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Latest Poll
Poll Week of 12/19
A 48-year-old woman with rheumatoid arthritis (RA) will be adding a tumor necrosis factor inhibitor (TNFi) to her regimen of methotrexate and prednisone since these agents have failed to adequately control her RA symptoms in the past several months.
Recent evidence confirms that RA patients taking a TNFi, a nonbiologic DMARD, or prednisone are at high risk of developing a serious infection that may lead to hospitalization, although increases in risk associated with TNFi initiation might be similar to those associated with the addition of nonbiologic DMARDs in patients failing methotrexate. From this study, the most commonly reported serious infections in patients with RA were pneumonia followed by skin and soft tissue infections, pyelonephritis/UTI, and bacteremia/septicemia.1 This patient is in a high-risk group for infection due to her use of immunosuppressive drugs (TNFi, methotrexate, and prednisone) and should be counseled about this risk. Further, efforts made to eliminate or reduce prednisone dose could mitigate this patient's risk.
References
Grijalva CG, Chen L, Delzell E, et al. Initiation of Tumor Necrosis Factor-α Antagonists and the Risk of Hospitalization for Infection in Patients With Autoimmune Diseases. JAMA. 2011 Nov 6. doi: 10.1001/jama.2011.1692.
Poll Week of 12/7
A 48-year-old woman with Granulomatosis with polyangiitis [GPA; Wegener's granulomatosis (WG)] diagnosed 1 month ago returns for an office visit after starting corticosteroid and cyclophosphamide therapy. She has responded well to therapy and states she feels better overall; she is relatively asymptomatic at this time.
Although ANCA or acute phase reactants such as ESR and CRP may decrease in response to immunosuppressive therapy, it is important to consider a variety of factors when determining whether a patient with GPA (WG) or other ANCA-associated vasculitis has achieved remission. Factors such as results of clinical examination, other laboratory testing (eg, CBC, CMP, renal function, urinalysis), and imaging findings, if indicated, support the decision of whether to begin tapering corticosteroids in this patient. Regular follow-up using objective and subjective measures (patient feedback) is important in assessing disease activity.
A 35-year-old man with worsening psoriatic arthritis has recently begun treatment with a tumor necrosis factor inhibitor (TNFi) to control worsening enthesitis in his left heel and new-onset inflammatory arthritis in his right knee.
Recent evidence confirms that patients taking a TNFi are at an increased risk of developing non-melanoma skin cancer.1 It would be advisable to refer this man to a dermatologist for annual skin cancer screening—not only to screen for non-melanoma skin cancer but also for melanoma, which has been associated with TNFi use in two studies2,3
References
Mariette X, Matucci-Cerinic M, Pavelka K et al. Malignancies associated with tumor necrosis factor inhibitors in registries and prospective observational studies: a systematic review and meta-analysis. Ann Rheum Dis. 2011;70:1895-1904.
Askling J, ARTIS Study Group. Anti-TNF therapy and risk of skin cancer; data from the Swedish ARTIS registry 1998-2006. Ann Rheum Dis. 2009;68(Suppl 3):423 Abstract FRI0201.
Wolfe F, Michaud K. Biologic treatment of rheumatoid arthritis and the risk of malignancy: analyses from a large US observational study. Arthritis Rheum. 2007;56:2886-2895.
