Rheumatoid Arthritis

Prescribing low-dose aspirin to all women at high risk for preeclampsia and women with two or more moderate risk factors is the most cost-beneficial approach to lowering the risk of preeclampsia, according to a new study.

The study, which modeled four approaches to low-dose aspirin prophylaxis in pregnant women, shows that the approach recommended by the U.S. Preventive Services Task Force is superior to the one currently recommended by the American College of Obstetricians and Gynecologists when it comes to lowering the risk of preeclampsia and reducing costs (Obstet Gynecol 2015. doi: 10.1097/AOG.0000000000001115).

Dr. Erika F. Werner and her colleagues at Brown University, Providence, R.I., used a hypothetical cohort of four million U.S. women to analyze the effectiveness of four distinct distribution models for low-dose aspirin prophylaxis: no prophylaxis; following the ACOG recommendations; following the USPSTF recommendations; and universal prophylaxis.

©American Heart Association

Prior randomized studies have established that low-dose aspirin prophylaxis lowers the risk of preeclampsia and preterm birth, the authors wrote. “The remaining question over low-dose aspirin use in pregnancy is not a scientific one, but rather a question of health policy: Who should be treated and what are the expected risks, benefits, and costs of one policy, compared with another?”

ACOG recommends that low-dose aspirin be given to pregnant women with a history of preeclampsia necessitating delivery before 34 weeks of gestation and to women with preeclampsia in more than one prior pregnancy. The USPSTF, on the other hand, takes a broader approach, recommending that women with a history of preeclampsia and those with multiple gestation, chronic hypertension, diabetes mellitus, renal disease, or autoimmune disease should receive low-dose aspirin. Women with two or more moderate risk factors such as nulliparity, obesity, African American race, age 35 years or older, a family history of preeclampsia, or a personal history of pregnancy complications should also receive aspirin, according to the USPSTF.

Under the decision model created by the researchers, women were assumed to be 77% compliant with adhering to their aspirin regimen of 81 mg daily.

Without any aspirin prophylaxis, researchers estimated that the rate of preeclampsia in this population would be 4.18%, meaning 167,200 women would develop preeclampsia. If ACOG’s approach were followed, the rate would dip to 4.17% (166,720 women). But following the USPSTF’s recommendations would result in a 3.83% rate of preeclampsia (153,160), while universal administration of low-dose aspirin prophylaxis would result in a rate of 3.81% (152,240).

The more widespread use of aspirin would also reduce preterm births and maternal deaths, but increase significant maternal gastrointestinal bleeding events, placental abruption, and aspirin-exacerbated respiratory disease, according to the study.

In the baseline analysis, the USPSTF approach was the most cost beneficial, with a direct annual medical cost savings of more than $364 million when compared with the ACOG approach.

“Our analysis suggests that the U.S. Preventive Services Task Force approach is the most cost beneficial, achieving 94% of the possible preeclampsia rate reduction that can be obtained with aspirin while exposing only one-fourth of pregnant women to the theoretical risks of aspirin,” the researchers wrote.

When compared with the USPSTF approach, universal administration would require more than 3 million women to take aspirin to prevent 920 cases of preeclampsia, an incremental number needed to treat of 3,325. Even after taking this into account, universal coverage would still be “highly cost-effective” and would maximize reductions in preterm birth and preeclampsia, according to the researchers.

“From the standpoint of parsimony, and minimization of potential aspirin risks, the U.S. Preventive Services Task Force approach is a better approach than universal administration,” the researchers wrote. “However, universal administration, with its ease of implementation and potential to maximize the health benefits of aspirin, may in fact be the more rational and clinically pragmatic approach.”

The researchers reported having no financial disclosures.

dchitnis@frontlinemedcom.com

Prescribing low-dose aspirin to all women at high risk for preeclampsia and women with two or more moderate risk factors is the most cost-beneficial approach to lowering the risk of preeclampsia, according to a new study.

The study, which modeled four approaches to low-dose aspirin prophylaxis in pregnant women, shows that the approach recommended by the U.S. Preventive Services Task Force is superior to the one currently recommended by the American College of Obstetricians and Gynecologists when it comes to lowering the risk of preeclampsia and reducing costs (Obstet Gynecol 2015. doi: 10.1097/AOG.0000000000001115).

Dr. Erika F. Werner and her colleagues at Brown University, Providence, R.I., used a hypothetical cohort of four million U.S. women to analyze the effectiveness of four distinct distribution models for low-dose aspirin prophylaxis: no prophylaxis; following the ACOG recommendations; following the USPSTF recommendations; and universal prophylaxis.

©American Heart Association

Prior randomized studies have established that low-dose aspirin prophylaxis lowers the risk of preeclampsia and preterm birth, the authors wrote. “The remaining question over low-dose aspirin use in pregnancy is not a scientific one, but rather a question of health policy: Who should be treated and what are the expected risks, benefits, and costs of one policy, compared with another?”

ACOG recommends that low-dose aspirin be given to pregnant women with a history of preeclampsia necessitating delivery before 34 weeks of gestation and to women with preeclampsia in more than one prior pregnancy. The USPSTF, on the other hand, takes a broader approach, recommending that women with a history of preeclampsia and those with multiple gestation, chronic hypertension, diabetes mellitus, renal disease, or autoimmune disease should receive low-dose aspirin. Women with two or more moderate risk factors such as nulliparity, obesity, African American race, age 35 years or older, a family history of preeclampsia, or a personal history of pregnancy complications should also receive aspirin, according to the USPSTF.

Under the decision model created by the researchers, women were assumed to be 77% compliant with adhering to their aspirin regimen of 81 mg daily.

Without any aspirin prophylaxis, researchers estimated that the rate of preeclampsia in this population would be 4.18%, meaning 167,200 women would develop preeclampsia. If ACOG’s approach were followed, the rate would dip to 4.17% (166,720 women). But following the USPSTF’s recommendations would result in a 3.83% rate of preeclampsia (153,160), while universal administration of low-dose aspirin prophylaxis would result in a rate of 3.81% (152,240).

The more widespread use of aspirin would also reduce preterm births and maternal deaths, but increase significant maternal gastrointestinal bleeding events, placental abruption, and aspirin-exacerbated respiratory disease, according to the study.

In the baseline analysis, the USPSTF approach was the most cost beneficial, with a direct annual medical cost savings of more than $364 million when compared with the ACOG approach.

“Our analysis suggests that the U.S. Preventive Services Task Force approach is the most cost beneficial, achieving 94% of the possible preeclampsia rate reduction that can be obtained with aspirin while exposing only one-fourth of pregnant women to the theoretical risks of aspirin,” the researchers wrote.

