Glucocorticoid Treatment, Chronic Lung Disease Associated with Increased Risk of Respiratory Tract Infection in PsA, SpA

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“Respiratory tract infections constitute the most common infections in patients with rheumatic diseases, especially under immunosuppressive treatment,” investigators explained.

Results from a retrospective analysis evaluating risk factors in patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) determined that multiple factors, including glucocorticoid therapy, female sex, chronic lung disease, and a history of severe airway infections, were linked to an increased risk of respiratory tract infections (RTIs) in this patient population, according to research published in Frontiers in Immunology.1

“RTIs constitute the most common infections in patients with rheumatic diseases, especially under immunosuppressive treatment,” investigators explained. “RTIs may cause significant morbidity with reduced quality of life (QoL), increased economic loss and healthcare costs and may lead to interruption of DMARD therapy. Additionally, serious infections may contribute to mortality in at-risk patients.”

Clinically confirmed patients with axSpA and PsA were recruited from the Rheumatology outpatient clinic of University Medical Center Freiburg in Freiburg, Germany. Investigators used a questionnaire-based screening approach, developed by the Center for Chronic Immunodeficiency, in addition to a retrospective medical chart analysis to evaluate infections, frequency, and duration of RTIs, along with antibiotic treatment. The questionnaire also included details on history of infections, hospitalization, and comorbidities. This was then cross-referenced with clinical data and demographic data, such as body mass index (BMI), age, height, and medication information.

Of the 330 patients included in the study (PsA: n = 168; axSpA: n = 162), the mean age was 53.3 years, mean disease duration was 11.3 years, 55.5% were male, and 80.5% were receiving disease-modifying antirheumatic (DMARD) therapy. Most (89.3%) had experienced 1 or more upper respiratory tract infections (URTI) and 31.1% reported 1 or more lower respiratory tract infections (LRTI) within the last 2 years. Of these, the most common URTIs were rhinitis (87.3%), laryngitis/pharyngitis (36.1%), and sinusitis (34.9%). The most common LRTI was bronchitis (29.7%).

A multivariate binomial logistic regression model indicated that chronic lung disease (OR 17, p=0.006), receiving glucocorticoids (OR 9.24, p=0.012), reporting a previous history of severe airway infections (OR 6.82, p=0.013), and the number of previous biologics (OR 1.72, p=0.017) were associated with LRTI occurrence. HLA B27 positivity was negatively associated with LRTI (OR 0.29, p=0.025). Further, females were more likely to develop LRTIs when compared with male patients (53.6% vs. 38.6%, respectively, p=0.006) and had had higher rates of antibiotic usage (p=0.009).

Although approximately half (45.4%) of patients needed antibiotics to treat their RTIs, no significant difference was seen among patients with axSpA and PsA. Patients were more likely to require antibiotic therapy if they had a history of smoking (OR 3.40, p=0.008), biological therapy (OR 3.38, p=0.004), and sleep quality (OR 1.13, p<0.001). Those experiencing LRTIs were more likely to be older in age (56.8 vs. 52.6 years, p=0.011) and reported more functional impairment (p<0.001). The regression model showed a negative association between age and antibiotic therapy, with patients aged 20-29 years receiving the highest rate of therapy, although LRTIs were less frequently reported in this group when compared with any other age group. Interestingly, hypogammaglobulinemia (IgG<7g/l) was rare in this cohort (3.4%) even though they were receiving continuous immunomodulatory therapy.

The relatively small patient cohort limited the study. Further, the questionnaire-based study design may have led to recall bias. However, the addition of medical chart analysis and medical reports mitigated this bias. Lastly, while this study took place during the COVID-19 pandemic, investigators note that COVID prevention measures may have influenced infection frequency.

“Awareness of these risk factors will assist physicians to identify patients with an increased infection risk, who will benefit from additional preventive measures, such as vaccination and smoking cessation or adjustment of DMARD therapy,” investigators concluded.


Frede N, Rieger E, Lorenzetti R, et al. Respiratory tract infections and risk factors for infection in a cohort of 330 patients with axial spondyloarthritis or psoriatic arthritis. Front Immunol. 2022;13:1040725. Published 2022 Oct 26. doi:10.3389/fimmu.2022.1040725