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Risk Factors for Pneumocystis jirovecii Pneumonia in Patients With Rheumatoid Arthritis and a Prophylactic Indication of Trimethoprim/Sulfamethoxazole

Yukawa, Kazutoshi, MD*; Nagamoto, Yasutsugu, MD, PhD; Watanabe, Hirofumi, MD*; Funaki, Masamoto, MD*; Iwahashi, Mitsuhiro, MD, PhD*; Yamana, Jiro, MD, PhD*; Sasaki, Rie, MD*; Yamana, Seizo, MD, PhD*

JCR: Journal of Clinical Rheumatology: October 2018 - Volume 24 - Issue 7 - p 355–360
doi: 10.1097/RHU.0000000000000731
Original Articles

Background/Objectives Immunosuppressant medications (ISPs) increase the occurrence of Pneumocystis jirovecii pneumonia (PCP) in rheumatoid arthritis (RA) patients. The prophylactic administration of trimethoprim/sulfamethoxazole (TMP/SMX) for PCP is effective but has serious adverse effects and so should be selectively used for patients at high risk. The aims of this study were to clarify the risk factors for PCP in RA patients and to establish the indications for administering TMP/SMX.

Methods This retrospective cohort study analyzed data from 2640 patients (2010–2014) diagnosed as having RA who had not received a prophylactic administration of TMP/SMX. The risk factors for PCP were evaluated by comparing the clinical parameters between patients with PCP (PCP group, n = 19) and those without (non-PCP group, n = 2621).

Results The PCP group was older (70 vs. 64 years), received higher doses of prednisolone (6.2 vs. 2.4 mg/d) and methotrexate (7.7 vs. 5.2 mg/wk), and had a greater number of ISPs (1.3 vs. 0.8) (p < 0.05). We stratified the PCP risk using a scoring system based on odds ratios (ORs) calculated for these parameters (methotrexate ≥6 mg/wk OR = 4.5, 1 point; age ≥65 years, OR = 3.7, 1 point; ≥2 ISPs, OR = 3.7, 1 point; prednisolone ≥5 mg/d, OR = 12.4, 3 points). The incidence of PCP among patients scoring 0 to 2 points was 0.04%; 3 to 4 points, 2.3%; and 5 points or more, 5.8%.

Conclusions The prophylactic administration of TMP/SMX for PCP is recommended for RA patients who score at least 5 points with our system.

From the *Division of Arthritis and Collagen Disease, Higashi-Hiroshima Memorial Hospital, Higashihiroshima; and

Division of Cardiology, Tsuchiya General Hospital, Hiroshima, Japan.

The authors declare no conflict of interest.

The authors alone are responsible for the content and writing of this article.

Correspondence: Yasutsugu Nagamoto, MD, PhD, Division of Cardiology, Tsuchiya General Hospital, Hiroshima, Japan, 3-30, Nakajima town, Nakaku, Hiroshima, Japan. E-mail:

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