When compared with the USPSTF approach, universal administration would require more than 3 million women to take aspirin to prevent 920 cases of preeclampsia, an incremental number needed to treat of 3,325. Even after taking this into account, universal coverage would still be “highly cost-effective” and would maximize reductions in preterm birth and preeclampsia, according to the researchers.

“From the standpoint of parsimony, and minimization of potential aspirin risks, the U.S. Preventive Services Task Force approach is a better approach than universal administration,” the researchers wrote. “However, universal administration, with its ease of implementation and potential to maximize the health benefits of aspirin, may in fact be the more rational and clinically pragmatic approach.”

The researchers reported having no financial disclosures.

dchitnis@frontlinemedcom.com

Prescribing low-dose aspirin to all women at high risk for preeclampsia and women with two or more moderate risk factors is the most cost-beneficial approach to lowering the risk of preeclampsia, according to a new study.

The study, which modeled four approaches to low-dose aspirin prophylaxis in pregnant women, shows that the approach recommended by the U.S. Preventive Services Task Force is superior to the one currently recommended by the American College of Obstetricians and Gynecologists when it comes to lowering the risk of preeclampsia and reducing costs (Obstet Gynecol 2015. doi: 10.1097/AOG.0000000000001115).

Dr. Erika F. Werner and her colleagues at Brown University, Providence, R.I., used a hypothetical cohort of four million U.S. women to analyze the effectiveness of four distinct distribution models for low-dose aspirin prophylaxis: no prophylaxis; following the ACOG recommendations; following the USPSTF recommendations; and universal prophylaxis.

©American Heart Association

Prior randomized studies have established that low-dose aspirin prophylaxis lowers the risk of preeclampsia and preterm birth, the authors wrote. “The remaining question over low-dose aspirin use in pregnancy is not a scientific one, but rather a question of health policy: Who should be treated and what are the expected risks, benefits, and costs of one policy, compared with another?”

ACOG recommends that low-dose aspirin be given to pregnant women with a history of preeclampsia necessitating delivery before 34 weeks of gestation and to women with preeclampsia in more than one prior pregnancy. The USPSTF, on the other hand, takes a broader approach, recommending that women with a history of preeclampsia and those with multiple gestation, chronic hypertension, diabetes mellitus, renal disease, or autoimmune disease should receive low-dose aspirin. Women with two or more moderate risk factors such as nulliparity, obesity, African American race, age 35 years or older, a family history of preeclampsia, or a personal history of pregnancy complications should also receive aspirin, according to the USPSTF.

Under the decision model created by the researchers, women were assumed to be 77% compliant with adhering to their aspirin regimen of 81 mg daily.

Without any aspirin prophylaxis, researchers estimated that the rate of preeclampsia in this population would be 4.18%, meaning 167,200 women would develop preeclampsia. If ACOG’s approach were followed, the rate would dip to 4.17% (166,720 women). But following the USPSTF’s recommendations would result in a 3.83% rate of preeclampsia (153,160), while universal administration of low-dose aspirin prophylaxis would result in a rate of 3.81% (152,240).

The more widespread use of aspirin would also reduce preterm births and maternal deaths, but increase significant maternal gastrointestinal bleeding events, placental abruption, and aspirin-exacerbated respiratory disease, according to the study.

In the baseline analysis, the USPSTF approach was the most cost beneficial, with a direct annual medical cost savings of more than $364 million when compared with the ACOG approach.

“Our analysis suggests that the U.S. Preventive Services Task Force approach is the most cost beneficial, achieving 94% of the possible preeclampsia rate reduction that can be obtained with aspirin while exposing only one-fourth of pregnant women to the theoretical risks of aspirin,” the researchers wrote.

When compared with the USPSTF approach, universal administration would require more than 3 million women to take aspirin to prevent 920 cases of preeclampsia, an incremental number needed to treat of 3,325. Even after taking this into account, universal coverage would still be “highly cost-effective” and would maximize reductions in preterm birth and preeclampsia, according to the researchers.

“From the standpoint of parsimony, and minimization of potential aspirin risks, the U.S. Preventive Services Task Force approach is a better approach than universal administration,” the researchers wrote. “However, universal administration, with its ease of implementation and potential to maximize the health benefits of aspirin, may in fact be the more rational and clinically pragmatic approach.”

The researchers reported having no financial disclosures.

dchitnis@frontlinemedcom.com

SAN FRANCISCO – Obese patients with rheumatoid arthritis are significantly less likely to achieve sustained disease remission than are their peers who are normal weight or overweight, based on data reported at the annual meeting of the American College of Rheumatology.

In an analysis of more than 1,000 patients with RA from the multicenter, prospective CATCH (Canadian Early Arthritis Cohort) study, about 28% of obese (body mass index of 30 kg/m² or greater) patients achieved sustained remission, defined as a 28-joint Disease Activity Score of 2.6 or less at two consecutive clinical visits.

In contrast, 38% of overweight (BMI 25-29.9) and 48% of normal-weight (BMI 18.5-24.9) patients reached that goal, said Dr. Vivian P. Bykerk, director of the Inflammatory Arthritis Center of Excellence at the Hospital for Special Surgery, New York, and a clinical researcher at Weill Cornell Medical College, New York. In an exclusive video interview, Dr. Bykerk discusses the findings and their implications.

Dr. Bykerk is the founder and principal investigator for the CATCH study, which is sponsored by Amgen, Pfizer, Hoffmann-La Roche, UCB Canada, Bristol-Myers Squibb, AbbVie, and Janssen Biotech.

SAN FRANCISCO – Obese patients with rheumatoid arthritis are significantly less likely to achieve sustained disease remission than are their peers who are normal weight or overweight, based on data reported at the annual meeting of the American College of Rheumatology.

In an analysis of more than 1,000 patients with RA from the multicenter, prospective CATCH (Canadian Early Arthritis Cohort) study, about 28% of obese (body mass index of 30 kg/m² or greater) patients achieved sustained remission, defined as a 28-joint Disease Activity Score of 2.6 or less at two consecutive clinical visits.

In contrast, 38% of overweight (BMI 25-29.9) and 48% of normal-weight (BMI 18.5-24.9) patients reached that goal, said Dr. Vivian P. Bykerk, director of the Inflammatory Arthritis Center of Excellence at the Hospital for Special Surgery, New York, and a clinical researcher at Weill Cornell Medical College, New York. In an exclusive video interview, Dr. Bykerk discusses the findings and their implications.

Dr. Bykerk is the founder and principal investigator for the CATCH study, which is sponsored by Amgen, Pfizer, Hoffmann-La Roche, UCB Canada, Bristol-Myers Squibb, AbbVie, and Janssen Biotech.

SAN FRANCISCO – Obese patients with rheumatoid arthritis are significantly less likely to achieve sustained disease remission than are their peers who are normal weight or overweight, based on data reported at the annual meeting of the American College of Rheumatology.

