (31%-38%) and the proportion reporting obstetrics and gynecology (OB/GYN) referral challenges as barriers to discussing reproductive goals decreased (41%-21%). During the implementation period, 83 of 957 (9%) eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (odds ratio 2.42, 95% confidence interval 1.21-4.85). Screened patients were more likely to have their contraceptive method documented (P < 0.001) and more likely to have been referred to OB/GYN for follow-up (P = 0.003) compared with patients who were not screened with OKQ. CONCLUSION Although uptake was low, this tool improved provider comfort with assessing reproductive goals, the quality of documentation, and the likelihood of OB/GYN referral. Future studies should examine whether automated medical record alerts to prompt screening increase uptake.
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Affiliation(s)
- Katherine P Pryor
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bill Albert
- Power to Decide, Washington, District of Columbia
| | - Sonali Desai
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan Y Ritter
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Tarter
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jonathan Coblyn
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Leah M Santacroce
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Caryn Dutton
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kari P Braaten
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lydia E Pace
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kathryn Rexrode
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Janiak
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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20
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Castro-Gutierrez A, Young K, Bermas BL. Pregnancy and Management in Women with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Obstetric Antiphospholipid Syndrome. Rheum Dis Clin North Am 2022; 48:523-535. [PMID: 35400376 DOI: 10.1016/j.rdc.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Management of women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and obstetric antiphospholipid syndrome (APS) during pregnancy presents unique clinical challenges. Women with both RA and SLE can have disease flares during pregnancy, leading to pregnancy complications, such as preeclampsia, small-for-gestational-age infants, and preterm delivery. Disease should be under control prior to conception. Women with obstetric APS need to be anticoagulated during pregnancy. Many but not all antirheumatic medications can be used during pregnancy and lactation.
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Affiliation(s)
| | - Kristen Young
- UT Southwestern Medical Center, 2001 Inwood Road, Dallas, TX 75390, USA
| | - Bonnie L Bermas
- UT Southwestern Medical Center, 2001 Inwood Road, Dallas, TX 75390, USA.
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21
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Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas (B.L.B.)
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22
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Abstract
Systemic lupus erythematosus (SLE) affects reproductive aged women. Issues regarding family planning are an important part of SLE patient care. Women with SLE can flare during pregnancy, in particular those who have active disease at conception or prior history of renal disease. These flares can lead to increased adverse pregnancy outcomes including fetal loss, pre-eclampsia, preterm birth and small for gestational aged infants. In addition, women with antiphospholipid antibodies can have thrombosis during pregnancy or higher rates of fetal loss. Women who have anti-Ro/SSA and anti-La/SSB antibodies need special monitoring as their offspring are at risk for congenital complete heart block and neonatal lupus. Ideally, SLE patients should have their disease under good control on medications compatible with pregnancy prior to conception. All patients with SLE should remain on hydroxychloroquine unless contraindicated. We recommend the addition of 81mg/d of aspirin at the end of the first trimester to reduce the risk of pre-eclampsia. The immunosuppressive azathioprine, tacrolimus and cyclosporine are compatible with pregnancy and lactation, mycophenolate mofetil (MMF)/mycophenolic acid are not. Providers should use glucocorticoids at the lowest possible dose. Methotrexate, leflunomide and cyclophosphamide are contraindicated in pregnancy and lactation. SLE patients on the biologics rituximab, belimumab and abatacept can continue these medications until conception and resume during lactation.
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Affiliation(s)
- Kathryn H Dao
- Division of Rheumatic Diseases, UTSouthwestern Medical Center, Dallas, TX, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, UTSouthwestern Medical Center, Dallas, TX, USA
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23
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Bermas BL, Gianfrancesco M, Tanner HL, Seet AM, Aguiar MC, Al Adhoubi NK, Al Emadi S, Cunha BM, Flood R, Kusevich DA, McCarthy EM, Patel NJ, Ruderman EM, Sattui SE, Sciascia S, Siddique F, Valenzuela-Almada MO, Wise LM, Worthing AB, Zell J, Bhana S, Costello W, Duarte-Garcia A, Grainger R, Gossec L, Hausmann JS, Hyrich K, Lawson-Tovey S, Liew JW, Sirotich E, Sparks JA, Sufka P, Wallace ZS, Machado PM, Strangfeld A, Clowse MEB, Yazdany J, Robinson PC. COVID-19 in Pregnant Women With Rheumatic Disease: Data From the COVID-19 Global Rheumatology Alliance. J Rheumatol 2022; 49:110-114. [PMID: 34470798 DOI: 10.3899/jrheum.210480] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe coronavirus disease 2019 (COVID-19) and pregnancy outcomes in patients with rheumatic disease who were pregnant at the time of infection. METHODS Since March 2020, the COVID-19 Global Rheumatology Alliance has collected cases of patients with rheumatic disease with COVID-19. We report details of pregnant women at the time of COVID-19 infection, including obstetric details separately ascertained from providers. RESULTS We report on 39 patients, including 22 with obstetric detail available. The mean and median age was 33 years, range 24-45 years. Rheumatic disease diagnoses included rheumatoid arthritis (n = 9), systemic lupus erythematosus (n = 9), psoriatic arthritis/other inflammatory arthritides (n = 8), and antiphospholipid syndrome (n = 6). Most had a term birth (16/22), with 3 preterm births, 1 termination, and 1 miscarriage; 1 woman had yet to deliver at the time of report. One-quarter (n = 10/39) of pregnant women were hospitalized following COVID-19 diagnosis. Two of 39 (5%) required supplemental oxygen (both hospitalized); no patients died. The majority did not receive specific medication treatment for their COVID-19 (n = 32/39, 82%), and 7 patients received some combination of antimalarials, colchicine, anti-interleukin 1β, azithromycin, glucocorticoids, and lopinavir/ritonavir. CONCLUSION Women with rheumatic diseases who were pregnant at the time of COVID-19 had favorable outcomes. These data have limitations due to the small size and methodology; however, they provide cautious optimism for pregnancy outcomes for women with rheumatic disease particularly in comparison to the increased risk of poor outcomes that have been reported in other series of pregnant women with COVID-19.
