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Test your knowledge on infections and rheumatic diseases

June 13 2015 8:58 AM ET via RheumReports RheumReports

How up to date are you on your knowledge of infections and rheumatic diseases? Test your knowledge below.


1. Do we need to treat HBV prophylactically before starting biologics?

2. Do we need to treat HCV?

3. Which vaccinations are needed?

4. What is new with respect to infections and rheumatic diseases?

5. Do we need to screen for TB?

6. What is the risk of serious infections in RA?

7. Have serious infections increased in SLE?

Hepatitis B and C

1. Do we need to treat HBV prophylactically before starting biologics?

There is a high prevalence of HBV exposure worldwide (5-80%). About 3% of patients with RA have HBV and about 2% have been exposed to HCV. So what is the risk of reactivation of HBV and HCV?

We know from our hematology colleagues that rituximab regimens lead to reactivation in 3-25% of patients with past HBV. There is limited data in rheumatology patients who are treated with rituximab or other biologics. An Italian study reported no cases of HBV reactivation during biologic treatment. However, in 9% of the patients, ALT levels increased. Overall the risk for HBV in patients with RA with past HBV infection is low. 

ANSWER: This is controversial as the author indicated there was no need for prophylactic treatment of HBV. This goes against how we currently practice.

2. Do we need to treat HCV?

HCV infection has a prevalence of 2.8% worldwide and is associated with serious health consequences. The CDC recommends screening anyone 45-65 years old for HCV before initiating treatment. The arrival of oral antivirals (DAAs) can cure greater than 90% of HCV infected patients.

ANSWER: Although the cost for this treatment is extremely expensive (a 12-week course in the USA is $84,000) a review of the research shows that it is still cost-effective to treat high priority patients and those who are at risk of severe complications.


3. Which ones are needed?

The rate of influenza and pneumococcal vaccinations in rheumatology patients remains very low (less than 25%). Should our patients be vaccinated?


Both 13-valent (Prevnar) and 23-valent (Pneummovax) should be administered to our patients. If they are younger than 65 years old, they should receive this treatment again in 5 years but not if they are older than 65 years.


Human papillomavirus

HPV vaccine has been recommended for all young females but is it safe and effective for rheumatology patients? A study compared JIA patients with healthy controls and found that vaccination was efficacious and safe in young females with JIA regardless of immunosuppressive therapy. They also found there was no effect on disease activity outcomes.


Herpes Zoster

The incidence of herpes zoster is almost 10x higher in RA patients than in the general population. It is unknown whether rheumatology medications may be a reason for the increased risk. The herpes zoster vaccine should be given to anyone aged 60 or older in Canada and the USA. It decreases the risk for HZ and post herpetic neuralgia. Guidelines recommend giving the vaccine to everyone before starting therapy but not during treatment with biologic therapy. A review of the literature suggests HZV is equally efficacious in immunocompromised patients compared to the general population. It can be administered in patients on low-dose steroids (less than 20 mg/d) and traditional DMARDs. Efficacy appears to be the similar in patients who are treated with biologics compared to healthy controls, with no increased rate of infections.

ANSWER: We need more data on patients on chronic biologic therapy, however it may be reasonable to hold the biologic medication for a period of time in order to vaccinate and then resume biologic therapy 30 days later.


4. What is new with respect to infections and rheumatic diseases?

There have been reports of emerging infections in migrants and travellers namely Chikungunya Virus (CHIKV). Although endemic to Africa, India and the Caribbean, there have been recent outbreaks in Italy, France and Florida. Patients typically present with fever, rash, myalgia and an acute seronegative polyarthritis. They have normal acute phase reactants. There is no known treatment yet for this virus. 

ANSWER: This is something to think about when assessing new patients who are immigrants to the country or who have recently travelled.

5. Do we need to screen for TB?

The ACR guidelines recommend screening for TB before starting biological therapy. A review of the literature suggests TB test conversions occur during anti-TNF therapy in approximately 10% of patients. It is unclear if these represent true conversions or not.

ANSWER: More data are needed in order to recommend universal re-screening in the absence of definitive exposure, especially in low prevalence countries.

Serious infections

6. What is the risk of serious infections on biologics compared to traditional DMARDs when treating RA?

ANSWER: There is a 30% increase in the rate of serious infections among RA patients receiving biologic therapy compared to traditional DMARDs, which in absolute numbers equals an increase from 2% to 2.6% per year. Clearly this is dependent on the nature of the population being treated.

7. Have serious infections increased with SLE?

ANSWER: The burden of serious infections and in-hospital deaths has increased in SLE patients, emphasizing the need for aggressive vaccinations and limitations on the use of glucocorticoids.

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About the Author

Marlene Thompson
Marlene Thompson

Marlene Thompson is an Associate Clinical Professor in Physical Therapy at Western University and an Advanced Physiotherapy Practitioner in Arthritis Care. Marlene′s research interests include models of care, triage, advanced practice roles, and arthritis education.

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