In an analysis of more than 1,000 patients with RA from the multicenter, prospective CATCH (Canadian Early Arthritis Cohort) study, about 28% of obese (body mass index of 30 kg/m² or greater) patients achieved sustained remission, defined as a 28-joint Disease Activity Score of 2.6 or less at two consecutive clinical visits.

In contrast, 38% of overweight (BMI 25-29.9) and 48% of normal-weight (BMI 18.5-24.9) patients reached that goal, said Dr. Vivian P. Bykerk, director of the Inflammatory Arthritis Center of Excellence at the Hospital for Special Surgery, New York, and a clinical researcher at Weill Cornell Medical College, New York. In an exclusive video interview, Dr. Bykerk discusses the findings and their implications.

Dr. Bykerk is the founder and principal investigator for the CATCH study, which is sponsored by Amgen, Pfizer, Hoffmann-La Roche, UCB Canada, Bristol-Myers Squibb, AbbVie, and Janssen Biotech.

San Francisco – Treat-to-target should be the goal of every office visit for rheumatoid arthritis, according to a joint European and North American investigation involving more than 500 patients.

That’s because it works, explained study investigator Dr. Sofia Ramiro, a rheumatology fellow at Leiden (the Netherlands) University Medical Center.

The study confirms what has long been suspected but not exactly demonstrated before in a robust, real-world setting, she noted. The findings also suggest that some rheumatoid arthritis patients probably could be pushed harder toward remission.

In an interview at the annual meeting of the American College of Rheumatology, Dr. Ramiro explained the project and why it matters for clinical care.

aotto@frontlinemedcom.com

San Francisco – Treat-to-target should be the goal of every office visit for rheumatoid arthritis, according to a joint European and North American investigation involving more than 500 patients.

That’s because it works, explained study investigator Dr. Sofia Ramiro, a rheumatology fellow at Leiden (the Netherlands) University Medical Center.

The study confirms what has long been suspected but not exactly demonstrated before in a robust, real-world setting, she noted. The findings also suggest that some rheumatoid arthritis patients probably could be pushed harder toward remission.

In an interview at the annual meeting of the American College of Rheumatology, Dr. Ramiro explained the project and why it matters for clinical care.

aotto@frontlinemedcom.com

San Francisco – Treat-to-target should be the goal of every office visit for rheumatoid arthritis, according to a joint European and North American investigation involving more than 500 patients.

That’s because it works, explained study investigator Dr. Sofia Ramiro, a rheumatology fellow at Leiden (the Netherlands) University Medical Center.

The study confirms what has long been suspected but not exactly demonstrated before in a robust, real-world setting, she noted. The findings also suggest that some rheumatoid arthritis patients probably could be pushed harder toward remission.

In an interview at the annual meeting of the American College of Rheumatology, Dr. Ramiro explained the project and why it matters for clinical care.

aotto@frontlinemedcom.com

SAN FRANCISCO – Deaths from cardiovascular disease are declining in rheumatoid arthritis patients diagnosed after the year 2000, compared with previous decades, according to a new study presented at the annual meeting of the American College of Rheumatology.

The study researchers found significant improvement in the relative 10-year cardiovascular mortality rate, including coronary heart disease mortality, in people with RA in the years 2000-2007, compared with previous decades, explained lead investigator Dr. Elena Myasoedova, assistant professor of medicine at the Mayo Clinic, Rochester, Minn.,

In a video interview, Dr. Myasoedova talked about the trends identified in the study, which included 315 people who developed RA between 2000 and 2007, 498 people who developed RA in earlier years, and 813 people without RA.

Dr. Myasoedova had no relevant financial disclosures.

SAN FRANCISCO – Deaths from cardiovascular disease are declining in rheumatoid arthritis patients diagnosed after the year 2000, compared with previous decades, according to a new study presented at the annual meeting of the American College of Rheumatology.

The study researchers found significant improvement in the relative 10-year cardiovascular mortality rate, including coronary heart disease mortality, in people with RA in the years 2000-2007, compared with previous decades, explained lead investigator Dr. Elena Myasoedova, assistant professor of medicine at the Mayo Clinic, Rochester, Minn.,

In a video interview, Dr. Myasoedova talked about the trends identified in the study, which included 315 people who developed RA between 2000 and 2007, 498 people who developed RA in earlier years, and 813 people without RA.

Dr. Myasoedova had no relevant financial disclosures.

SAN FRANCISCO – Deaths from cardiovascular disease are declining in rheumatoid arthritis patients diagnosed after the year 2000, compared with previous decades, according to a new study presented at the annual meeting of the American College of Rheumatology.

The study researchers found significant improvement in the relative 10-year cardiovascular mortality rate, including coronary heart disease mortality, in people with RA in the years 2000-2007, compared with previous decades, explained lead investigator Dr. Elena Myasoedova, assistant professor of medicine at the Mayo Clinic, Rochester, Minn.,

In a video interview, Dr. Myasoedova talked about the trends identified in the study, which included 315 people who developed RA between 2000 and 2007, 498 people who developed RA in earlier years, and 813 people without RA.

Dr. Myasoedova had no relevant financial disclosures.

SAN FRANCISCO – Mortality rates are declining in people with rheumatoid arthritis (RA) and more closely match those in the general population, according to a retrospective, population-based study reported at the annual meeting of the American College of Rheumatology.

The study did not identify why deaths from cardiovascular disease and cancer declined in people diagnosed with RA in the years 2001-2006, compared with those diagnosed between 1996 and 2000. But the findings suggest that the decline is related to earlier and more aggressive treatment of RA, as well as recognition of the importance of managing cardiovascular risk factors in patients with the disease.

In a video interview, the study’s lead investigator, Dr. Diane Lacaille, professor of rheumatology at the University of British Columbia, Vancouver, discussed the study findings and the implications for management of inflammation in both RA and cardiovascular disease.

Dr. Lacaille had no relevant financial disclosures to report.

SAN FRANCISCO – Mortality rates are declining in people with rheumatoid arthritis (RA) and more closely match those in the general population, according to a retrospective, population-based study reported at the annual meeting of the American College of Rheumatology.

The study did not identify why deaths from cardiovascular disease and cancer declined in people diagnosed with RA in the years 2001-2006, compared with those diagnosed between 1996 and 2000. But the findings suggest that the decline is related to earlier and more aggressive treatment of RA, as well as recognition of the importance of managing cardiovascular risk factors in patients with the disease.

In a video interview, the study’s lead investigator, Dr. Diane Lacaille, professor of rheumatology at the University of British Columbia, Vancouver, discussed the study findings and the implications for management of inflammation in both RA and cardiovascular disease.

Dr. Lacaille had no relevant financial disclosures to report.