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Affiliation(s)
- Bonnie L Bermas
- B.L. Bermas, MD, UTSouthwestern Medical Center, Dallas, Texas, USA
| | - Milena Gianfrancesco
- M. Gianfrancesco, MPH, PhD, A.M. Seet, MPH, J. Yazdany, MPH, MD, Division of Rheumatology, School of Medicine, University of California, San Francisco, California, USA
| | - Helen L Tanner
- H.L. Tanner, MBChB, FRACP, University of Queensland School of Clinical Medicine, Faculty of Medicine, Queensland, Australia
| | - Andrea M Seet
- M. Gianfrancesco, MPH, PhD, A.M. Seet, MPH, J. Yazdany, MPH, MD, Division of Rheumatology, School of Medicine, University of California, San Francisco, California, USA
| | - Mathia C Aguiar
- M.C. Aguiar, MD, Hospital General Agustin O'Horan, Merida, Mexico
| | - Nasra K Al Adhoubi
- N.K. Al Adhoubi, MD, FRCP, Rheumatology Unit, Royal Hospital, Muscat, Oman
| | - Samar Al Emadi
- S. Al Emadi, MBBS, FRCPC, Hamad Medical Corporation, Doha, Qatar
| | - Bernardo M Cunha
- B.M. Cunha, MD, PhD, Sarah Network of Rehabilitation Hospitals, Brasília, Brazil
| | - Rachael Flood
- R. Flood, MB, BCh, BAO, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Daria A Kusevich
- D.A. Kusevich, MD,PhD, V.A. Nasonova Research Institute of Rheumatology, Moscow, and Anikina Clinic, Vidnoe, Russia
| | - Eoghan M McCarthy
- E.M. McCarthy, MB, MRCPI, Manchester University Foundation Trust, Manchester, UK
| | - Naomi J Patel
- N.J. Patel, MD, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric M Ruderman
- E.M. Ruderman, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sebastian E Sattui
- S.E. Sattui, MD, MS, Hospital for Special Surgery, New York, New York, USA
| | - Savino Sciascia
- S. Sciascia, MD, PhD, Center of Research of Immunopathology and Rare Diseases/Nephrology and Dialysis Unit, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, Turin, Italy
| | - Faizah Siddique
- F. Siddique, MD, Loyola University Medical Center, Maywood, Illinois, USA
| | - Maria O Valenzuela-Almada
- M.O. Valenzuela-Almada, MBBS, A. Duarte-Garcia, MD, MS, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Leanna M Wise
- L.M. Wise, MD, University of Southern California, Los Angeles, California, USA
| | - Angus B Worthing
- A.B. Worthing, MD, Arthritis & Rheumatism Associates, PC, and Georgetown University Medical Center, Washington, DC, USA
| | - JoAnn Zell
- J. Zell, MD, University of Colorado, Aurora, Colorado, USA
| | - Suleman Bhana
- S. Bhana, MD, Crystal Run Healthcare, Middletown, New York, USA
| | - Wendy Costello
- W. Costello, Irish Children's arthritis network (iCan), Tipperary, Ireland
| | - Ali Duarte-Garcia
- M.O. Valenzuela-Almada, MBBS, A. Duarte-Garcia, MD, MS, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rebecca Grainger
- R. Grainger, MBChB, PhD, FRACP, Department of Medicine, University of Otago, Wellington, New Zealand
| | - Laure Gossec
- L. Gossec, MD, PhD, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, and Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Rheumatology Department, Paris, France
| | - Jonathan S Hausmann
- J.S. Hausmann, MD, Program in Rheumatology, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kimme Hyrich
- K. Hyrich, MD, PhD, FRCPC, Centre for Epidemiology Versus Arthritis, The University of Manchester, and National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Saskia Lawson-Tovey
- S. Lawson-Tovey, BA, National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, and Centre for Genetics and Genomics Versus Arthritis, The University of Manchester, Manchester, UK
| | - Jean W Liew
- J.W. Liew, MS, MD, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Emily Sirotich
- E. Sirotich, BSc, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey A Sparks
- J.A. Sparks, MD, MMSc, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Sufka
- P. Sufka, MD, Healthpartners, St. Paul, Minnesota, USA
| | - Zachary S Wallace
- Z.S. Wallace, MD, MSc, Rheumatology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro M Machado
- P.M. Machado, MD, PhD, Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, and National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, and Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Anja Strangfeld
- A. Strangfeld, MD, Epidemiology Unit, German Rheumatism Research Centre (DRFZ) Berlin, Berlin, Germany
| | - Megan E B Clowse
- M.E.B. Clowse, MD, MPH, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jinoos Yazdany
- M. Gianfrancesco, MPH, PhD, A.M. Seet, MPH, J. Yazdany, MPH, MD, Division of Rheumatology, School of Medicine, University of California, San Francisco, California, USA
| | - Philip C Robinson
- P.C. Robinson, MBChB, PhD, FRACP, Associate Professor, University of Queensland School of Clinical Medicine, Faculty of Medicine, Queensland, Australia, and Royal Brisbane & Women's Hospital, Metro North Hospital & Health Service, Herston, Queensland, Australia.
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24
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Gonugunta AS, von Itzstein MS, Mu-Mosley H, Fattah F, Farrar JD, Mobely A, Rashdan S, Lai S, Bhai SF, Bermas BL, Karp D, Li QZ, Wakeland EK, Gerber DE. Humoral and cellular correlates of a novel immune-related adverse event and its treatment. J Immunother Cancer 2021; 9:jitc-2021-003585. [PMID: 34880115 PMCID: PMC8655605 DOI: 10.1136/jitc-2021-003585] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 11/03/2022] Open
Abstract
Immune-related adverse events (irAE) may affect almost any organ system and occur at any point during treatment with immune checkpoint inhibitors (ICI). We present a patient with advanced lung cancer receiving antiprogrammed death 1 checkpoint inhibitor who developed a delayed-onset visual irAE treated with corticosteroids. Through assessment of longitudinal biospecimens, we analyzed serial autoantibodies, cytokines, and cellular populations. Months after ICI initiation and preceding clinical toxicity, the patient developed broad increases in cytokines (most notably interleukin-6 (IL-6), interferon-γ (IFNγ), C-X-C motif chemokine ligand 2 (CXCL2), and C-C motif chemokine ligand 17 (CCL17)), autoantibodies (including anti-angiotensin receptor, α-actin, and amyloid), CD8 T cells, and plasmablasts. Such changes were not observed in healthy controls and ICI-treated patients without irAE. Administration of corticosteroids resulted in immediate and profound decreases in cytokines, autoantibodies, and inflammatory cells. This case highlights the potential for late-onset changes in humoral and cellular immunity in patients receiving ICI. It also demonstrates the biologic effects of corticosteroids on these parameters. Application of humoral and cellular immune biomarkers across ICI populations may inform toxicity monitoring and management.
