2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases

George E Fragoulis^{1

2}, Elena Nikiphorou^{3

4}, Mrinalini Dey^{5

6}, Sizheng Steven Zhao⁷, Delphine Sophie Courvoisier⁸, Laurent Arnaud⁹, Fabiola Atzeni¹⁰, Georg Mn Behrens¹¹, Johannes Wj Bijlsma¹², Peter Böhm¹³, Costas A Constantinou¹⁴, Silvia Garcia-Diaz¹⁵, Meliha Crnkic Kapetanovic¹⁶, Kim Lauper^{7

17}, Mariana Luís¹⁸, Jacques Morel¹⁹, György Nagy^{20

21

22}, Eva Polverino²³, Jef van Rompay²⁴, Marco Sebastiani²⁵, Anja Strangfeld²⁶, Annette de Thurah^{27

28}, James Galloway^{3

4}, Kimme L Hyrich^{29

30}

Affiliations

¹ Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece.
² Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
³ Centre for Rheumatic Diseases, King's College London, London, UK.
⁴ Rheumatology Department, King's College London, London, UK.
⁵ Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
⁶ Rheumatology Department, Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
⁷ Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK.
⁸ Division of Rheumatology, Geneva University Hospitals, Geneve, Switzerland.
⁹ Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), University Hospitals Strasbourg, Strasbourg, France.
¹⁰ Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy.
¹¹ Department for Rheumatology and Immunology, Hannover Medical School, Hannover, Germany.
¹² Dept of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands.
¹³ Forschungspartner, German League against rheumatism, Bonn, Germany.
¹⁴ Department of Internal Medicine, Nicosia General Hospital, Leukosia, Cyprus.
¹⁵ Rheumatology Department, Complex Hospitalari Moises Broggi, Barcelona, Spain.
¹⁶ Skåne University Hospital, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
¹⁷ Division of Rheumatology, University of Geneva, Geneva, Switzerland.
¹⁸ Rheumatology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal.
¹⁹ Department of Rheumatology, Montpellier University Hospital, University of Montpellier, Montpellier, France.
²⁰ Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary.
²¹ Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
²² Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary.
²³ Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias CIBERES, Barcelona, Spain.
²⁴ Belgium Patient Partner Program, EULAR People with Arthritis/Rheumatism across Europe (PARE), Antwerpen, Belgium.
²⁵ Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy.
²⁶ Epidemiology and Health Services Research, German Rheumatism Research Centre (DRFZ) Berlin and Charite University Medicine, Berlin, Germany.
²⁷ Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.
²⁸ Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
²⁹ Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK kimme.hyrich@manchester.ac.uk.
³⁰ National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester NHS Foundation Trust, Manchester, UK.

PMID: 36328476
DOI: 10.1136/ard-2022-223335

Free article

2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases

George E Fragoulis et al. Ann Rheum Dis. 2023 Jun.

Free article

. 2023 Jun;82(6):742-753.

doi: 10.1136/ard-2022-223335. Epub 2022 Nov 3.

Authors

Affiliations

¹ Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece.
² Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
³ Centre for Rheumatic Diseases, King's College London, London, UK.
⁴ Rheumatology Department, King's College London, London, UK.
⁵ Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
⁶ Rheumatology Department, Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
⁷ Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK.
⁸ Division of Rheumatology, Geneva University Hospitals, Geneve, Switzerland.
⁹ Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), University Hospitals Strasbourg, Strasbourg, France.
¹⁰ Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy.
¹¹ Department for Rheumatology and Immunology, Hannover Medical School, Hannover, Germany.
¹² Dept of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands.
¹³ Forschungspartner, German League against rheumatism, Bonn, Germany.
¹⁴ Department of Internal Medicine, Nicosia General Hospital, Leukosia, Cyprus.
¹⁵ Rheumatology Department, Complex Hospitalari Moises Broggi, Barcelona, Spain.
¹⁶ Skåne University Hospital, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
¹⁷ Division of Rheumatology, University of Geneva, Geneva, Switzerland.
¹⁸ Rheumatology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal.
¹⁹ Department of Rheumatology, Montpellier University Hospital, University of Montpellier, Montpellier, France.
²⁰ Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary.
²¹ Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
²² Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary.
²³ Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias CIBERES, Barcelona, Spain.
²⁴ Belgium Patient Partner Program, EULAR People with Arthritis/Rheumatism across Europe (PARE), Antwerpen, Belgium.
²⁵ Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy.
²⁶ Epidemiology and Health Services Research, German Rheumatism Research Centre (DRFZ) Berlin and Charite University Medicine, Berlin, Germany.
²⁷ Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.
²⁸ Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
²⁹ Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK kimme.hyrich@manchester.ac.uk.
³⁰ National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester NHS Foundation Trust, Manchester, UK.