SAN FRANCISCO – Mortality rates are declining in people with rheumatoid arthritis (RA) and more closely match those in the general population, according to a retrospective, population-based study reported at the annual meeting of the American College of Rheumatology.

The study did not identify why deaths from cardiovascular disease and cancer declined in people diagnosed with RA in the years 2001-2006, compared with those diagnosed between 1996 and 2000. But the findings suggest that the decline is related to earlier and more aggressive treatment of RA, as well as recognition of the importance of managing cardiovascular risk factors in patients with the disease.

In a video interview, the study’s lead investigator, Dr. Diane Lacaille, professor of rheumatology at the University of British Columbia, Vancouver, discussed the study findings and the implications for management of inflammation in both RA and cardiovascular disease.

Dr. Lacaille had no relevant financial disclosures to report.

Stroke risk was 50% higher in the month after patients with autoimmune diseases developed herpes zoster, compared with the next 2-6 years, according to Dr. Leonard H. Calabrese.

“These data provide urgency for developing strategies to reduce the risk of varicella zoster virus in vulnerable immunosuppressed patients,” said Dr. Calabrese of the department of rheumatic and immunologic diseases at the Cleveland Clinic.

Immunosuppressive therapies increase the frequency and complexity of herpes zoster, which is a known risk factor for stroke. To examine the temporal relationship between herpes zoster and stroke among immunosuppressed patients, Dr. Calabrese and his associates studied Medicare data for almost 51,000 patients with new-onset herpes zoster who also had physician-diagnosed ankylosing spondylitis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or rheumatoid arthritis. The researchers excluded patients with a history of stroke.

In the multivariable analysis, stroke was 1.5 times more likely during the 6 months immediately after herpes zoster than in the 2-6 years after herpes zoster (95% confidence interval, 1.06-2.12). During this 6-month window, there were 9.8 strokes per 1,000 person-years, compared with 8.7 per 1,000 person-years in the 2-6 years after herpes zoster. Stroke risk also remained somewhat elevated during the entire year after herpes zoster (incidence rate ratio, 1.3; 95% CI, 1.05-1.61).

In general, stroke was more likely to occur among patients who were older, were receiving high-dose glucocorticoids, or had diabetes, hypertension, atrial fibrillation, or a history of transient ischemic attack, he said at the annual meeting of the American College of Rheumatology in San Francisco.

Dr. Calabrese disclosed relationships with Bristol-Myers Squibb, Crescendo, AbbVie, Genentech, Biogen, Pfizer, Sanofi-Aventis Pharmaceutical, and Johnson & Johnson. Two coauthors also disclosed relationships with several pharmaceutical companies. The other four coinvestigators had no disclosures.

Stroke risk was 50% higher in the month after patients with autoimmune diseases developed herpes zoster, compared with the next 2-6 years, according to Dr. Leonard H. Calabrese.

“These data provide urgency for developing strategies to reduce the risk of varicella zoster virus in vulnerable immunosuppressed patients,” said Dr. Calabrese of the department of rheumatic and immunologic diseases at the Cleveland Clinic.

Immunosuppressive therapies increase the frequency and complexity of herpes zoster, which is a known risk factor for stroke. To examine the temporal relationship between herpes zoster and stroke among immunosuppressed patients, Dr. Calabrese and his associates studied Medicare data for almost 51,000 patients with new-onset herpes zoster who also had physician-diagnosed ankylosing spondylitis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or rheumatoid arthritis. The researchers excluded patients with a history of stroke.

In the multivariable analysis, stroke was 1.5 times more likely during the 6 months immediately after herpes zoster than in the 2-6 years after herpes zoster (95% confidence interval, 1.06-2.12). During this 6-month window, there were 9.8 strokes per 1,000 person-years, compared with 8.7 per 1,000 person-years in the 2-6 years after herpes zoster. Stroke risk also remained somewhat elevated during the entire year after herpes zoster (incidence rate ratio, 1.3; 95% CI, 1.05-1.61).

In general, stroke was more likely to occur among patients who were older, were receiving high-dose glucocorticoids, or had diabetes, hypertension, atrial fibrillation, or a history of transient ischemic attack, he said at the annual meeting of the American College of Rheumatology in San Francisco.

Dr. Calabrese disclosed relationships with Bristol-Myers Squibb, Crescendo, AbbVie, Genentech, Biogen, Pfizer, Sanofi-Aventis Pharmaceutical, and Johnson & Johnson. Two coauthors also disclosed relationships with several pharmaceutical companies. The other four coinvestigators had no disclosures.

Stroke risk was 50% higher in the month after patients with autoimmune diseases developed herpes zoster, compared with the next 2-6 years, according to Dr. Leonard H. Calabrese.

“These data provide urgency for developing strategies to reduce the risk of varicella zoster virus in vulnerable immunosuppressed patients,” said Dr. Calabrese of the department of rheumatic and immunologic diseases at the Cleveland Clinic.

Immunosuppressive therapies increase the frequency and complexity of herpes zoster, which is a known risk factor for stroke. To examine the temporal relationship between herpes zoster and stroke among immunosuppressed patients, Dr. Calabrese and his associates studied Medicare data for almost 51,000 patients with new-onset herpes zoster who also had physician-diagnosed ankylosing spondylitis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or rheumatoid arthritis. The researchers excluded patients with a history of stroke.

In the multivariable analysis, stroke was 1.5 times more likely during the 6 months immediately after herpes zoster than in the 2-6 years after herpes zoster (95% confidence interval, 1.06-2.12). During this 6-month window, there were 9.8 strokes per 1,000 person-years, compared with 8.7 per 1,000 person-years in the 2-6 years after herpes zoster. Stroke risk also remained somewhat elevated during the entire year after herpes zoster (incidence rate ratio, 1.3; 95% CI, 1.05-1.61).

In general, stroke was more likely to occur among patients who were older, were receiving high-dose glucocorticoids, or had diabetes, hypertension, atrial fibrillation, or a history of transient ischemic attack, he said at the annual meeting of the American College of Rheumatology in San Francisco.

Dr. Calabrese disclosed relationships with Bristol-Myers Squibb, Crescendo, AbbVie, Genentech, Biogen, Pfizer, Sanofi-Aventis Pharmaceutical, and Johnson & Johnson. Two coauthors also disclosed relationships with several pharmaceutical companies. The other four coinvestigators had no disclosures.

Protection against shingles appeared to wane between the fifth and sixth years after patients with autoimmune diseases received the live herpes zoster vaccine, according to a large retrospective cohort study presented at the annual meeting of the American College of Rheumatology.

