Risk of first and recurrent serious infection in sarcoidosis: a Swedish register-based cohort study

Abstract

Serious infections (SI) impair quality of life and increase costs. Our aim was to determine if sarcoidosis is associated with a higher rate of SI and whether this varies by age, sex, time since diagnosis, or treatment status around diagnosis.We compared individuals with sarcoidosis (≥2 ICD codes in the Swedish National Patient Register 2003–2013; n=8737) and general population comparators matched 10:1 on age, sex, and residential location (n=86 376). Patients diagnosed 2006–2013 who were dispensed ≥1 immunosuppressant ±3 months from diagnosis (Prescribed Drug Register) were identified. Cases and comparators were followed in the National Patient Register for hospitalisations for infection. Using Cox and flexible parametric models, we estimated adjusted hazard ratios and 95% confidence intervals (aHR;CI) for first and recurrent SIs (new SI >30 days after the previous).We identified 895 first SIs in sarcoidosis and 3881 in comparators. The rate of SI was 1.8-fold increased in sarcoidosis compared to the general population (aHR 1.81 [95%CI 1.65, 1.98]). The aHR was higher in females than males and during the first 2 years of follow-up. Sarcoidosis cases treated with immunosuppressants around diagnosis had a threefold increased risk whereas non-treated patients had a 50% increased risk. The rate of SI recurrence was 2.8-fold higher in cases than in comparators.SIs are more common in sarcoidosis than in the general population, particularly during the first few years after diagnosis. Patients who need immunosuppressant treatment around diagnosis are twice as likely to develop a serious infection than those who do not.

Sarcoidosis in a time of pandemic

“…On the one hand, patients can be reassured that opportunistic infection is infrequent despite high corticosteroid use. This is shown in previous studies [8][9][10], and in the current study data, where after adjustment for having one or more healthcare visits in the 2 years prior to diagnosis, the risk of SI in untreated, newly diagnosed patients sarcoidosis appeared to be minimal (adjusted HR 1.03, 95% CI 0.88-1.22) [4]. On the other hand, risk for serious infections (i.e.…”

“…Patients can relapse upon withdrawal, thus these agents are often prescribed for prolonged periods resulting in side-effects that can significantly impact quality of life [14]. In the current analysis, risk of first SI was three-fold higher among those treated with immunosuppressants compared to those who were not [4]. Although the indications for therapy, the length of therapy, and the cumulative dose of immunosuppressants used in the sarcoidosis cohort are unknown, prescribed treatment alone at the start of diagnosis was sufficient to increase one's risk for infection.…”

“…The current paper by ROSSIDES et al [4] re-emphasises this latter observation; the negative impact of therapy. Immunosuppressive therapy is recommended, according to Wells's Law [12], for impaired quality of life or fear of danger (i.e.…”

“…transportation, insurance co-payments) may make multiple clinic visits burdensome [19]. However, Sweden has a tax-funded, universally accessible healthcare system, therefore, it is not clear from the current analysis whether Swedish patients face similar impediments to care [4]. Additionally, Sweden and the USA differ in terms of racial composition, healthcare access, and the distribution of chronic health conditions (e.g.…”

“…On the other hand, risk for serious infections (i.e. hospitaliseable infection) is higher in treated, newly diagnosed patients [4]. Should sarcoidosis patients be worried about COVID-19 specifically?…”