AB0423 Severe infections in rheumatoid arthritis (RA) are related to the use of biologic dmards. assessment of real-life patients
Authors: C.A. Arce-Salinas, A. Tripp-Aguilar, J.L. Amaya-Estrada, F. Rodríguez-García, F. Espinosa-Ortega
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background</h3> Current strategies for treatment of RA promotes early use of synthetic (s-)DMARDs, their combination, or biologic (b-)DMARDs to achieve remission or low-disease activity. However, such strategies are related to a wide variety of adverse effects, from mild to life threatening. Infections could be detected more frequently among patients with b-DMARDs, although comorbidities, steroid use, chronic accumulated damage, or disease activity could bias such conclusions. <h3>Objectives</h3> To investigate the frequency and severity of infections comparing RA patients users of s-DMARDs or b-DMARDs in a long-term period. <h3>Methods</h3> Patients were selected from our RA Clinic. Those with at least 5 years using b-DMARD were compared with patients on s-DMARD, each one matched by disease duration, age, and comorbidities in a 1:1 ratio. Demographic features, disease characteristics, number and nature of infections during the follow-up, as well as disease activity, and treatment were recorded. Infections were considered as severe when it required hospitalisation or intravenous antibiotics. Comparison between groups was made with X<sup>2</sup> or t-test as required. <h3>Results</h3> A total of 200 patients were prospectively assessed, 100 per group, mean age was 63.5±12.03 year-old, 91% were female, 78% were RF or ACPA positive, 20% had diabetes mellitus, and 3% other relevant comorbidities. When patients starting the use of b-DMARD, they had more active disease than those in the s-DMARD group (DAS28=4.99±1.5 vs. 3.91±1.2; p=0.01). Throughout 5 years of follow-up, there were 18 episodes of severe infections in the b-DMARDs group, and 2 episodes in the s-DMARD group (p=0.01); number of non-severe infections was 569 vs. 577 in such period, respectively (p=NS). No association was observed between severe infections and presence of diabetes mellitus, cumulative annual dose of prednisone, or DAS28, which did not differ in any other measure between groups. Sixteen patients in b-DMARD had severe infections: 6 acute pyelonephritis, 4 pneumonia, 4 acute bronchitis, 1 infectious diarrhoea, 1 emphysematous cystitis, 1 septic arthritis, and 1 haemorrhagic dengue compared with two severe infections in the s-DMARDs group: 1 pneumonia and 1 infectious diarrhoea. Median of hospitalisation days was 4.5, and no deaths were recorded. Infectious agents isolated were <i>E. coli</i>, <i>C. albicans</i>, <i>Salmonella sp.</i>, and <i>P. aeruginosa</i>. The most frequent non-severe infections were upper respiratory disease, urinary tract infection, herpes zoster, acute diarrhoea, and bacterial vaginosis. Notoriously, 11 episodes of severe infection occurred in the first 2 years of b-DAMRD use (7 in first, and 4 in second year), the other 7 in remaining 3 years. b-DMARDs more frequently used were etanercept, rituximab, adalimumab, certolizumab pegol, and tocilizumab, without association between severe infections and any biologic agent. <h3>Conclusions</h3> b-DMARDs use in our setting, combined with low dose methotrexate, reach higher frequency of severe infections than s-DMARDs, irrespective of comorbidities, steroid use or disease characteristics including disease activity. <h3>Disclosure of Interest</h3> None declared