In contrast, shingles risk remained fairly constant among unvaccinated patients, reported Dr. Huifeng Yun, assistant professor of epidemiology at the University of Alabama, Birmingham. Based on the findings, clinicians could consider revaccinating patients with autoimmune diseases about 5 years after their first live herpes zoster vaccine, she said.*

© clsgraphics/iStockphoto.com

The long-term Shingles Prevention Study recently showed that the live herpes zoster vaccine is effective for about a decade among healthy older individuals, but the duration of protection for patients with autoimmune diseases was unclear, the investigators said. Therefore, they retrospectively studied Medicare data for more than 130,000 such patients between 2006 and 2012. About one-third of patients were vaccinated against herpes zoster, and 47% had rheumatoid arthritis, 32% had psoriasis, 21% had inflammatory bowel disease, 5% had psoriatic arthritis, and 1% had ankylosing spondylitis.

Rates of herpes zoster among vaccinated patients rose from 0.75 per 100 person-years during the first year after vaccination to 1.36 during the sixth year. In the adjusted analysis, vaccinated patients had about half the risk of herpes zoster, compared with unvaccinated patients, during year 1 (relative risk, 0.52; 95% confidence interval, 0.45-0.61) and remained substantially less likely to develop shingles until year 6, when the gap in risk between vaccinated and unvaccinated patients essentially closed (RR, 0.92; 95% CI, 0.45-1.86). There was no overall change in risk among unvaccinated patients during the study period, the investigators noted.

Dr. Yun disclosed a financial relationship with Amgen. The senior author and two coauthors also disclosed relationships with several pharmaceutical companies. Two investigators had no disclosures.

* Correction, 11/13/2015: The article previously misstated Dr. Yun's gender.

rhnews@frontlinemedcom.com

Protection against shingles appeared to wane between the fifth and sixth years after patients with autoimmune diseases received the live herpes zoster vaccine, according to a large retrospective cohort study presented at the annual meeting of the American College of Rheumatology.

In contrast, shingles risk remained fairly constant among unvaccinated patients, reported Dr. Huifeng Yun, assistant professor of epidemiology at the University of Alabama, Birmingham. Based on the findings, clinicians could consider revaccinating patients with autoimmune diseases about 5 years after their first live herpes zoster vaccine, she said.*

© clsgraphics/iStockphoto.com

The long-term Shingles Prevention Study recently showed that the live herpes zoster vaccine is effective for about a decade among healthy older individuals, but the duration of protection for patients with autoimmune diseases was unclear, the investigators said. Therefore, they retrospectively studied Medicare data for more than 130,000 such patients between 2006 and 2012. About one-third of patients were vaccinated against herpes zoster, and 47% had rheumatoid arthritis, 32% had psoriasis, 21% had inflammatory bowel disease, 5% had psoriatic arthritis, and 1% had ankylosing spondylitis.

Rates of herpes zoster among vaccinated patients rose from 0.75 per 100 person-years during the first year after vaccination to 1.36 during the sixth year. In the adjusted analysis, vaccinated patients had about half the risk of herpes zoster, compared with unvaccinated patients, during year 1 (relative risk, 0.52; 95% confidence interval, 0.45-0.61) and remained substantially less likely to develop shingles until year 6, when the gap in risk between vaccinated and unvaccinated patients essentially closed (RR, 0.92; 95% CI, 0.45-1.86). There was no overall change in risk among unvaccinated patients during the study period, the investigators noted.

Dr. Yun disclosed a financial relationship with Amgen. The senior author and two coauthors also disclosed relationships with several pharmaceutical companies. Two investigators had no disclosures.

* Correction, 11/13/2015: The article previously misstated Dr. Yun's gender.

rhnews@frontlinemedcom.com

Protection against shingles appeared to wane between the fifth and sixth years after patients with autoimmune diseases received the live herpes zoster vaccine, according to a large retrospective cohort study presented at the annual meeting of the American College of Rheumatology.

In contrast, shingles risk remained fairly constant among unvaccinated patients, reported Dr. Huifeng Yun, assistant professor of epidemiology at the University of Alabama, Birmingham. Based on the findings, clinicians could consider revaccinating patients with autoimmune diseases about 5 years after their first live herpes zoster vaccine, she said.*

© clsgraphics/iStockphoto.com

The long-term Shingles Prevention Study recently showed that the live herpes zoster vaccine is effective for about a decade among healthy older individuals, but the duration of protection for patients with autoimmune diseases was unclear, the investigators said. Therefore, they retrospectively studied Medicare data for more than 130,000 such patients between 2006 and 2012. About one-third of patients were vaccinated against herpes zoster, and 47% had rheumatoid arthritis, 32% had psoriasis, 21% had inflammatory bowel disease, 5% had psoriatic arthritis, and 1% had ankylosing spondylitis.

Rates of herpes zoster among vaccinated patients rose from 0.75 per 100 person-years during the first year after vaccination to 1.36 during the sixth year. In the adjusted analysis, vaccinated patients had about half the risk of herpes zoster, compared with unvaccinated patients, during year 1 (relative risk, 0.52; 95% confidence interval, 0.45-0.61) and remained substantially less likely to develop shingles until year 6, when the gap in risk between vaccinated and unvaccinated patients essentially closed (RR, 0.92; 95% CI, 0.45-1.86). There was no overall change in risk among unvaccinated patients during the study period, the investigators noted.

Dr. Yun disclosed a financial relationship with Amgen. The senior author and two coauthors also disclosed relationships with several pharmaceutical companies. Two investigators had no disclosures.

* Correction, 11/13/2015: The article previously misstated Dr. Yun's gender.

rhnews@frontlinemedcom.com

If you haven’t dealt with a chikungunya patient yet, you probably will soon.

The mosquito-borne virus, long considered a tropical disease, is on the upswing in the United States, carried back especially by vacationers returning from the Caribbean. It causes an inflammatory arthritis that’s hard to recognize and treat.

“We’ve actually even had some here in Seattle,” said Dr. Gregory Gardner, a rheumatologist at the University of Washington, Seattle.

So a session this year at the annual meeting of the American College of Rheumatology, “Coming to a Joint Near You: Chikungunya” on Sunday, Nov. 8, at 8:30 a.m., is probably one that attendees won’t want to miss, said Dr. Gardner, one of the many planners of this year’s meeting.

The session will cover chikungunya immunopathology, clinical manifestations, and treatment – just about all you need to know to handle a case. The chikungunya session is just one example of the meeting’s timely, on-point clinical information. Another one that’s likely to be popular is “Maintenance Therapy in ANCA-Associated Vasculitis: Evaluation and Treatment of Patients in Remission,” on Monday, Nov. 9, at 7:30 a.m., and “The Great Debate: Long-Term, Low-Dose Corticosteroid Use in the Treatment of Rheumatoid Arthritis” on Sunday at 2:30 p.m. While some worry about the long-term side effects of steroids in rheumatoid arthritis, others think the approach is safe and possibly even disease modifying, Dr. Gardner said.

