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Extended report
Risk of hospitalised infection in rheumatoid arthritis patients receiving biologics following a previous infection while on treatment with anti-TNF therapy
  1. Huifeng Yun1,2,
  2. Fenglong Xie2,
  3. Elizabeth Delzell1,
  4. Lang Chen2,
  5. Emily B Levitan1,
  6. James D Lewis3,
  7. Kenneth G Saag2,
  8. Timothy Beukelman2,
  9. Kevin Winthrop4,
  10. John W Baddley5,
  11. Jeffrey R Curtis1,2
  1. 1Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
  2. 2Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
  3. 3Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  4. 4Divisions of Infectious Diseases, Public Health, and Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
  5. 5Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
  1. Correspondence to Dr Jeffrey R Curtis, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Towers 802D, Birmingham, AL 35294, USA; jcurtis{at}


Background The risk of subsequent infections in rheumatoid arthritis (RA) patients who receive biologic therapy after a serious infection is unclear.

Objective To compare the subsequent risk of hospitalised infections associated with specific biologic agents among RA patients previously hospitalised for infection while receiving anti-tumour necrosis factor (anti-TNF) therapy.

Methods Using 2006–2010 Medicare data for 100% of beneficiaries with RA enrolled in Medicare, we identified patients hospitalised with an infection while on anti-TNF agents. Follow-up began 61 days after hospital discharge and ended at the earliest of: next infection, loss of Medicare coverage or 18 months after start of follow-up. We calculated the incidence rate of subsequent hospitalised infection for each biologic and used Cox regression to control for potential confounders.

Results 10 794 eligible hospitalised infections among 10183 unique RA patients who contributed at least 1 day of biologic exposure during follow-up. We identified 7807 person-years of exposure to selected biologics—333 abatacept, 133 rituximab and 7341 anti-TNFs (1797 etanercept, 1405 adalimumab, 4139 infliximab)—and 2666 associated infections. Mean age across biologic exposure cohorts was 64–69 years. The crude incidence rate of subsequent hospitalised infection ranged from 27.1 to 34.6 per 100 person-years. After multivariable adjustment, abatacept (HR: 0.80, 95% CI 0.64 to 0.99) and etanercept (HR: 0.83, 95% CI 0.72 to 0.96) users had significantly lower risks of subsequent infection compared to infliximab users.

Conclusions Among RA patients who experienced a hospitalised infection while on anti-TNF therapy, abatacept and etanercept were associated with the lowest risk of subsequent infection compared to other biologic therapies.

  • infection
  • biologics
  • rheumatoid arthritis
  • anti-TNF therapy
  • abatacept
  • rituximab

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