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Affiliation(s)
- Amrit S Gonugunta
- Medical School, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mitchell S von Itzstein
- Department of Internal Medicine (Division of Hematology and Oncology), University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hong Mu-Mosley
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Farjana Fattah
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - J David Farrar
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Immunology (Division of Microarray and Immune Phenotyping Core Facility), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Angela Mobely
- Department of Immunology (Division of Microarray and Immune Phenotyping Core Facility), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sawsan Rashdan
- Department of Internal Medicine (Division of Hematology and Oncology), University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sunny Lai
- Department of Internal Medicine (Division of Hematology and Oncology), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Salman F Bhai
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bonnie L Bermas
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Internal Medicine (Division of Rheumatology), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David Karp
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Internal Medicine (Division of Rheumatology), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Quan-Zhen Li
- Department of Immunology (Division of Microarray and Immune Phenotyping Core Facility), University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Internal Medicine (Division of Rheumatology), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Edward K Wakeland
- Department of Immunology (Division of Microarray and Immune Phenotyping Core Facility), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David E Gerber
- Department of Internal Medicine (Division of Hematology and Oncology), University of Texas Southwestern Medical Center, Dallas, Texas, USA .,Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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25
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Williams JN, Xu C, Costenbader KH, Bermas BL, Pace LE, Feldman CH. Racial Differences in Contraception Encounters and Dispensing Among Female Medicaid Beneficiaries With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2021; 73:1396-1404. [PMID: 32526084 PMCID: PMC7728620 DOI: 10.1002/acr.24346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/02/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE African American and Hispanic women with systemic lupus erythematosus (SLE) have the highest rates of potentially avoidable pregnancy complications, yet racial disparities in family planning among reproductive-age women with SLE have not been well-studied. Our objective was to examine whether there are racial differences in contraception encounters and dispensing among US Medicaid-insured women with SLE. METHODS Using Medicaid claims data from 2000-2010, we identified women ages 18-50 years with SLE. We examined contraception encounters and uptake over 24 months. We used multivariable logistic regression to estimate the odds ratio and 95% confidence interval by race/ethnicity of contraception encounters, any contraception dispensing, and highly effective contraception (HEC) use, adjusted for age, region, year, SLE severity, and contraindication to estrogen. We also compared contraception encounters and dispensing among women with SLE to the general population and women with diabetes mellitus. RESULTS We identified 24,693 reproductive-age women with SLE; 43% were African American, 35% White, 15% Hispanic, 4% Asian, 2% other race, and 1% American Indian/Alaska Native. Nine percent had a contraceptive visit, 10% received any contraception, and 2% received HEC. Compared to White women, African American and Asian women had lower odds of contraception dispensing, and African American women had lower odds of HEC use. Women with SLE were more likely to receive HEC than the general population and women with diabetes mellitus. CONCLUSION In this study of reproductive-age women with SLE, African American and Asian women had lower odds of contraception dispensing and African American women had lower odds of HEC use. Further study is needed to understand the factors driving these racial disparities among this population.
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Affiliation(s)
- Jessica N. Williams
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Chang Xu
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen H. Costenbader
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bonnie L. Bermas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lydia E. Pace
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Candace H. Feldman
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Bermas BL, Chambers C. Hydroxychloroquine early in pregnancy and risk of birth defects: don't throw out the baby with the bathwater. Am J Obstet Gynecol 2021; 224:548-549. [PMID: 33434555 PMCID: PMC9746025 DOI: 10.1016/j.ajog.2020.12.1218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022]
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Castro-Gutierrez A, Young K, Bermas BL. Pregnancy and Management in Women with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Obstetric Antiphospholipid Syndrome. Med Clin North Am 2021; 105:341-353. [PMID: 33589107 DOI: 10.1016/j.mcna.2020.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Management of women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and obstetric antiphospholipid syndrome (APS) during pregnancy presents unique clinical challenges. Women with both RA and SLE can have disease flares during pregnancy, leading to pregnancy complications, such as preeclampsia, small-for-gestational-age infants, and preterm delivery. Disease should be under control prior to conception. Women with obstetric APS need to be anticoagulated during pregnancy. Many but not all antirheumatic medications can be used during pregnancy and lactation.
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Affiliation(s)
| | - Kristen Young
- UT Southwestern Medical Center, 2001 Inwood Road, Dallas, TX 75390, USA
| | - Bonnie L Bermas
- UT Southwestern Medical Center, 2001 Inwood Road, Dallas, TX 75390, USA.
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Affiliation(s)
- Bonnie L Bermas
- Rheumatic Diseases Division (B.L.B.), University of Texas Southwestern Medical Center, Dallas.,Parkland Health and Hospital System, Dallas, TX (B.L.B., V.G.Z.)
| | - Vlad G Zaha
- Cardiology Division (V.G.Z.), University of Texas Southwestern Medical Center, Dallas.,Department of Internal Medicine, Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center (V.G.Z.), University of Texas Southwestern Medical Center, Dallas.,Advanced Imaging Research Center (V.G.Z.), University of Texas Southwestern Medical Center, Dallas.,Parkland Health and Hospital System, Dallas, TX (B.L.B., V.G.Z.)