The clinical sessions will be complimented by a full slate of original science. “We’ve had more abstracts submitted this year than to any other previous meeting,” over 4,000. “There’s great research being presented,” said Dr. Victoria Shanmugam, a Washington, D.C., rheumatologist and also a planner of this year’s meeting.

Getting into the late-breaking abstract session on Tuesday, Nov. 10, at 4:30 p.m. “was incredibly competitive this year,” she said. Just a handful of the 70 submissions made it. Investigators who did will share their latest findings on tocilizumab for giant cell arteritis; baricitinib versus placebo or adalimumab for rheumatoid arthritis; adalimumab with methotrexate for uveitis in juvenile idiopathic arthritis; epratuzumab in moderate to severe systemic lupus; tofacitinib in ankylosing spondylitis; and interleukin-17a inhibition in active ankylosing spondylitis.

There’ll also be a strong show of original research in the plenary sessions at 11 a.m. Sunday, Monday, and Tuesday. Studies in Tuesday’s session, for instance, include investigations into the pharmacogenetics of allopurinol in gout and the role of anakinra in recurrent pericarditis.

Results from the Scleroderma Lung Study II, which pitted oral cyclophosphamide against mycophenolate mofetil for interstitial lung disease in systemic sclerosis, will be revealed Sunday at 4:30 p.m. in the “Systemic Sclerosis, Fibrosing Syndromes, and Raynaud’s – Clinical Aspects and Therapeutics I” session. Until now, there haven’t been strong prospective data to support the use of mycophenolate in scleroderma lung disease. “There will be a lot of interest in this. People have been waiting for these results to come out,” Dr. Shanmugam said.

Planners have done something new this year by bringing fertility and pregnancy research into its own dedicated abstract session, “Reproductive Issues in Rheumatic Disorders: Basic and Clinical Aspects,” on Monday at 4:30 p.m.

It’s recognition of the central role those issues play in rheumatology. Fertility and pregnancy are a “major clinical challenge we face in daily practice. Our diseases often present during pregnancy, and we tend to have diseases that affect young women. Patients have a lot of questions,” Dr. Shanmugam said.

The abstract session will be a mix of basic and clinical research across a range of rheumatic conditions. The hope is to break down the silos in rheumatology to foster collaboration and move the field forward, she said.

That session will be complemented by “Reproductive Issues in Rheumatology” on Wednesday at 11:00 a.m. – focusing on biologics in pregnancy and pregnancy outcomes in rheumatoid arthritis – as well as “Pregnancy and Infertility in Rheumatic Disease” on Monday at 2:30 p.m.

Macrophage activation is getting its share of attention, too, especially in adults, for instance during the “Nuts and Bolts of Macrophage Activation Syndrome” session on Monday at 8:30 a.m.

“Historically, it’s mainly been studied in children. We wanted to focus on bringing this into adult rheumatology. I think this is going to be a very good session,” Dr. Shanmugam said.

aotto@frontlinemedcom.com

If you haven’t dealt with a chikungunya patient yet, you probably will soon.

The mosquito-borne virus, long considered a tropical disease, is on the upswing in the United States, carried back especially by vacationers returning from the Caribbean. It causes an inflammatory arthritis that’s hard to recognize and treat.

“We’ve actually even had some here in Seattle,” said Dr. Gregory Gardner, a rheumatologist at the University of Washington, Seattle.

So a session this year at the annual meeting of the American College of Rheumatology, “Coming to a Joint Near You: Chikungunya” on Sunday, Nov. 8, at 8:30 a.m., is probably one that attendees won’t want to miss, said Dr. Gardner, one of the many planners of this year’s meeting.

The session will cover chikungunya immunopathology, clinical manifestations, and treatment – just about all you need to know to handle a case. The chikungunya session is just one example of the meeting’s timely, on-point clinical information. Another one that’s likely to be popular is “Maintenance Therapy in ANCA-Associated Vasculitis: Evaluation and Treatment of Patients in Remission,” on Monday, Nov. 9, at 7:30 a.m., and “The Great Debate: Long-Term, Low-Dose Corticosteroid Use in the Treatment of Rheumatoid Arthritis” on Sunday at 2:30 p.m. While some worry about the long-term side effects of steroids in rheumatoid arthritis, others think the approach is safe and possibly even disease modifying, Dr. Gardner said.

The clinical sessions will be complimented by a full slate of original science. “We’ve had more abstracts submitted this year than to any other previous meeting,” over 4,000. “There’s great research being presented,” said Dr. Victoria Shanmugam, a Washington, D.C., rheumatologist and also a planner of this year’s meeting.

Getting into the late-breaking abstract session on Tuesday, Nov. 10, at 4:30 p.m. “was incredibly competitive this year,” she said. Just a handful of the 70 submissions made it. Investigators who did will share their latest findings on tocilizumab for giant cell arteritis; baricitinib versus placebo or adalimumab for rheumatoid arthritis; adalimumab with methotrexate for uveitis in juvenile idiopathic arthritis; epratuzumab in moderate to severe systemic lupus; tofacitinib in ankylosing spondylitis; and interleukin-17a inhibition in active ankylosing spondylitis.

There’ll also be a strong show of original research in the plenary sessions at 11 a.m. Sunday, Monday, and Tuesday. Studies in Tuesday’s session, for instance, include investigations into the pharmacogenetics of allopurinol in gout and the role of anakinra in recurrent pericarditis.

Results from the Scleroderma Lung Study II, which pitted oral cyclophosphamide against mycophenolate mofetil for interstitial lung disease in systemic sclerosis, will be revealed Sunday at 4:30 p.m. in the “Systemic Sclerosis, Fibrosing Syndromes, and Raynaud’s – Clinical Aspects and Therapeutics I” session. Until now, there haven’t been strong prospective data to support the use of mycophenolate in scleroderma lung disease. “There will be a lot of interest in this. People have been waiting for these results to come out,” Dr. Shanmugam said.

Planners have done something new this year by bringing fertility and pregnancy research into its own dedicated abstract session, “Reproductive Issues in Rheumatic Disorders: Basic and Clinical Aspects,” on Monday at 4:30 p.m.

It’s recognition of the central role those issues play in rheumatology. Fertility and pregnancy are a “major clinical challenge we face in daily practice. Our diseases often present during pregnancy, and we tend to have diseases that affect young women. Patients have a lot of questions,” Dr. Shanmugam said.

The abstract session will be a mix of basic and clinical research across a range of rheumatic conditions. The hope is to break down the silos in rheumatology to foster collaboration and move the field forward, she said.

That session will be complemented by “Reproductive Issues in Rheumatology” on Wednesday at 11:00 a.m. – focusing on biologics in pregnancy and pregnancy outcomes in rheumatoid arthritis – as well as “Pregnancy and Infertility in Rheumatic Disease” on Monday at 2:30 p.m.

