RABBIT risk score and ICU admission due to infection in patients with rheumatoid arthritis

Abstract

Rheumatoid arthritis (RA) patients are at increased risk of infection. Aim of the present study was to investigate whether RA patients admitted to an intensive care unit (ICU) due to infection have higher Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) risk scores compared to control RA patients. Seventy-four RA patients (32.4% male) admitted to an ICU due to infection (from January 2002 to December 2013) and 74 frequency-matched control RA patients (16.2% male) were included in this cross-sectional study. There was strong evidence for a higher RABBIT risk score in ICU patients (median 2.0; IQR 1.3-3.2) as compared to controls (1.3; IQR 0.8-2.0; p < 0.0001). Traditional disease-modifying anti-rheumatic drugs (DMARDs) (82.4 vs 64.9%; p = 0.015) and biological DMARDs (28.4 vs 14.9%; p = 0.012) were more frequently given to RA patients without ICU admission. Glucocorticoid users were more frequently found in the ICU group (51.4 vs 31.1%; p = 0.012). In a multivariable analysis tDMARD use was associated with lower (OR 0.38; 95% CI 0.15-0.93; p = 0.034) and glucocorticoid use with borderline higher odds of ICU admission (OR 2.05; 95% CI 0.92-4.58; p = 0.078). Chronic obstructive pulmonary disease (OR 2.89; 95% CI 1.10-7.54; p = 0.03), chronic kidney disease (OR 16.08; 95% CI 2.00-129.48; p = 0.009), and age category (OR 2.67; 95% CI 1.46-4.87; p = 0.001) were strongly associated with ICU admission. There was a strong trend towards higher odds of ICU admission with increasing RABBIT risk score. Use of tDMARDs was associated with lower odds of ICU admission. In an adjusted analysis, bDMARDs were not associated with ICU admission. COPD, CKD, and age were strong risk factors for ICU admission.

Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units

“…Although the reported HBV-related mortality ranges from 1.9% to 4.0% in Taiwanese patients with RA [33], all three patients with HBV reactivation in our study died of liver failure, suggesting that the prevention of HBV reactivation is important. A previous study proved that the risk factors for the ICU admission of RA patients due to infection included the non-use of csDMARDs, old age, and comorbidity with COPD or CKD [15]. The current study found that the majority of the 30-day mortality group admitted to our ICU due to infection was nonsurvivors.…”

“…The current study found that the majority of the 30-day mortality group admitted to our ICU due to infection was nonsurvivors. Immunosuppressive treatments, including bDMARDs, csDMARDs, and glucocorticoids, are reportedly associated with infection [15,[34][35][36][37][38][39], whereas we found that the use of csDMARDs reduced the risk of mortality after ICU admission using the multivariate Cox proportional hazards model. Additionally, despite the lack of a signi cant difference in dose-related risk of glucocorticoids in the multivariate analysis, a higher glucocorticoid dose appeared to be associated with an increased risk of mortality.…”

“…Additionally, despite the lack of a signi cant difference in dose-related risk of glucocorticoids in the multivariate analysis, a higher glucocorticoid dose appeared to be associated with an increased risk of mortality. Based on previous reports on the risks related to infections and medications, including glucocorticoid, csDMARDs, and bDMARDs [6,15,17,36,39,40] [35,41], a dose-related glucocorticoid was reported to increase the risk of infection, whereas csDMARDs were reported to reduce the risk and mortality in RA [42] [15,43]. Treatment with glucocorticoids raised the incidence and hazard of adverse effects in RA patients, such as diabetes mellitus, osteoporosis, thrombotic stroke, CVD, serious infection, and death [44][45][46].…”

“…RA patients often have several comorbidities, and previous studies have reported the risk factors for ICU admission and mortality, such as pulmonary disorder, renal dysfunction, and hypertension [6,13,15]. To evaluate comorbidities, we calculated the updated CCI, which can be used to predict hospital mortality [20].…”

“…shows the univariate and multivariate Cox proportional hazards models for mortality after ICU admission. The signi cant factors after univariate analyses, including glucocorticoid dose, updated CCI, APACHE II score, platelet number, and PT-INR, and previously reported prognostic factors, including sex, age, duration of RA, and use of csDMARDs or b/tsDMARDs,[6,8,15] were selected using the Lasso approach. This was done after the analysis of the prognostic factors for survival after ICU admission from the isolated variables (use of csDMARDs, glucocorticoid dose, updated CCI, APACHE II score, platelet number, and PT-INR) using the multivariate Cox proportional hazards model.…”