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Bitencourt N, Makris UE, Solow EB, Wright T, Reisch EJ, Bermas BL. Predictors of Adverse outcomes in patients with systemic lupus erythematosus transitioning to adult care. Semin Arthritis Rheum 2021; 51:353-359. [PMID: 33601191 DOI: 10.1016/j.semarthrit.2021.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The transition from pediatric to adult care is a vulnerable period for individuals with chronic diseases. We sought to identify risk factors associated with poor outcomes in patients with childhood-onset systemic lupus erythematosus (cSLE) who have transitioned to adult care. METHODS A retrospective analysis of cSLE patients was performed. Outcomes of interest were development of end-stage renal disease (ESRD) or death and time to first hospitalization following final pediatric rheumatology visit. Multivariable logistic and Cox regression models were used. RESULTS Of 190 patients with cSLE, 21 (11%) developed ESRD and 9 (5%) died following the final pediatric rheumatology visit. In logistic regression, public insurance, history of Child Protective Services involvement, and an unscheduled hospitalization during the final year in pediatric care were predictive of ESRD or death (odds ratio (95% confidence intervals (CI)) 6.7 (1.5-30.7), 6.6 (2.3-19.1), and 3.2 (1.3-8.3), respectively). Among 114 patients with healthcare utilization data, 53% had a hospitalization in adult care. In Cox regression analysis, a pediatric outpatient opioid prescription was associated with shorter time to adult hospitalization and White or Asian race was associated with longer time to adult hospitalization (hazard ratio (CI) 3.5 (1.7-7.0) and 0.1 (0.03-0.4), respectively). CONCLUSIONS Risks factors associated with poor outcomes in adult care amongst patients with cSLE include public insurance, history of Child Protective Services involvement, unscheduled care utilization in pediatric care, pediatric outpatient opioid prescription, Black race and Hispanic ethnicity. Efforts to improve long-term outcomes among patients with cSLE should focus on these populations.
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Affiliation(s)
- Nicole Bitencourt
- Division of Pediatric Rheumatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas 75390-9063, TX, United States.
| | - Una E Makris
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States; Medical Service, VA North Texas Health Care System, Dallas, TX, United States; Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - E Blair Solow
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Tracey Wright
- Division of Pediatric Rheumatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas 75390-9063, TX, United States
| | - E Joan Reisch
- Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Feldman CH, Speyer C, Ashby R, L Bermas B, Bhattacharyya S, Chakravarty E, Everett B, Ferucci E, Hersh AO, Marty FM, Merola JF, Ramsey-Goldman R, Rovin BH, Son MB, Tarter L, Waikar S, Yazdany J, Weissman JS, Costenbader KH. Development of a Set of Lupus-Specific, Ambulatory Care-Sensitive, Potentially Preventable Adverse Conditions: A Delphi Consensus Study. Arthritis Care Res (Hoboken) 2021; 73:146-157. [PMID: 31628721 DOI: 10.1002/acr.24095] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/15/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Individuals with systemic lupus erythematosus (SLE) are at high risk for infections and SLE- and medication-related complications. The present study was undertaken to define a set of SLE-specific adverse outcomes that could be prevented, or their complications minimized, if timely, effective ambulatory care had been received. METHODS We used a modified Delphi process beginning with a literature review and key informant interviews to select initial SLE-specific potentially preventable conditions. We assembled a panel of 16 nationally recognized US-based experts from 8 subspecialties. Guided by the RAND-UCLA Appropriateness Method, we held 2 survey rounds with controlled feedback and an interactive webinar to reach consensus regarding preventability and importance on a population level for a set of SLE-specific adverse conditions. In a final round, the panelists endorsed the potentially preventable conditions. RESULTS Thirty-five potential conditions were initially proposed; 62 conditions were ultimately considered during the Delphi process. The response rate was 100% for both survey rounds, 88% for the webinar, and 94% for final approval. The 25 SLE-specific conditions meeting consensus as potentially preventable and important on a population level fell into 4 categories: vaccine-preventable illnesses (6 conditions), medication-related complications (8 conditions), reproductive health-related complications (6 conditions), and SLE-related complications (5 conditions). CONCLUSION We reached consensus on a diverse set of adverse outcomes relevant to SLE patients that may be preventable if patients receive high-quality ambulatory care. This set of outcomes may be studied at the health system level to determine how to best allocate resources and improve quality to reduce avoidable outcomes and disparities among those at highest risk.
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Affiliation(s)
- Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cameron Speyer
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rachel Ashby
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | - Brendan Everett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Francisco M Marty
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph F Merola
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Brad H Rovin
- Ohio State University Wexner Medical Center, Columbus
| | - Mary Beth Son
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Tarter
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sushrut Waikar
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Karen H Costenbader
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Mills BS, Bermas BL. Improving Knowledge of Lactation Compatibility of Antirheumatic Medications Among Providers Who Care for Patients With Rheumatic Disease. ACR Open Rheumatol 2021; 3:50-54. [PMID: 33393732 PMCID: PMC7811689 DOI: 10.1002/acr2.11214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE We sought to evaluate and improve knowledge of lactation compatibility of medications commonly used to treat rheumatic diseases among rheumatology, obstetric, and newborn providers practicing at an academic safety net hospital. METHODS Baseline knowledge of rheumatic disease medication compatibility with lactation among 49 providers was obtained via a multiple-choice questionnaire. Following initial evaluation, providers were given a rheumatic diseases and lactation information card. The questionnaire was readministered at the time of card distribution and 5 months later. RESULTS At baseline, more rheumatology providers correctly identified a higher number of lactation-compatible and noncompatible medications than nonrheumatology providers (78% and 65% vs 31% and 46%, respectively; P < 0.0001). After the intervention, rheumatology providers correctly identified lactation-compatible and noncompatible medications 98% and 100% of the time, compared with 78% and 65% of the time before the intervention (P < 0.0001 and P < 0.0001). This improvement was durable because rheumatology providers correctly identified lactation-compatible and noncompatible medications 96% and 98% of the time 5 months following the initial intervention (P = 0.0021 and P < 0.0001). Nonrheumatology providers correctly identified lactation-compatible and noncompatible medications 31% and 46% of the time before the intervention and 95% and 100% of the time after the intervention (P < 0.0001 and P < 0.0001). CONCLUSION Rheumatology providers had better baseline knowledge than obstetric and newborn providers of the breastfeeding compatibility of medications used to treat rheumatic diseases. However, all providers had knowledge gaps. After a simple educational intervention, the knowledge gap was significantly narrowed in all provider groups. This improvement was durable because repeat testing of the rheumatology provider subset 5 months post intervention continued to show significant improvement.