Macrophage activation is getting its share of attention, too, especially in adults, for instance during the “Nuts and Bolts of Macrophage Activation Syndrome” session on Monday at 8:30 a.m.

“Historically, it’s mainly been studied in children. We wanted to focus on bringing this into adult rheumatology. I think this is going to be a very good session,” Dr. Shanmugam said.

aotto@frontlinemedcom.com

If you haven’t dealt with a chikungunya patient yet, you probably will soon.

The mosquito-borne virus, long considered a tropical disease, is on the upswing in the United States, carried back especially by vacationers returning from the Caribbean. It causes an inflammatory arthritis that’s hard to recognize and treat.

“We’ve actually even had some here in Seattle,” said Dr. Gregory Gardner, a rheumatologist at the University of Washington, Seattle.

So a session this year at the annual meeting of the American College of Rheumatology, “Coming to a Joint Near You: Chikungunya” on Sunday, Nov. 8, at 8:30 a.m., is probably one that attendees won’t want to miss, said Dr. Gardner, one of the many planners of this year’s meeting.

The session will cover chikungunya immunopathology, clinical manifestations, and treatment – just about all you need to know to handle a case. The chikungunya session is just one example of the meeting’s timely, on-point clinical information. Another one that’s likely to be popular is “Maintenance Therapy in ANCA-Associated Vasculitis: Evaluation and Treatment of Patients in Remission,” on Monday, Nov. 9, at 7:30 a.m., and “The Great Debate: Long-Term, Low-Dose Corticosteroid Use in the Treatment of Rheumatoid Arthritis” on Sunday at 2:30 p.m. While some worry about the long-term side effects of steroids in rheumatoid arthritis, others think the approach is safe and possibly even disease modifying, Dr. Gardner said.

The clinical sessions will be complimented by a full slate of original science. “We’ve had more abstracts submitted this year than to any other previous meeting,” over 4,000. “There’s great research being presented,” said Dr. Victoria Shanmugam, a Washington, D.C., rheumatologist and also a planner of this year’s meeting.

Getting into the late-breaking abstract session on Tuesday, Nov. 10, at 4:30 p.m. “was incredibly competitive this year,” she said. Just a handful of the 70 submissions made it. Investigators who did will share their latest findings on tocilizumab for giant cell arteritis; baricitinib versus placebo or adalimumab for rheumatoid arthritis; adalimumab with methotrexate for uveitis in juvenile idiopathic arthritis; epratuzumab in moderate to severe systemic lupus; tofacitinib in ankylosing spondylitis; and interleukin-17a inhibition in active ankylosing spondylitis.

There’ll also be a strong show of original research in the plenary sessions at 11 a.m. Sunday, Monday, and Tuesday. Studies in Tuesday’s session, for instance, include investigations into the pharmacogenetics of allopurinol in gout and the role of anakinra in recurrent pericarditis.

Results from the Scleroderma Lung Study II, which pitted oral cyclophosphamide against mycophenolate mofetil for interstitial lung disease in systemic sclerosis, will be revealed Sunday at 4:30 p.m. in the “Systemic Sclerosis, Fibrosing Syndromes, and Raynaud’s – Clinical Aspects and Therapeutics I” session. Until now, there haven’t been strong prospective data to support the use of mycophenolate in scleroderma lung disease. “There will be a lot of interest in this. People have been waiting for these results to come out,” Dr. Shanmugam said.

Planners have done something new this year by bringing fertility and pregnancy research into its own dedicated abstract session, “Reproductive Issues in Rheumatic Disorders: Basic and Clinical Aspects,” on Monday at 4:30 p.m.

It’s recognition of the central role those issues play in rheumatology. Fertility and pregnancy are a “major clinical challenge we face in daily practice. Our diseases often present during pregnancy, and we tend to have diseases that affect young women. Patients have a lot of questions,” Dr. Shanmugam said.

The abstract session will be a mix of basic and clinical research across a range of rheumatic conditions. The hope is to break down the silos in rheumatology to foster collaboration and move the field forward, she said.

That session will be complemented by “Reproductive Issues in Rheumatology” on Wednesday at 11:00 a.m. – focusing on biologics in pregnancy and pregnancy outcomes in rheumatoid arthritis – as well as “Pregnancy and Infertility in Rheumatic Disease” on Monday at 2:30 p.m.

Macrophage activation is getting its share of attention, too, especially in adults, for instance during the “Nuts and Bolts of Macrophage Activation Syndrome” session on Monday at 8:30 a.m.

“Historically, it’s mainly been studied in children. We wanted to focus on bringing this into adult rheumatology. I think this is going to be a very good session,” Dr. Shanmugam said.

aotto@frontlinemedcom.com

Patients taking opioids for rheumatoid arthritis are at significantly higher risk of serious infection, particularly those taking long-acting formulations or opioids known to have immunosuppressive properties, new data suggest.

While it has been known for some time that opioids have wide-ranging adverse effects, this is the first convincing evidence of an increased risk of infection associated with opioid use in patients with rheumatoid arthritis, Dr. Samuel Whittle, consultant rheumatologist at the Queen Elizabeth Hospital in Adelaide, Australia, said when asked to comment on the study.

©thegoodphoto/thinkstockphotos.com

Dr. Whittle, who was not involved in the study, said that these data add to the growing body of evidence that the adverse effects of opioids outweigh the benefits.

“It fits with our general sense these days that opioids really are a poor choice of analgesics in people with rheumatoid arthritis, but people continue to prescribe them because our analgesic armory is not that good,” he said.

Andrew D. Wiese of Vanderbilt University, Nashville, Tenn., and his colleagues analyzed a retrospective cohort of 1,790 patients with rheumatoid arthritis who were enrolled in Tennessee Medicaid during 1995-2009 and experienced at least one hospitalization for serious infection. The patients served as their own controls during periods of opioid nonuse. The rate of infection in these patients was 39% higher when they were taking opioids, compared with periods of nonuse, after adjusting for age, season, nursing home residency, and medication use.

The rate of infection was twice as high when they were using long-acting opioids, compared with nonuse, and 72% higher for the use of immunosuppressive opioids. New opioid use also more than doubled the risk of serious infection in the study (Arthritis Rheumatol. 2015 Oct 16. doi: 10.1002/art.39462)

Researchers also found evidence of a dose-response effect, as patients taking 60 mg or more of morphine equivalent per day had a 73% greater rate of infection than in periods of nonuse, compared with a 24% higher rate in those taking less than 15 mg morphine equivalent per day.

Patients who experienced infections were most likely to get a nonpneumonia infection, while the rates of pneumonia infection were not significantly different between periods of opioid use and nonuse.

To assess whether pain could have been a confounding factor, the researchers looked at nonsteroidal anti-inflammatory medication use as the exposure of interest and found no significant increase in the rate of hospitalizations for serious infections when compared with nonuse.