PMID: 36328476
DOI: 10.1136/ard-2022-223335

Abstract

Objectives: To develop EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD).

Methods: An international Task Force (TF) (22 members/15 countries) formulated recommendations, supported by systematic literature review findings. Level of evidence and grade of recommendation were assigned for each recommendation. Level of agreement was provided anonymously by each TF member.

Results: Four overarching principles (OAP) and eight recommendations were developed. The OAPs highlight the need for infections to be discussed with patients and with other medical specialties, in accordance with national regulations. In addition to biologic/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) for which screening for latent tuberculosis (TB) should be performed, screening could be considered also before conventional synthetic DMARDs, glucocorticoids and immunosuppressants. Interferon gamma release assay should be preferred over tuberculin skin test, where available. Hepatitis B (HBV) antiviral treatment should be guided by HBV status defined prior to starting antirheumatic drugs. All patients positive for hepatitis-C-RNA should be referred for antiviral treatment. Also, patients who are non-immune to varicella zoster virus should be informed about the availability of postexposure prophylaxis should they have contact with this pathogen. Prophylaxis against Pneumocystis jirovecii seems to be beneficial in patients treated with daily doses >15-30 mg of prednisolone or equivalent for >2-4 weeks.

Conclusions: These recommendations provide guidance on the screening and prevention of chronic and opportunistic infections. Their adoption in clinical practice is recommended to standardise and optimise care to reduce the burden of opportunistic infections in people living with AIIRD.

Keywords: Antirheumatic Agents; Autoimmune Diseases; Tuberculosis.

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Conflict of interest statement

Competing interests: GEF: Consulting fees/honoraria: Pfizer, Abbvie, Novartis, UCB, AENorasis, Janssen, Pharmaserv-Lilly. EN: speaker fees/honoraria: Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Fresenius. Research funding: Pfizer, Lilly. MD: none SZ: consulting fees: UCBDC: None. LA: has received consulting fees and/or research funding from Astra-Zeneca, GSK, Pfizer. FA: none. GMNB: has received consulting fees/honoraria as speaker from Gilead, ViiV Healthcare, Janssen, MSD, Roche, Moderna unrelated to this work. JWJB: none PB: none CAC: none SG-D: none MCK: none KL: has received consulting/speaker fees from Pfizer, Viatris, Celltrion outside of the submitted work. ML: none. JM: none GN: consulting fees/honoraria as speaker from AbbVie, Amgen, Boehringer Ingelheim, Janssen, Miltenyi Biotech, Lilly, Pfizer, Roche unrelated to this work. EP: consulting fees/honoraria as speaker from Bayer, Menarini, Grifols, Zambon, Pfizer, Chiesi, Teva, Shire, Shionogi, Insmed, Boehringer-Ingelheim, unrelated to this work. JvR: none MS: consulting fees: BMS, Boehringer-Ingheleim, Eli Lilly, Celltrion, Amgen, Pfizer, Janssen Cilag. AS: has received consulting fees/honoraria as speaker from AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, MSD, Pfizer, Roche unrelated to this workAdT: none JG: speaker fees/honoraria: Abbvie, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB. Research funding: Abbvie, Astrazeneca, Galapagos, Gilead, Gritstone, Janssen, Moderna, Novovax, PfizerKH: honoraria from Abbvie; grant income from Pfizer and BMS.

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2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases

Affiliations

2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases

Authors

Affiliations

Abstract

Conflict of interest statement

Publication types

MeSH terms

Substances

LinkOut - more resources

Full Text Sources

Miscellaneous