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Affiliation(s)
- Brooke S Mills
- The University of Texas Southwestern Medical Center, Dallas
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32
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Mikuls TR, Johnson SR, Fraenkel L, Arasaratnam RJ, Baden LR, Bermas BL, Chatham W, Cohen S, Costenbader K, Gravallese EM, Kalil AC, Weinblatt ME, Winthrop K, Mudano AS, Turner A, Saag KG. American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 3. Arthritis Rheumatol 2020; 73:e1-e12. [PMID: 33277981 DOI: 10.1002/art.41596] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the management of adult rheumatic disease in the context of the coronavirus disease 2019 (COVID-19) pandemic. METHODS A task force, including 10 rheumatologists and 4 infectious disease specialists from North America, was convened. Clinical questions were collated, and an evidence report was rapidly generated and disseminated. Questions and drafted statements were reviewed and assessed using a modified Delphi process. This included asynchronous anonymous voting by email and webinars with the entire panel. Task force members voted on agreement with draft statements using a 1-9-point numerical scoring system, and consensus was determined to be low, moderate, or high based on the dispersion of votes. For approval, median votes were required to meet predefined levels of agreement (median values of 7-9, 4-6, and 1-3 defined as agreement, uncertainty, or disagreement, respectively) with either moderate or high levels of consensus. RESULTS Draft guidance statements approved by the task force have been combined to form final guidance. CONCLUSION These guidance statements are provided to promote optimal care during the current pandemic. However, given the low level of available evidence and the rapidly evolving literature, this guidance is presented as a "living document," and future updates are anticipated.
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Affiliation(s)
- Ted R Mikuls
- University of Nebraska Medical Center, Omaha, Nebraska and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Liana Fraenkel
- Berkshire Health Systems, Pittsfield, Massachusetts, and Yale University, New Haven, Connecticut
| | | | | | | | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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33
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Bitencourt N, Kramer J, Bermas BL, Solow EB, Wright T, Makris UE. Clinical Team Perspectives on the Psychosocial Aspects of Transition to Adult Care for Patients With Childhood-Onset Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 73:39-47. [PMID: 32976698 DOI: 10.1002/acr.24463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/17/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The transition from pediatric to adult care for youth with childhood-onset systemic lupus erythematosus (SLE) is a vulnerable period. Adverse outcomes during this transition include gaps in care, unscheduled health care utilization, loss of insurance, and high disease activity. The objective of this study was to examine the clinical care teams' perspective on the psychosocial factors associated with transition outcomes, which are poorly understood in this population. METHODS We conducted in-depth interviews with clinical care team members who interact with childhood-onset SLE patients during transfer from pediatric to adult rheumatology. A semistructured interview guide was used to prompt participants' perspectives about the psychosocial factors associated with the transition process for patients with childhood-onset SLE. Audio recordings were transcribed and analyzed using the constant comparative method. We stopped conducting interviews once thematic saturation was achieved. RESULTS Thirteen in-depth interviews were conducted. Participants included pediatric rheumatologists (n = 4), adult rheumatologists from both academic and private practice settings (n = 4), nurses (n = 2), a nurse practitioner, a social worker, and a psychologist. We identified several themes deemed by clinical care teams as important during the transition, including the impact of the family, patient resilience and coping mechanisms, the role of mental health and emotional support, and the need for education, peer support, and social connectedness. CONCLUSION We identified several psychosocial themes that clinical team members believe impact the transition of patients with childhood-onset SLE into adult care. The role of parental modeling, youth resilience, mental health and emotional care, improved childhood-onset SLE education, and structured peer support and social connectedness are highlighted, which may be amenable to interventions.
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Affiliation(s)
| | - Justin Kramer
- University of Texas Southwestern Medical Center, Dallas
| | | | - E Blair Solow
- University of Texas Southwestern Medical Center, Dallas
| | - Tracey Wright
- University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children, Dallas
| | - Una E Makris
- University of Texas Southwestern Medical Center and Veterans Administration North Texas Health Care System, Dallas
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Mikuls TR, Johnson SR, Fraenkel L, Arasaratnam RJ, Baden LR, Bermas BL, Chatham W, Cohen S, Costenbader K, Gravallese EM, Kalil AC, Weinblatt ME, Winthrop K, Mudano AS, Turner A, Saag KG. American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 2. Arthritis Rheumatol 2020; 72:e1-e12. [PMID: 32734689 DOI: 10.1002/art.41437] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the management of adult rheumatic disease in the context of the coronavirus disease 2019 (COVID-19) pandemic. METHODS A task force, including 10 rheumatologists and 4 infectious disease specialists from North America, was convened. Clinical questions were collated, and an evidence report was rapidly generated and disseminated. Questions and drafted statements were reviewed and assessed using a modified Delphi process. This included asynchronous anonymous voting by e-mail and webinars with the entire panel. Task force members voted on agreement with draft statements using a 1-9-point numerical scoring system, and consensus was determined to be low, moderate, or high based on the dispersion of votes. For approval, median votes were required to meet predefined levels of agreement (median values of 7-9, 4-6, and 1-3 defined as agreement, uncertainty, or disagreement, respectively) with either moderate or high levels of consensus. RESULTS To date, the task force has approved 80 guidance statements: 36 with moderate and 44 with high consensus. These were combined, resulting in 27 final guidance statements. CONCLUSION These guidance statements are provided to promote optimal care during the current pandemic. However, given the low level of available evidence and the rapidly evolving literature, this guidance is presented as a "living document," and future updates are anticipated.