“The potential association between the risk of infection and opioid use is supported by the literature regarding the immunosuppressive effects of certain opioids from in vitro experiments and animal models, including morphine, methadone, and fentanyl (fentanyl [was] not included in our study, which is restricted to oral formulations),” the investigators wrote.

“Although our study lends support to the idea that opioids might cause further immunosuppression in patients with RA, these patients are already at higher risk of infection and possibly more likely to receive opioid therapy compared to other patient populations. Further studies are needed to determine whether this association exists in other patient populations.”

Another big research challenge, Dr. Whittle said, is “to learn better the mechanisms for persistent pain in people with rheumatoid arthritis, and hopefully through that we might be able to target therapies a little bit better.”

The study was supported by the National Institute on Aging and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. There were no conflicts of interest declared.

Patients taking opioids for rheumatoid arthritis are at significantly higher risk of serious infection, particularly those taking long-acting formulations or opioids known to have immunosuppressive properties, new data suggest.

While it has been known for some time that opioids have wide-ranging adverse effects, this is the first convincing evidence of an increased risk of infection associated with opioid use in patients with rheumatoid arthritis, Dr. Samuel Whittle, consultant rheumatologist at the Queen Elizabeth Hospital in Adelaide, Australia, said when asked to comment on the study.

©thegoodphoto/thinkstockphotos.com

Dr. Whittle, who was not involved in the study, said that these data add to the growing body of evidence that the adverse effects of opioids outweigh the benefits.

“It fits with our general sense these days that opioids really are a poor choice of analgesics in people with rheumatoid arthritis, but people continue to prescribe them because our analgesic armory is not that good,” he said.

Andrew D. Wiese of Vanderbilt University, Nashville, Tenn., and his colleagues analyzed a retrospective cohort of 1,790 patients with rheumatoid arthritis who were enrolled in Tennessee Medicaid during 1995-2009 and experienced at least one hospitalization for serious infection. The patients served as their own controls during periods of opioid nonuse. The rate of infection in these patients was 39% higher when they were taking opioids, compared with periods of nonuse, after adjusting for age, season, nursing home residency, and medication use.

The rate of infection was twice as high when they were using long-acting opioids, compared with nonuse, and 72% higher for the use of immunosuppressive opioids. New opioid use also more than doubled the risk of serious infection in the study (Arthritis Rheumatol. 2015 Oct 16. doi: 10.1002/art.39462)

Researchers also found evidence of a dose-response effect, as patients taking 60 mg or more of morphine equivalent per day had a 73% greater rate of infection than in periods of nonuse, compared with a 24% higher rate in those taking less than 15 mg morphine equivalent per day.

Patients who experienced infections were most likely to get a nonpneumonia infection, while the rates of pneumonia infection were not significantly different between periods of opioid use and nonuse.

To assess whether pain could have been a confounding factor, the researchers looked at nonsteroidal anti-inflammatory medication use as the exposure of interest and found no significant increase in the rate of hospitalizations for serious infections when compared with nonuse.

“The potential association between the risk of infection and opioid use is supported by the literature regarding the immunosuppressive effects of certain opioids from in vitro experiments and animal models, including morphine, methadone, and fentanyl (fentanyl [was] not included in our study, which is restricted to oral formulations),” the investigators wrote.

“Although our study lends support to the idea that opioids might cause further immunosuppression in patients with RA, these patients are already at higher risk of infection and possibly more likely to receive opioid therapy compared to other patient populations. Further studies are needed to determine whether this association exists in other patient populations.”

Another big research challenge, Dr. Whittle said, is “to learn better the mechanisms for persistent pain in people with rheumatoid arthritis, and hopefully through that we might be able to target therapies a little bit better.”

The study was supported by the National Institute on Aging and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. There were no conflicts of interest declared.

Patients taking opioids for rheumatoid arthritis are at significantly higher risk of serious infection, particularly those taking long-acting formulations or opioids known to have immunosuppressive properties, new data suggest.

While it has been known for some time that opioids have wide-ranging adverse effects, this is the first convincing evidence of an increased risk of infection associated with opioid use in patients with rheumatoid arthritis, Dr. Samuel Whittle, consultant rheumatologist at the Queen Elizabeth Hospital in Adelaide, Australia, said when asked to comment on the study.

©thegoodphoto/thinkstockphotos.com

Dr. Whittle, who was not involved in the study, said that these data add to the growing body of evidence that the adverse effects of opioids outweigh the benefits.

“It fits with our general sense these days that opioids really are a poor choice of analgesics in people with rheumatoid arthritis, but people continue to prescribe them because our analgesic armory is not that good,” he said.

Andrew D. Wiese of Vanderbilt University, Nashville, Tenn., and his colleagues analyzed a retrospective cohort of 1,790 patients with rheumatoid arthritis who were enrolled in Tennessee Medicaid during 1995-2009 and experienced at least one hospitalization for serious infection. The patients served as their own controls during periods of opioid nonuse. The rate of infection in these patients was 39% higher when they were taking opioids, compared with periods of nonuse, after adjusting for age, season, nursing home residency, and medication use.

The rate of infection was twice as high when they were using long-acting opioids, compared with nonuse, and 72% higher for the use of immunosuppressive opioids. New opioid use also more than doubled the risk of serious infection in the study (Arthritis Rheumatol. 2015 Oct 16. doi: 10.1002/art.39462)

Researchers also found evidence of a dose-response effect, as patients taking 60 mg or more of morphine equivalent per day had a 73% greater rate of infection than in periods of nonuse, compared with a 24% higher rate in those taking less than 15 mg morphine equivalent per day.

Patients who experienced infections were most likely to get a nonpneumonia infection, while the rates of pneumonia infection were not significantly different between periods of opioid use and nonuse.

To assess whether pain could have been a confounding factor, the researchers looked at nonsteroidal anti-inflammatory medication use as the exposure of interest and found no significant increase in the rate of hospitalizations for serious infections when compared with nonuse.

“The potential association between the risk of infection and opioid use is supported by the literature regarding the immunosuppressive effects of certain opioids from in vitro experiments and animal models, including morphine, methadone, and fentanyl (fentanyl [was] not included in our study, which is restricted to oral formulations),” the investigators wrote.

“Although our study lends support to the idea that opioids might cause further immunosuppression in patients with RA, these patients are already at higher risk of infection and possibly more likely to receive opioid therapy compared to other patient populations. Further studies are needed to determine whether this association exists in other patient populations.”

Another big research challenge, Dr. Whittle said, is “to learn better the mechanisms for persistent pain in people with rheumatoid arthritis, and hopefully through that we might be able to target therapies a little bit better.”

The study was supported by the National Institute on Aging and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. There were no conflicts of interest declared.