PMC:7102591 / 10152-17809 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7102591","sourcedb":"PMC","sourceid":"7102591","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7102591","text":"4 The impact of drugs for rheumatic diseases on viral infections: what do we know?\n\n4.1 Corticosteroids and NSAIDs\nIt has now been more than 70 years that corticosteroids (CS) are pivotal for RA management and their role as remission inducer and bridging therapy for the management of disease flare has recently been renewed by the latest update of EULAR recommendations for RA treatment [36]. Even though CS efficacy in rapidly suppressing inflammation during RA initial course or flares is well recognized [37], their downside is the broad spectrum of adverse events, including severe infections and the high risk of developing comorbidities further increasing the risk of infection [27,38]. Although RCTs conducted in the past with CS showed no higher risk of infections in RA patients [[39], [40], [41]], cohort and case-control studies reported increased rates of overall infections in RA patients treated with CS, according to a dose-dependent fashion [42]. The majority of these infectious events are of bacterial etiology, but RA patients receiving CS exhibit a greater risk of developing even viral infections. As an example, a 2012 retrospective cohort-study demonstrated an increased risk of Herpes Zoster infections with an incidence rate of 8.54 cases per 1000 patient-years in CS treated population [29].\nThus, CS on the one hand inhibit the immune response and delay the clearance of the pathogen, while on the other hand they suppress the host inflammatory response, which in the case of viral infections of the respiratory tract is the major responsible for lung damage and occurrence of ARDS [43]. The latter represented the rational for the widely use of CS for the management of Middle East respiratory syndrome (MERS)-CoV [44] and SARS-CoV [45] outbreaks, both histologically characterized by lung inflammation and diffuse alveolar damage [46]. However, evidence from the literature points to a predominantly negative effect of CS in the management of this type of infection. A 2019 systematic review and meta-analysis including ten observational studies (n = 6548) conducted in influenza reported increased mortality (risk ratio [RR] 1.75, 95% CI 1.3–2.4; p = .0002),\nincreased rate of secondary bacterial or fungal infection (RR 2·0, 95% CI 1·0–3·8; p = .04), and longer stay in an intensive care unit (mean difference 2.1, 95% CI 1.2–3.1; p \u003c .0001) in patients receiving CS [47]. Moreover, a review exploring treatments for ARDS, including six studies with a total of 574 patients, concluded that insufficient evidence exists to recommend CS treatment [48]. Overall, no clear reason exists to expect that patients with COVID-19 infection will benefit from CS, and they might be more likely to be harmed with such therapy [49]. In fact, current interim guidance from WHO on clinical management of COVID-19 infection advises against the use of CS unless indicated for another reason [10].\nThe role of NSAIDs in the course of viral infections is still controversial. Ibuprofen has been demonstrated to induce an overexpression of ACE2 when used in diabetic rats [50] and this effect might theoretically increase the susceptibility and worsen the clinical course of COVID-19 infection in treated patients [15]. In addition, the use of both NSAIDs and acetaminophen could be associated with a masking of the fever rise during COVID-19, resulting in a delay in diagnosis and proper management of the infection.\n\n4.2 csDMARDs\nThe most comprehensive analysis of infectious risk in patients treated with csDMARDs is a retrospective, longitudinal study of a population-based RA cohort using an administrative database including a total of 27,710 individuals with RA and providing 162,710 person-years of follow-up [51]. Use of csDMARDs without corticosteroids was associated with a small decrease in mild infection risk (adjusted rate ratio [RR] 0.90, 95% confidence interval [95% CI] 0.88–0.93) and was not associated with increased serious infection risk (adjusted RR 0.92, 95% CI 0.85–1.0). Similarly, another retrospective analysis conducted on 1993 patients from a claim database demonstrated a slightly reduced risk of hospitalized infection for methotrexate (adjusted RR 0.81, 95% CI 0.70–0.93) and hydroxychloroquine (adjusted RR 0.74, 95% CI 0.62–0.89) [52]. A recent systematic review and meta-analysis of the literature confirmed the lack of an increased risk of infection in patients receiving MTX (RR: 1.14; 95% CI, 0.98–1.34) [53]. However, all these reports provided no data on the risk of stratified infection by pathogen.\n\n4.3 bDMARDs\nThe risk of infection observed in RA patients treated with bDMARDs is generally considered slightly higher (from 1.5- up to 2-fold) compared with csDMARDs [27,54]. This evidence recurred in most RCTs [55] and observational registry studies [[56], [57], [58]] and was confirmed by a recent meta-analysis which showed that this risk is progressively increasing in relation to the use of bDMARDs at higher than recommended dosages [59]. Following the results of comparative metanalyses and real-life studies, abatacept is accepted as the safest bDMARD in terms of infectious risk [60,61].\nData focused on viral respiratory infections in bDMARD cohort are still very limited. The incidence of influenza-like infections observed in a cohort of 159 Italian patients treated with bDMARDs during the influenza season 2009–2010 was higher than the value reported in a wide sample of Italian population in the same period, even though no important complications or hospitalizations have been reported [62]. Overall, post-marketing experience is relatively reassuring that anti-TNF treated patients may not be at any specifically increased risk of influenza and that severe adverse outcomes, including death, do not appear to be exceedingly frequent [63].\n\n4.4 tsDMARDs\nThe overall risk of serious and opportunistic infections observed with Janus Kinase (JAK) inhibitors in RA patients is roughly comparable with bDMARDs [64,65], although these early years of tofacitinib and baricitinib use have raised the issue of an increased risk of Herpes Zoster virus (HZV) infections [66]. Data from tofacitinib pooled population enrolled in RCTs showed an HZV incidence rate of 4.0 per 100 patient-years (with greater incidence in geographic area with high HZV endemicity), doubling the rates of RA patients not receiving JAKis [67]. A similar picture has also been observed in the overall development program of baricitinib, with an incidence rate of 3.2 cases per patient-years [68]. The subsequent real-life experience from US claim databases revealed that the risk of HZV was higher in patients receiving tofacitinib compared to those treated with abatacept (aHR 2.01 (95% CI 1.40; 2.88) [69], and the risk of serious hospitalized HZV infection is 2-fold higher versus all bDMARDs [70]. Older age, female sex, prednisone \u003e7.5 mg/day, prior infection, and greater number of hospitalizations were associated with increased HZV risk, whereas vaccination was associated with a lower risk [71]. More recent reports from RCTs conducted with novel JAK-1 selective inhibitors upadacitinib and filgotinib have basically confirmed the same trend, suggesting that the increase in HZV infections can be considered as a class effect of JAKis [72,73]. Although the exact mechanism by which HZV reactivation occurs in the context of JAK inhibition is unclear, the downregulation of both cell-mediated immunity and innate antiviral signaling through type I and II interferons (IFN) is likely to be involved [74].\nCurrently, no data are available on the risk of respiratory virus infections carried by JAK 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