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Affiliation(s)
- Ted R Mikuls
- University of Nebraska Medical Center, Omaha, Nebraska and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Liana Fraenkel
- Berkshire Health Systems, Pittsfield, Massachusetts, and Yale University, New Haven, Connecticut
| | | | | | | | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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35
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Mikuls TR, Johnson SR, Fraenkel L, Arasaratnam RJ, Baden LR, Bermas BL, Chatham W, Cohen S, Costenbader K, Gravallese EM, Kalil AC, Weinblatt ME, Winthrop K, Mudano AS, Turner A, Saag KG. American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID‐19 Pandemic: Version 1. Arthritis Rheumatol 2020; 72:1241-1251. [DOI: 10.1002/art.41301] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Ted R. Mikuls
- University of Nebraska Medical Center, Omaha, Nebraska and VA Nebraska–Western Iowa Health Care System Omaha Nebraska
| | - Sindhu R. Johnson
- Toronto Western HospitalMount Sinai Hospital, and University of Toronto Toronto Ontario Canada
| | - Liana Fraenkel
- Berkshire Health Systems, Pittsfield, Massachusetts, and Yale University New Haven Connecticut
| | | | | | | | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology Atlanta Georgia
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von Itzstein MS, Khan S, Popat V, Lu R, Khan SA, Fattah FJ, Park JY, Bermas BL, Karp DR, Ahmed M, Saltarski JM, Gloria-McCutchen Y, Xie Y, Li QZ, Wakeland EK, Gerber DE. Statin Intolerance, Anti-HMGCR Antibodies, and Immune Checkpoint Inhibitor-Associated Myositis: A "Two-Hit" Autoimmune Toxicity or Clinical Predisposition? Oncologist 2020; 25:e1242-e1245. [PMID: 32400023 DOI: 10.1634/theoncologist.2019-0911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/16/2020] [Indexed: 01/19/2023] Open
Abstract
Immune-related adverse events induced by immune checkpoint inhibitor (ICI) therapy may affect diverse organ systems, including skeletal and cardiac muscle. ICI-associated myositis may result in substantial morbidity and occasional mortality. We present a case of a patient with advanced non-small cell lung cancer who developed grade 4 myositis with concurrent myocarditis early after initiation of anti-programmed death ligand 1 therapy (durvalumab). Autoantibody analysis revealed marked increases in anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody levels that preceded clinical toxicity, and further increased during toxicity. Notably, the patient had a history of intolerable statin myopathy, which had resolved clinically after statin discontinuation and prior to ICI initiation. This case demonstrates a potential association between statin exposure, autoantibodies, and ICI-associated myositis.
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Affiliation(s)
- Mitchell S von Itzstein
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shaheen Khan
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Vinita Popat
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rong Lu
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Saad A Khan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Farjana J Fattah
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jason Y Park
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bonnie L Bermas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Rheumatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David R Karp
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Rheumatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Murtaza Ahmed
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jessica M Saltarski
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yvonne Gloria-McCutchen
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yang Xie
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Quan-Zhen Li
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Edward K Wakeland
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David E Gerber
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Abstract
BACKGROUND The coexistence of inflammatory myositis in systemic lupus erythematosus (SLE) has not been extensively studied. In this study, we describe the incidence, distinct types of inflammatory myositis, and risk factors for this finding in a cohort of pediatric and adult SLE patients. METHODS We identified SLE patients with coexisting myositis followed between 2010 and 2019 at two pediatric hospitals and one adult hospital. Demographic, clinical, laboratory, and pathological features of myositis were collected, and descriptive statistics were applied. RESULTS A total of 1718 individuals were identified as having SLE (451 pediatric and 1267 adult patients). Of these, 108 were also diagnosed with inflammatory myositis (6.3%). People of black race had a significantly higher prevalence of inflammatory myositis, as did those with childhood-onset SLE compared to adult-onset disease. In the majority of patients (68%), SLE and inflammatory myositis presented concurrently. Overlapping features of systemic sclerosis occurred in 48%, while dermatomyositis-specific rashes were present in a third. Arthralgias and inflammatory arthritis were seen in >90%. Thrombotic events and significant pregnancy-related morbidity were present in more than a third of patients. Lymphopenia, hypocomplementemia, and a positive RNP were the most common laboratory features noted. Myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) were present in >40% of patients. A review of 28 muscle biopsy reports revealed a wide array of pathological features, including nonspecific changes, dermatomyositis, polymyositis, and necrotizing auto-immune myopathy. CONCLUSION In our SLE patient population, 6.3% presented with concurrent inflammatory myositis. Dermatomyositis-specific rashes, clinical features of systemic sclerosis, arthralgias and arthritis, and cytopenias were common coexisting clinical manifestations. A high frequency of RNP, MSA, and MAA were found. People of black race and with childhood-onset disease had a higher prevalence of myositis. Our findings suggest that SLE patients of black race, with childhood-onset SLE, and who possess MSA or MAA should be routinely screened for myositis.
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Affiliation(s)
- Nicole Bitencourt
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA
| | - E Blair Solow
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA
| | - Tracey Wright
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA.,Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA
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Khan S, von Itzstein MS, Lu R, Bermas BL, Karp DR, Khan SA, Fattah FJ, Park JY, Saltarski JM, Gloria‐McCutchen Y, Xie Y, Li Q, Wakeland EK, Gerber DE. Late-Onset Immunotherapy Toxicity and Delayed Autoantibody Changes: Checkpoint Inhibitor-Induced Raynaud's-Like Phenomenon. Oncologist 2020; 25:e753-e757. [PMID: 32167195 PMCID: PMC7216445 DOI: 10.1634/theoncologist.2019-0666] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 02/03/2020] [Indexed: 01/29/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)‐induced immune‐related adverse events (irAEs) may affect almost any organ system and occur at any point during therapy. Autoantibody analysis may provide insight into the mechanism, nature, and timing of these events. We report a case of ICI‐induced late‐onset Raynaud's‐like phenomenon in a patient receiving combination immunotherapy. A 53‐year‐old woman with advanced non‐small lung cancer received combination anti‐cytotoxic T‐lymphocyte antigen 4 and anti‐programmed death 1 ICI therapy. She developed early (hypophysitis at 4 months) and late (Raynaud's at >20 months) irAEs. Longitudinal assessment of 124 autoantibodies was correlated with toxicity. Although autoantibody levels were generally stable for the first 18 months of therapy, shortly before the development of Raynaud's, a marked increase in multiple autoantibodies was observed. This case highlights the potential for delayed autoimmune toxicities and provides potential biologic insights into the dynamic nature of these events. Key Points A patient treated with dual anti‐PD1 and anti‐CTLA4 therapy developed Raynaud's‐like signs and symptoms more than 18 months after starting therapy. In this case, autoantibody changes became apparent shortly before onset of clinical toxicity. This case highlights the potential for late‐onset immune‐related adverse events checkpoint inhibitors, requiring continuous clinical vigilance. The optimal duration of checkpoint inhibitor therapy in patients with profound and prolonged responses remains unclear.
Autoantibody analysis may provide insight into the mechanism, nature, and timing of immune‐related adverse events. This case report describes a case of immune checkpoint inhibitor‐induced late‐onset Raynaud's‐like phenomenon in a patient receiving combination immunotherapy.
