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RA with infection risk — SCE Rheumatology MCQ

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HardRheumatological pharmacologyRA with infection riskSCE Rheumatology

A 68-year-old woman has seropositive rheumatoid arthritis with a DAS28 of 6.0 despite an adequate trial of methotrexate in combination with sulfasalazine and hydroxychloroquine. Methotrexate is tolerated and will be continued. She has CT-confirmed bronchiectasis and has had three infective exacerbations during the preceding year, including one requiring hospital admission. Respiratory review confirms that there is no current infection, and sputum cultures, including cultures for non-tuberculous mycobacteria, are negative. Which of the following is the most appropriate targeted DMARD from the options listed?

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Correct answer: D — Abatacept

Abatacept is the best option listed. Bronchiectasis and a previous infection requiring admission confer substantial future respiratory-infection risk, although abatacept is not infection-free and should only be started once active infection has been excluded. Comparative cohort evidence found fewer hospitalised and pulmonary infections with abatacept than with TNF inhibitors, with the clearest difference versus infliximab. Infliximab is therefore less attractive in this infection-prone patient. Tofacitinib is a targeted synthetic rather than biological DMARD, and its UK SmPC states that in patients aged 65 years or older it should be used only when no suitable alternative exists because of increased serious-infection and other safety risks. Secukinumab is used for psoriatic and axial spondyloarthritis, not RA, while belimumab is licensed for SLE and lupus nephritis. Respiratory co-management, vaccination and close infection surveillance remain essential.

Reference: Chen SK, Liao KP, Liu J, Kim SC. Risk of Hospitalized Infection and Initiation of Abatacept Versus Tumor Necrosis Factor Inhibitors Among Patients With Rheumatoid Arthritis: A Propensity Score-Matched Cohort Study. Arthritis Care Res. 2020;72:9–17. https://pubmed.ncbi.nlm.nih.gov/30570833/