NEW guidelines set by the European Alliance of Associations for Rheumatology (EULAR) recommend that patients with autoimmune inflammatory rheumatic disease (AIIRD) should be screened for infections prior to commencing disease-modifying antirheumatic drugs (DMARD).
A task force of experts in the fields of epidemiology, infectious diseases, pulmonology, research, and rheumatology conducted a systematic literature review where they collated the overarching principles and recommendations for infectious disease screening in patients due to commence DMARD therapy for AIIRDs. Following the identification of these, the task force reviewed each recommendation through three rounds of voting. Recommendations were only included in the new guidelines if a voting consensus of ≥75% was achieved during round one, ≥67% in round two, and ≥50% in round three. Lead author, George E. Fragoulis, Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Greece, highlighted the previous difficulties in developing guidelines for screening and prophylaxis in patients with AIIRDs due to the variability in type of AIIRD, comorbidities, treatments, and geographical location as well as challenges in unifying procedures across different infections.
The outcome of voting saw agreement on four overarching principles and eight recommendations. The agreed principles include discussing the risk of chronic or opportunistic infections before commencing DMARD or other immunosuppressant therapy, the importance of cross–specialty collaboration, considering individual risk factors when deciding upon screening procedures, and considering both national and international guidelines. The recommendations state that before commencing DMARDs or other immunosuppressant therapies, patients should be screened for latent tuberculosis following national or international guidelines, and any treatment for this should follow national or international guidelines; screened for hepatitis B, chronic hepatitis C, and HIV; counselled on pre-exposure prophylaxis following contact with the varicella zoster if they do not have immunity; considered for pneumocystis jirovecii pneumonia prophylaxis if they are treated with high dose of glucocorticoids.
This guidance will aid clinicians in patient counselling, enhance informed discussions around starting immunosuppressive therapy, and could help reduce chronic and opportunistic infections, as well as provide a standardised framework for counselling and management.