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Affiliation(s)
- Shaheen Khan
- Department of Immunology, University of Texas Southwestern Medical CenterDallasTexasUSA
| | | | - Rong Lu
- Department of Population and Data Sciences, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Bonnie L. Bermas
- Department of Rheumatology, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - David R. Karp
- Department of Rheumatology, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Saad A. Khan
- Department of Internal Medicine, University of Texas Southwestern Medical CenterDallasTexasUSA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Farjana J. Fattah
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Jason Y. Park
- Department of Pathology, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Jessica M. Saltarski
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Yvonne Gloria‐McCutchen
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Yang Xie
- Department of Population and Data Sciences, University of Texas Southwestern Medical CenterDallasTexasUSA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Quan‐Zhen Li
- Department of Immunology, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Edward K. Wakeland
- Department of Immunology, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - David E. Gerber
- Department of Internal Medicine, University of Texas Southwestern Medical CenterDallasTexasUSA
- Department of Population and Data Sciences, University of Texas Southwestern Medical CenterDallasTexasUSA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
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Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, Marder W, Guyatt G, Branch DW, Buyon J, Christopher-Stine L, Crow-Hercher R, Cush J, Druzin M, Kavanaugh A, Laskin CA, Plante L, Salmon J, Simard J, Somers EC, Steen V, Tedeschi SK, Vinet E, White CW, Yazdany J, Barbhaiya M, Bettendorf B, Eudy A, Jayatilleke A, Shah AA, Sullivan N, Tarter LL, Birru Talabi M, Turgunbaev M, Turner A, D'Anci KE. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken) 2020; 72:461-488. [PMID: 32090466 DOI: 10.1002/acr.24130] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD). METHODS We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary. RESULTS This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD. CONCLUSION This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.
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Affiliation(s)
- Lisa R Sammaritano
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Michael D Lockshin
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | - Wendy Marder
- University of Michigan School of Medicine, Ann Arbor
| | | | | | - Jill Buyon
- New York University School of Medicine, New York, New York
| | | | | | - John Cush
- Baylor Research Institute, Dallas, Texas
| | | | | | | | - Lauren Plante
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jane Salmon
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Evelyne Vinet
- McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Medha Barbhaiya
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | - Amanda Eudy
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, Marder W, Guyatt G, Branch DW, Buyon J, Christopher‐Stine L, Crow‐Hercher R, Cush J, Druzin M, Kavanaugh A, Laskin CA, Plante L, Salmon J, Simard J, Somers EC, Steen V, Tedeschi SK, Vinet E, White CW, Yazdany J, Barbhaiya M, Bettendorf B, Eudy A, Jayatilleke A, Shah AA, Sullivan N, Tarter LL, Birru Talabi M, Turgunbaev M, Turner A, D'Anci KE. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2020; 72:529-556. [DOI: 10.1002/art.41191] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/10/2019] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | | | | | | | - Wendy Marder
- University of Michigan School of Medicine Ann Arbor
| | | | | | - Jill Buyon
- New York University School of Medicine New York New York
| | | | | | - John Cush
- Baylor Research Institute Dallas Texas
| | | | | | | | - Lauren Plante
- Drexel University College of Medicine Philadelphia Pennsylvania
| | - Jane Salmon
- Weill Cornell MedicineHospital for Special Surgery New York New York
| | | | | | | | | | - Evelyne Vinet
- McGill University Health Center Montreal Quebec Canada
| | | | | | - Medha Barbhaiya
- Weill Cornell MedicineHospital for Special Surgery New York New York
| | | | - Amanda Eudy
- Duke University Medical Center Durham North Carolina
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology Atlanta Georgia
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Affiliation(s)
- Bonnie L Bermas
- UT Southwestern Medical Center, Division of Rheumatic Diseases, Dallas, Texas, USA.
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Abstract
Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.
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Affiliation(s)
- Nicole Bitencourt
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA.
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Bermas BL, Tassinari M, Clowse M, Chakravarty E. The new FDA labeling rule: impact on prescribing rheumatological medications during pregnancy. Rheumatology (Oxford) 2018; 57:v2-v8. [PMID: 30137587 PMCID: PMC6099131 DOI: 10.1093/rheumatology/key010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/11/2018] [Indexed: 12/30/2022] Open
Abstract
After several decades of deliberation, the US Food and Drug Administration updated the Pregnancy and Lactation Labeling Rule in 2015, eliminating the prior A, B, C, D, X grading system for medication use in pregnancy. Although physicians and patients liked the relative ease of use of this system, it was often misconstrued and not updated to include new data suggesting greater compatibility of medications with pregnancy. The new label is designed to include more clinically relevant data, including data from human studies and registries, and fewer animal data. A key goal of the new label is to assist physicians and patients as they weigh the risks and benefits of medications vs the risks of pregnancy in a woman with a chronic, untreated illness. As such, each label now includes a section outlining the pregnancy risks of the diseases that the medication treats. This review includes a historical perspective on the label change and a guide to the interpretation of the new label. It also includes an assessment of the baseline risk of pregnancy in women with SLE and RA, to help balance the consideration of medication risks and benefits in pregnancy.
