Corticosteroid dose and the risk of opportunistic infection in a national systemic lupus erythematosus cohort

Abstract

Objective This study investigated whether the incidence of opportunistic infection differed in systemic lupus erythematosus patients who received different doses of corticosteroids. Methods We included patients with diagnosed systemic lupus erythematosus from 1997 to 2010 using Taiwan national health insurance data. The index day for systemic lupus erythematosus patients was 3 months after the systemic lupus erythematosus diagnosis. A non-steroid cohort was matched 4:1 with the steroid cohort according to age, sex and index day. The end of the follow-up period was the day of opportunistic infection diagnosis, 1 year after the index day, or death. Results The overall cumulative incidence of opportunistic infection was 136-fold higher in the steroid cohort than in the non-steroid cohort. The adjusted hazard ratio for developing mycobacterium infection in the steroid cohort was 11, and the adjusted hazard ratio for developing herpes zoster was 43.6 compared to the non-steroid cohort after adjusting for immunosuppressive agents and comorbidities. The adjusted hazard ratio value for opportunistic infection was 1.40 (95% confidence interval (CI) 0.78-2.51) for a daily prednisone-equivalent dose of 7.5-15 mg, 1.72 (95% CI 1.02-2.91) for 15-30 mg, 1.96 (95% CI 1.17-3.28) for 30-60 mg and 2.24 (95% CI 1.26-4.00) for over 60 mg compared with low-dose steroids (<7.5 mg). Conclusion This study confirmed that the risk of opportunistic infection is higher in systemic lupus erythematosus patients treated with steroids in the first 3 months after diagnosis versus those not treated with steroids. Medium and high doses were associated with a higher risk of opportunistic infection compared with low doses. However, there was no controlling for disease activity, making it hard to know if increases in infection were due to disease itself or corticosteroids.

Orofacial manifestations and dental management of systemic lupus erythematosus: A review

“…In addition, patients receiving immunosuppressants, biological agents or corticosteroids have an increased risk of infection, particularly, oral infection including oral candidiasis. The higher risk of opportunistic infections related to the mean daily doses of medicaments has been confirmed in SLE patients (Yang, Lai, Huang, Tsai, & Wang, 2018). The reported infections in this group of patients are fungal infections (disseminated candidiasis, pneumocystosis, aspergillosis, cryptococcosis, and zygomycosis), mycobacterium infection (tuberculosis, extrapulmonary tuberculosis, and non‐tuberculous mycobacteria), cytomegalovirus, varicella or herpes zoster, non‐typhoid salmonella, and Pneumocystis carinii pneumonia (Danza & Ruiz‐Irastorza, 2013; Tektonidou, Wang, Dasgupta, & Ward, 2015; Yang et al, 2018).…”

Comparing the burdens of opportunistic infections among patients with systemic rheumatic diseases: a nationally representative cohort study

“…Frequent use of glucocorticoids and immunosuppressive agents is also an important risk factor for unusual infection, and it has been reported that cyclophosphamide use for serious SLE manifestations is linked to fatal OIs [31]. A recent observational study also revealed that corticosteroid use had a dose-dependent effect on the rate of OIs [10].…”

“…In addition to common infections, opportunistic infection (OI) has emerged as an important complication in developed countries [8]. Interestingly, the risks of herpes zoster and Pneumocystis jiroveci pneumonia are elevated among SLE patients [9, 10], while DM was recently shown to be associated with elevated rates of herpes zoster and tuberculosis [11, 12]. However, most previous studies regarding the relationship between rheumatic diseases and OI were focused on SLE and were limited by their small-scale or single-centre designs.…”

The risk of herpes zoster among patients with ankylosing spondylitis: A population‐based cohort study in Taiwan

“…The reason for regional differences in HZ morbidity are still unclear; this may be because of the ethnic distinction and the cultural differences . Many studies have shown that the incidence of HZ is higher in some autoimmune diseases, for example RA and SLE, but few studies have shown the incidence of HZ in AS patients. In the USA, the incidence rate of HZ in AS patients is higher than in the general population, but the results showed no statistical significance .…”