AB0357 INCIDENCE AND DETERMINANTS OF INFECTION IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH GOLIMUMAB IN REAL-WORLD PRACTICE

Background

Although biologic use in rheumatoid arthritis (RA) has a well-characterized infections risk factor, most studies evaluating this association were conducted on first-generation anti-tumor necrosis factor (TNFi) agents or in early years post-drug development (early 2000).

Objectives

To (i) characterize the long-term incidence of infection in a real-world cohort of RA patients treated with subcutaneous golimumab (GLM) in Canadian routine care; (ii) assess the impact of infections on GLM retention, and (iii) explore factors associated with the risk of infection.

Methods

BioTRAC registry was a prospective, multicenter study that collected real-world clinical, laboratory, safety and patient-reported data from TNFi naïve patients or treated with biologics for a period of <6 months before enrolment. This post-hoc analysis included patients with RA who initiated GLM treatment. The incidence density rates (IDR) of total serious (SI) and non-serious (NSI) infections were calculated for the overall follow-up (90 months) period as well as by 6-month interval. Time to first infection and time to treatment discontinuation were assessed with the Kaplan-Meier estimator of the survival function. Determinants of infection over time or within the first 6 months were explored using generalized estimating equation models and logistic regression, respectively.

Results

530 patients were included with a mean (SD) age of 57.7 (13.0) years and disease duration of 8.0 (8.3) years. Of these, 404 (76.2%) were females, 74 (14.0%) were treated with ≤15mg/week MTX, 280 (52.8%) with >15mg/week MTX, while 173 (32.6%) were not on MTX. In terms of corticosteroids (CS), 72 (13.6%) were treated with ≤5mg/day, 63 (11.9%) with >5mg/day, and 391 (73.8%) were not on CS. Diabetes (4.5%), pulmonary disease (8.9%), and renal disease (18.5%) were present.

Over a mean follow-up duration of 27.0 months, the IDR for total infections, NSI, and SI was 35.10 events/100 PYs, 32.90 events/100 PYs, and 2.23 events/100 PYs. Median estimated time to first infection was 52.9 months (SI: 84.9 months; NSI: 55.1 months) (Table 1). The incidence of total infections was 44.0, 37.3, 35.1, 29.4, 31.1, 35.7, 19.3 and 7.4 events/100 PYs at 0-6 months, 6-12 months, 12-24 months, 24-36 months, 36-48 months, 48-60 months, 60-72 months, 72-84 months, respectively and no infections between 84-90 months. In terms of determinants, no significant associations were identified for the incidence of infections within the first 6 months. However, presence of pulmonary disease was identified as a significant determinant of total infections (OR [95%CI]: 2.19 [1.36-3.52]) and NSI (2.22 [1.35-3.66]) over time, while higher age (1.08 [1.00-1.26]) and high (≥5 mg/day) CS dose (7.25 [1.12-46.80]) were associated with significantly higher odds of SI. Incidence of SI (6.48 [1.16-36.13]), but not NSI, was associated with significantly higher odds of GLM discontinuation; additional predictors of discontinuation were increased baseline CDAI (1.06 [1.04-1.08]) and use of concomitant MTX at low dose (0.52 [0.30-0.91]) or high dose (0.71 [0.49-1.04]).

Table 1.

Incidence Density Rate (IDR) by Infection Type.

Infection TypeIDR (Events/100 PYs)Median Time to 1st Infection (months)Total Infections35.152.9Non-serious Infections32.984.9Serious Infections2.255.1

Conclusion

The infection rates reported with GLM in this cohort are low compared to the rates reported in earlier registry studies with TNFi. Changes in the characteristics of patients starting TNFi (lower disease activity, shorter disease duration, less exposure to CS) in recent years may explain the decreased risk of infection. Compared to the available literature, treatment with GLM was associated with relatively low infection rate. Most infections occurred during the first 6 months of treatment and decreased thereafter. Presence of pulmonary disease, higher age, and higher CS dose were identified as significant predictors of infections. SIs, but not NSIs, were associated with significantly higher odds of treatment discontinuation-TNFi.