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Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Megan Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Eliza Chakravarty
- Division of Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
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Sparks JA, Iversen MD, Yu Z, Triedman NA, Prado MG, Kroouze RM, Kalia SS, Atkinson ML, Mody EA, Helfgott SM, Todd DJ, Dellaripa PF, Bermas BL, Costenbader KH, Deane KD, Lu B, Green RC, Karlson EW. Disclosure of Personalized Rheumatoid Arthritis Risk Using Genetics, Biomarkers, and Lifestyle Factors to Motivate Health Behavior Improvements: A Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2018; 70:823-833. [PMID: 29024454 PMCID: PMC5897224 DOI: 10.1002/acr.23411] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 09/05/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine the effect of disclosure of rheumatoid arthritis (RA) risk personalized with genetics, biomarkers, and lifestyle factors on health behavior intentions. METHODS We performed a randomized controlled trial among first-degree relatives without RA. Subjects assigned to the Personalized Risk Estimator for Rheumatoid Arthritis (PRE-RA) group received the web-based PRE-RA tool for RA risk factor education and disclosure of personalized RA risk estimates, including genotype/autoantibody results and behaviors (n = 158). Subjects assigned to the comparison arm received standard RA education (n = 80). The primary outcome was readiness for change based on the trans-theoretical model, using validated contemplation ladder scales. Increased motivation to improve RA risk-related behaviors (smoking, diet, exercise, or dental hygiene) was defined as an increase in any ladder score compared to baseline, assessed immediately, 6 weeks, and 6 months post-intervention. Subjects reported behavior change at each visit. We performed intent-to-treat analyses using generalized estimating equations for the binary outcome. RESULTS Subjects randomized to PRE-RA were more likely to increase ladder scores over post-intervention assessments (relative risk 1.23, 95% confidence interval [95% CI] 1.01, 1.51) than those randomized to nonpersonalized education. At 6 months, 63.9% of PRE-RA subjects and 50.0% of comparison subjects increased motivation to improve behaviors (age-adjusted difference 15.8%; 95% CI 2.8%, 28.8%). Compared to nonpersonalized education, more PRE-RA subjects increased fish intake (45.0% versus 22.1%; P = 0.005), brushed more frequently (40.7% versus 22.9%; P = 0.01), flossed more frequently (55.7% versus 34.8%; P = 0.004), and quit smoking (62.5% versus 0.0% among 11 smokers; P = 0.18). CONCLUSION Disclosure of RA risk personalized with genotype/biomarker results and behaviors increased motivation to improve RA risk-related behaviors. Personalized medicine approaches may motivate health behavior improvements for those at risk for RA and provide rationale for larger studies evaluating effects of behavior changes on clinical outcomes, such as RA-related autoantibody production or RA development.
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Affiliation(s)
- Jeffrey A. Sparks
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Maura D. Iversen
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston, MA
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Zhi Yu
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
| | - Nellie A. Triedman
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
| | - Maria G. Prado
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
| | - Rachel Miller Kroouze
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
| | | | - Michael L. Atkinson
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Elinor A. Mody
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Simon M. Helfgott
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Derrick J. Todd
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Paul F. Dellaripa
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bonnie L. Bermas
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Karen H. Costenbader
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kevin D. Deane
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, CO
| | - Bing Lu
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Robert C. Green
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of Genetics, Brigham and Women’s Hospital, Boston, MA
- Broad Institute, Cambridge, MA
| | - Elizabeth W. Karlson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Kuswanto WF, MacFarlane LA, Gedmintas L, Mulloy A, Choueiri TK, Bermas BL. Rheumatologic symptoms in oncologic patients on PD-1 inhibitors. Semin Arthritis Rheum 2018; 47:907-910. [DOI: 10.1016/j.semarthrit.2017.10.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/25/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
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Bermas BL, Tedeschi SK, Frits M, Shadick NA. An evaluation of the patient-administered Rheumatoid Arthritis Disease Activity Index for assessing disease activity during pregnancy. Rheumatology (Oxford) 2018; 56:2237-2239. [PMID: 29155980 DOI: 10.1093/rheumatology/kex364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Indexed: 01/18/2023] Open
Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Sara K Tedeschi
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Michelle Frits
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy A Shadick
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
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Bermas BL, Kim SC, Huybrechts K, Mogun H, Hernandez-Diaz S, Bateman BT, Desai RJ. Trends in use of hydroxychloroquine during pregnancy in systemic lupus erythematosus patients from 2001 to 2015. Lupus 2018; 27:1012-1017. [DOI: 10.1177/0961203317749046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- B L Bermas
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA, USA
| | - S C Kim
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
| | - K Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
| | - H Mogun
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA, USA
| | - S Hernandez-Diaz
- Department of Epidemiology, Harvard Chan School of Public Health, Boston, MA, USA
| | - B T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
| | - R J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
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50
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Kreps DJ, Halperin F, Desai SP, Zhang ZZ, Losina E, Olson AT, Karlson EW, Bermas BL, Sparks JA. Association of weight loss with improved disease activity in patients with rheumatoid arthritis: A retrospective analysis using electronic medical record data. ACTA ACUST UNITED AC 2018; 13:1-10. [PMID: 29606976 DOI: 10.4172/1758-4272.1000154] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective To evaluate the association between weight loss and rheumatoid arthritis (RA) disease activity. Methods We conducted a retrospective cohort study of RA patients seen at routine clinic visits at an academic medical center, 2012-2015. We included patients who had ≥2 clinical disease activity index (CDAI) measures. We identified visits during follow-up where the maximum and minimum weights occurred and defined weight change and CDAI change as the differences of these measures at these visits. We defined disease activity improvement as CDAI decrease of ≥5 and clinically relevant weight loss as ≥5 kg. We performed logistic regression analyses to establish the association between improved disease activity and weight loss and baseline BMI category (≥25 kg/m2 or <25 kg/m2). We built linear regression models to investigate the association between continuous weight loss and CDAI change among patients who were overweight/obese at baseline and who lost weight during follow-up. Results We analyzed data from 174 RA patients with a median follow-up of 1.9 years (IQR 1.3-2.4); 117 (67%) were overweight/obese at baseline, and 53 (31%) lost ≥5 kg during follow-up. Patients who were overweight/obese and lost ≥5 kg had three-fold increased odds of disease activity improvement compared to those who did not (OR 3.03, 95%CI 1.18-7.83). Among those who were overweight/obese at baseline, each kilogram weight loss was associated with CDAI improvement of 1.15 (95%CI 0.42-1.88). Our study was limited by using clinical data from a single center without fixed intervals for assessments. Conclusion Clinically relevant weight loss (≥5 kg) was associated with improved RA disease activity in the routine clinical setting. Further studies are needed for replication and to evaluate the effect of prospective weight loss interventions on RA disease activity.
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Affiliation(s)
- David J Kreps
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Florencia Halperin
- Harvard Medical School, Boston, MA.,Center for Weight Management and Metabolic Surgery, Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA
| | - Sonali P Desai
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Zhi Z Zhang
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Elena Losina
- Harvard Medical School, Boston, MA.,Orthopedic and Arthritis Center for Outcomes Research, Policy and Innovation evaluation of Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Amber T Olson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Elizabeth W Karlson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Bonnie L Bermas
- Univerisity of Texas Southwestern Medical Center, Dallas, TX
| | - Jeffrey A Sparks
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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