Current rheumatology reports
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Review
B Cell Therapies, Approved and Emerging: a Review of Infectious Risk and Prevention During Use.
The development of B cell-targeted biologics represents a major advance in the treatment of autoimmune rheumatic diseases. As with other immunosuppressive agents, risk of infection is a key clinical concern. This review summarises safety data from 15 years of experience of rituximab in autoimmune diseases with a particular focus on opportunistic infection and class-specific complications and infection risk. ⋯ With repeat cycles of therapy, hypogammaglobulinaemia has been observed in a larger proportion of patients and is associated with increased risk of serious infections. The infection profile of the newer B cell-targeted agent, belimumab, in patients with active systemic lupus erythematosus is also discussed. Data from registries are needed to extend insights further and also to evaluate for any impact with the difference in mode of action of belimumab and infection risk in this population.
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In 2011, the European League Against Rheumatism (EULAR) published recommendations regarding the vaccination of children with rheumatic diseases. These recommendations were based on a systematic literature review published in that same year. Since then, the evidence body on this topic has grown substantially. ⋯ Biologicals could accelerate a waning of antibody levels over time, although most patients were initially protected adequately. Overall, persistence of immunological memory may be reduced in children with rheumatic diseases, which shows the need for (booster) vaccination. This update of the 2011 systematic literature review strengthens the evidence base for the EULAR recommendations, and it must be concluded that vaccinations in patients with rheumatic diseases should be advocated.
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In 2011, the European League Against Rheumatism (EULAR) published recommendations regarding the vaccination of children with rheumatic diseases. These recommendations were based on a systematic literature review published in that same year. Since then, the evidence body on this topic has grown substantially. ⋯ Biologicals could accelerate a waning of antibody levels over time, although most patients were initially protected adequately. Overall, persistence of immunological memory may be reduced in children with rheumatic diseases, which shows the need for (booster) vaccination. This update of the 2011 systematic literature review strengthens the evidence base for the EULAR recommendations, and it must be concluded that vaccinations in patients with rheumatic diseases should be advocated.
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Four new oral anticoagulants (NOAC), apixaban, rivaroxaban, edoxaban, and dabigatran, are now available in the USA; however, only apixaban and rivaroxaban are FDA approved for the prevention of venous thromboembolism following orthopedic surgery. Apixaban, rivaroxaban, and edoxaban's anticoagulant activity can be measured using a chromogenic anti-factor Xa assay but there is no widely available means of measuring dabigatran blood levels. ⋯ Dabigatran is 80% renally excreted, and patients with atrial fibrillation taking dabigatran for stroke prevention should stop the drug 4-5 days prior to major orthopedic surgery. Apixaban, rivaroxaban, and edoxaban should be held for 48 h preoperatively in this setting.
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Pulmonary hypertension (PH) is associated with significant morbidity and mortality. While the advent of disease-modifying therapies in the treatment of PH has dramatically increased the life expectancy of these patients, they remain at high risk for perioperative complications. Outcome studies suggest that patients with PH undergoing non-cardiac surgery have higher morbidity and mortality than those without, independent of severity. ⋯ A multidisciplinary approach involving all intraoperative physicians is imperative to forming a safe intraoperative plan based on the inherent physiology underlying the patient's disease. Finally, because complications in this patient population often occur postoperatively, patients should be monitored in an appropriate setting with a goal of preventing right ventricular dysfunction. In this review article, we focus on the evaluation, risk stratification, and optimization of patients with PH undergoing non-cardiac surgery.