Disclosure of Interests

Louis Bessette Speakers bureau: Amgen, BMS, Janssen, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Gilead, Sandoz, Fresenius Kabi, Teva, Consultant of: Amgen, BMS, Janssen, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Gilead, Sandoz, Fresenius Kabi, Teva, Grant/research support from: Amgen, BMS, Janssen, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Gilead, Sandoz, Fresenius Kabi, Teva, Proton Rahman Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Grant/research support from: Janssen and Novartis, John Kelsall: None declared, Jane Purvis: None declared, Emmanouil Rampakakis Consultant of: Janssen, Allen Lehman Shareholder of: Johnson & Johnson, Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, Meagan Rachich Shareholder of: Johnson & Johnson, Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, Francois Nantel Shareholder of: Johnson & Johnson, Employee of: Retiree from Janssen Pharmaceutical Companies of Johnson & Johnson, Marilise Marrache Shareholder of: Johnson & Johnson, Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, Odalis Asin Milan Shareholder of: Johnson & Johnson, Employee of: Employees of Janssen Pharmaceutical Companies of Johnson & Johnson

Risk behaviours of young Indo-Chinese injecting drug users in Sydney and Melbourne

OBJECTIVE

To investigate patterns of drug use and injection-related risk behaviours among young Indo-Chinese injecting drug users (IDUs).

METHOD

Cross-sectional survey. A structured questionnaire was administered to 184 Indo-Chinese IDUs aged 15 to 24 in Sydney and Melbourne. Participants were recruited using snowball sampling techniques; measures included patterns of heroin and other drug use, injection-related risk behaviours, perceived susceptibility to HIV and HCV infection and access to services.

RESULTS

Despite perceived high availability of sterile injecting equipment, 36% had ever shared a needle and syringe and 22% had done so in the preceding month. Lifetime sharing was significantly associated with duration of injecting, history of incarceration and residence in Sydney. Sharing of injecting paraphernalia other than needles and syringes was also common, with young women and Sydney residents significantly more likely to report sharing equipment in the preceding month.

CONCLUSIONS

Young Indo-Chinese IDUs are at high risk of infection with hepatitis C and other blood-borne viruses. Results indicate an urgent need for culturally appropriate and sustainable risk reduction programs which specifically target this population.

IMPLICATIONS

Health services must respond swiftly to implement effective blood-borne virus prevention programs for young Indo-Chinese IDUs. Failure to do so may sustain the current epidemic of hepatitis C among IDUs.

Does weather confound or modify the association of particulate air pollution with mortality? An analysis of the Philadelphia data, 1973-1980

Because weather has the potential to confound or modify the pollution-mortality relationship, researchers have developed several approaches for controlling it in estimating the independent effect of air pollution on mortality. This report considers the consequences of using alternative approaches to controlling for weather and explores modification of air pollution effects by weather, as weather patterns could plausibly alter air pollution's effect on health. We analyzed 1973-1980 total mortality data for Philadelphia using four weather models and compared estimates of the effects of TSP and SO2 on mortality using a Poisson regression model. Two synoptic categories developed by Kalkstein were selected--the Temporal Synoptic Index (TSI) and the Spatial Synoptic Classification (SSC)--and compared with (1) descriptive models developed by Schwartz and Dockery (S-D); and (2) LOESS, a non-parametric function of the previous day's temperature and dew point. We considered model fit using Akaike's Information Criterion (AIC) and changes in the estimated effects of TSP and SO2. In the full-year analysis, S-D is better than LOESS at predicting mortality, and S-D and LOESS are better than TSI, as measured by AIC. When TSP or SO2 was fit alone, the results were qualitatively similar, regardless of how weather was controlled; when TSP and SO2 were fit simultaneously, the S-D and LOESS models give qualitatively different results than TSI, which attributes more of the pollution effect to SO2 than to TSP. Model fit is substantially poorer with TSI. This pattern was repeated in analyses of summer and winter months, which included SSC. In summary, using synoptic weather categories in regression models does not meaningfully change the association between mortality and air pollution indexes. We also found little evidence that weather conditions modified the effect of pollution, regardless of the approach used to represent weather.

She can lip-read, she'll be all right: improving maternity care for the deaf and hearing-impaired

In the UK a midwife is unlikely to meet many deaf women during her working life. Therefore very few midwives have a wealth of experience in providing care for these women. Postnatal discussion with one woman showed us that despite our good intentions the care we had given her was inadequate for her individual needs. We recognised that other deaf women were possibly receiving inadequate care. We set out to investigate this, and when we discovered that our suspicions were correct, devised a method that we hoped would improve the care we provided. The process of investigating the needs of deaf women is described in this paper together with the development of a teaching package for student and qualified midwives.