Anti-TNF therapy in Jordan: a focus on severe infections and tuberculosis

Abstract

BackgroundA high rate of infection has been reported in patients receiving treatment with anti-tumor necrosis factor (anti-TNF). This study describes the rate of and risk factors for serious infections in patients receiving anti-TNF agents in Jordan.MethodsThis retrospective observational study was conducted at a large tertiary referral center in the north of Jordan. Between January 2006 and January 2012, 199 patients who received an anti-TNF agent (infliximab, adalimumab, or etanercept) were included. Patients received the anti-TNF treatment for rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, or other conditions. A serious infection was defined as any bacterial, viral, or fungal infection that required hospitalization, administration of appropriate intravenous antimicrobial therapy, and temporary withholding of anti-TNF treatment.ResultsThe mean duration of anti-TNF treatment was 26.2 months. Steroids were used in 29.1% of patients, while 54.8% were given additional immunosuppressant therapy (methotrexate or azathioprine). Only one anti-TNF agent was given in 70.4% of patients, while 29.6% received different anti-TNF agents for the duration of treatment. Serious infections were documented in 39 patients (19.6%), including respiratory tract infections (41%), urinary tract infections (30.8%), and skin infections (20.5%), and extrapulmonary tuberculosis in three patients (7.7%). Exposure to more than one anti-TNF agent was the only factor associated with a significant increase in the rate of infection (relative risk 1.9, 95% confidence interval 1.06–4.0, P=0.03).ConclusionSerious infections, including tuberculosis, were a common problem in patients receiving anti-TNF agents, and exposure to more than one anti-TNF agent increased the risk of serious infection.

Tuberculosis in people with rheumatic disease in Finland 1995–2007: a nationwide retrospective register study

“…During TNFi treatment, TB in RA patients is often disseminated or extra-pulmonary [7, 8, 20], but clinical manifestations of TB during treatment with synthetic DMARDs (sDMARDs) or in rheumatic disease (RD) patients without specific medication remain poorly documented.…”

Severe bacterial sepsis results in delayed diagnosis of tuberculous lymphadenitis in a rheumatoid arthritis patient treated with adalimumab

“…Due to the immunological role of TNF-α, the infection caused by anti-TNF-α treatment of the greatest concern is TB; the risk of TB in patients with RA receiving anti-TNF-α treatment has been documented to range from 0.2 to 4% (6). Previous reports estimated extrapulmonary TB to constitute more than 50% of cases of TB in patients treated with anti-TNF-α drugs (4,7,8). In the patients treated with ADA, Dixon et al previously reported that disseminated disease was the most common (40%), although lymph node disease was relatively low (10%) (7).…”

Safety of Anti‐TNF Therapies in Immune‐Mediated Inflammatory Diseases: Focus on Infections and Malignancy

“…Conversely, in a large cohort of patients with IMIDs, TNF‐α antagonist treatment was not associated with an increased risk of hospitalizations for serious infections, compared with non‐biologic treatment [Grijalva et al, ]. Exposure to more than one anti‐TNF agent during therapy may also be related with a twofold risk of developing a serious infection [Alawneh et al, ].…”

“…Extrapulmonary TB was constituted more than 50% of cases of TB in this setting [Keane et al, ; Dixon et al, ; Jauregui‐Amezaga et al, ]. Moreover, extrapulmonary TB has been reported in patients receiving anti‐TNF therapy despite negative screening with a tuberculin skin test (TST) [Alawneh et al, ]. The introduction of latent TB infection screening prior to initiation of therapy precipitated a reduction of the incidence of TB, bringing it close to the levels of the background population [Carmona et al, ].…”