title: Mycobacterial diseases and antitumour necrosis factor therapy in USA.
abstract: OBJECTIVE
  In North America, tuberculosis and nontuberculous mycobacterial (NTM) disease rates associated with antitumour necrosis factor α (anti-TNFα) therapy are unknown.
  
  
  METHODS
  At Kaiser Permanente Northern California, the authors searched automated pharmacy records to identify inflammatory disease patients who received anti-TNF therapy during 2000-2008 and used validated electronic search algorithms to identify NTM and tuberculosis cases occurring during anti-TNF drug exposure.
  
  
  RESULTS
  Of 8418 anti-TNF users identified, 60% had rheumatoid arthritis (RA). Among anti-TNF users, 18 developed NTM and 16 tuberculosis after drug start. Anti-TNF associated rates of NTM and tuberculosis were 74 (95% CI: 37 to 111) and 49 (95% CI: 18 to 79) per 100 000 person-years, respectively. Rates (per 100, 000 person-years) for NTM and tuberculosis respectively for etanercept were 35 (95% CI: 1 to 69) and 17 (95% CI: 0 to 41); infliximab, 116 (95% CI: 30 to 203) and 83 (95% CI: 10 to 156); and adalimumab, 122 (95% CI: 3 to 241) and 91 (95% CI: 19 to 267). Background rates for NTM and tuberculosis in unexposed RA-patients were 19.2 (14.2 to 25.0) and 8.7 (5.3 to 13.2), and in the general population were 4.1 (95% CI 3.9 to 4.4) and 2.8 (95% CI 2.6 to 3.0) per 100, 000 person-years. Among anti-TNF users, compared with uninfected individuals, NTM case-patients were older (median age 68 vs 50 years, p<0.01) and more likely to have RA (100% vs 60%, p<0.01); whereas, tuberculosis case-patients were more likely to have diabetes (37% vs 16%, p=0.02) or chronic renal disease (25% vs 6%, p=0.02).
  
  
  CONCLUSIONS
  Among anti-TNF users in USA, mycobacterial disease rates are elevated, and NTM is associated with RA.
authors.affiliation: Oregon Health Sciences University, Portland, OR, USA. winthrop@ohsu.edu
authors.forename: K L
authors.initials: KL
authors.lastname: Winthrop
authors.forename: R
authors.initials: R
authors.lastname: Baxter
authors.forename: L
authors.initials: L
authors.lastname: Liu
authors.forename: C D
authors.initials: CD
authors.lastname: Varley
authors.forename: J R
authors.initials: JR
authors.lastname: Curtis
authors.forename: J W
authors.initials: JW
authors.lastname: Baddley
authors.forename: B
authors.initials: B
authors.lastname: McFarland
authors.forename: D
authors.initials: D
authors.lastname: Austin
authors.forename: L
authors.initials: L
authors.lastname: Radcliffe
authors.forename: Eb
authors.initials: E
authors.lastname: Suhler
authors.forename: D
authors.initials: D
authors.lastname: Choi
authors.forename: J T
authors.initials: JT
authors.lastname: Rosenbaum
authors.forename: L J
authors.initials: LJ
authors.lastname: Herrinton
mesh_terms: D000068879:Adalimumab; D000818:Animals; D000911:Antibodies, Monoclonal / Q000009:adverse effects; D061067:Antibodies, Monoclonal, Humanized / Q000009:adverse effects; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D015331:Cohort Studies; D000068800:Etanercept; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000009:adverse effects; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D015994:Incidence; D000069285:Infliximab; D008297:Male; D008875:Middle Aged; D009164:Mycobacterium Infections / Q000139:chemically induced* / Q000453:epidemiology*; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D014481:United States / Q000453:epidemiology
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab; D000068800:Etanercept