Infection risk in Rheumatoid Arthritis and Spondyloarthropathy patients under treatment with DMARDs, Corticosteroids and TNF-α antagonists

Abstract

BackgroundInfections which complicate rheumatic diseases such as Rheumatoid Arthritis (RA) and Spondyloarthropathy (SpA) (Psoriatic Arthritis [PA] and Ankylosing Spondylitis [AS]), may cause significant morbidity and mortality. However, among the studies on the incidence rate (IR) of infections in such patients, very few have involved controls and the results have been controversial, probably due to methodological difficulties.To estimate infection rates in RA and SpA patients under disease-modifying anti-rheumatic drugs (DMARDs), corticosteroids (CS) and tumor necrosis factor (TNF)α antagonists, alone or combined, a single-centre retrospective observational cohort study has been performed.Patients and methodsIncidence rates/100 patient-years of any infections were evaluated in RA and SpA outpatients observed in the period November 1, 2003 through December 31, 2009 and stratified according to therapy. Infection incidence rate ratios (IRR) were calculated using Poisson regression models which adjusted for demographic/clinical characteristics of the patients.ResultsThree hundred and thirtyone infections [318 (96.1%) non-serious and 13 (3.9%) serious] have been registered among 176 of the 341 patients (52%). The IR/100 patient-years of all infections was 36.3 ranging from 12.4 (DMARDs + CS) to 62.7 (anti-TNFα + CS). The most frequent infection site was respiratory tract, and bacteria were responsible for three quarters of all infections. In the multivariate analysis, adding anti-TNFα to DMARDs doubled the IRR compared to DMARDs alone, anti-TNFα + CS significantly tripled it, whereas anti-TNFα + CS + DMARDs only increased the risk 2.5 times. The degree of disease activity was strongly and significantly associated with the infection risk (severe or moderate versus mild, IRR = 4). Female sex was significantly associated with increased infection risk, while duration of disease and anti-influenza vaccination were protective, the latter even for cutaneous/soft-tissue (mainly herpetic) infections.ConclusionThe combination anti-TNFα with CS was found to be the most pro-infective treatment, whereas DMARDs alone were relatively safe. Physicians, therefore, should be aware that there may be an increased risk of infection when using anti-TNFα and CS therapy together. Anti-influenza vaccination appears to provide broad protection, adding evidence to support its use in these patients, and deserves further study.

Identifying risk factors associated with infection in patients with chronic leg ulcers

“…Although rheumatoid arthritis and peripheral vascular disease were believed to increase the risk of wound infections, the current study found no association between rheumatoid arthritis or peripheral vascular disease and infection in chronic leg ulcers. This result is similar to findings reported by Adam (2011) in a retrospective case‐control study of 48 patients with diabetic foot ulcer …”

Validation of predictive factors for infection in adults with chronic leg ulcers: A prospective longitudinal study

“…The current study found no associations between other medical conditions and infection, including peripheral vascular disease, diabetes mellitus, rheumatoid arthritis and unhealthy weight, which is similar to those from Bui, Finlayson, et al (). Corticosteroids were reported to increase skin and soft tissue infection (Germano et al, ) and acute wound infection (Finan et al, ). However, the current study did not find any associations between taking steroids and infected CLUs, which was consistent with the finding from previous studies (Barnard, Regan, Burke, Chung, & Wilgis, ; Bui, Finlayson, et al, ; Ruyssen‐Witrand, Fautrel, Saraux, Le‐Loët, & Pham, ).…”

Vaccination of patients with autoimmune inflammatory rheumatic diseases

“…In patients with RA, the combination of anti-TNF therapy and corticosteroids is associated with the highest risk of infection, whereas DMARDs alone are comparatively safe. 8,9 In systemic lupus erythematosus (SLE), treating patients with prednisone, even at moderate doses (median 7.5 mg per day), increases the risk of infection, whereas chloroquine-based antimalarial drugs have a protective effect. 10 The risk of pulmonary infection is particularly high for patients with an AIRD.…”