Zusammenfassung
Das Risiko an einer schweren Infektion zu erkranken steigt mit zunehmendem Alter. Dies liegt im Wesentlichen an der Immunoseneszenz und den mit dem Alter zunehmenden Komorbiditäten. Besonders kritisch ist die Situation, wenn ältere Patienten aufgrund des Vorliegens einer rheumatologischen Grunderkrankung mit einer immunsuppressiven Therapie behandelt werden oder eine solche erforderlich wird. Hier gilt es bei der Auswahl der zum Einsatz kommenden Substanzen besonders sorgfältig abzuwägen. Noch wichtiger als bei jungen ist es bei älteren Patienten mit Glukokortikoiden möglichst kurz und niedrig dosiert zu therapieren. Durch Impfungen gegen Influenza und Pneumokokken kann ein großer Teil der Infektionen vermieden werden. Kommt es zum Auftreten einer Infektion, sollten Antibiotika konsequent und möglichst gemäß Antibiogramm eingesetzt werden. Gerade bei älteren Betroffenen gilt es, Nutzen und mögliche Nebenwirkungen einer medikamentösen Therapie besonders sorgfältig abzuwägen und mögliche Wechselwirkungen zu beachten. Dies setzt eine Erfassung des Gesundheitszustands im Ganzen voraus.
Abstract
In general, the risk of serious infections increases with age, mainly explained by immunosenescence and accumulation of comorbidities. Those patients with rheumatoid arthritis who are of advanced age and require treatment with immunosuppressive agents are at particular risk to develop an infectious disease. Actual requirement and kind of treatment on the one hand, and risk of infection on the other hand, have to be considered carefully for each patient. For example, in high-risk patients, it is important to use glucocorticoids in a minimal way, i.e. in low doses and as short as possible. Vaccination, especially against influenza and pneumococci, plays an essential role in preventing infectious diseases, particularly in the elderly. Nevertheless, in cases of suspected bacterial infection, empiric antibiotic therapy should be started promptly. Due to the burden of drugs taken by patients of advanced age, the benefits and possible side effects as well as potential drug interactions have to be carefully considered. In summary, drug treatment of the elderly requires bearing in mind the complete health status of the individual patient.
Literatur
Adrian JR, Chirkova T, Kim JH et al (2013) Immunosenescence and challenges of vaccination against influenza in the aging population. Aging Dis 3:68–90
Bosch X, Guilabert A, Pallarés L et al (2006) Infections in systemic lupus erythematosus: a prospective and controlled study of 110 patients. Lupus 15:584–589
Carmona L, Gomez-Reino J, Rodrıguez-Valverde V et al (2005) Effectiveness of recommendations to prevent reactivation of latent tuberculosis infection in patients treated with tumor necrosis factor antagonists. Arthritis Rheum 52:1766–1772
Crowson CS, Hoganson DD, Fitz-Gibbon PD, Matteson EL (2012) Development and validation of a risk score for serious infection in patients with rheumatoid arthritis. Arthritis Rheum 64:2847–2855
Curtis JR, Xie F, Chen L et al (2012) Use of a disease risk score to compare serious infections associated with anti-TNF therapy among high versus lower risk rheumatoid arthritis patients. Arthritis Care Res 64:1480–1489
Cornberg M, Protzer U, Petersen J et al (2011) Prophylaxis, diagnosis and therapy of hepatitis B virus infection – the German guideline. Z Gastroenterol 49:871–930
Diel R, Hauer B, Loddenkemper R et al (2009) Empfehlungen für das Tuberkulosescreening vor Gabe von TNF-α-Inhibitoren bei rheumatischen Erkrankungen. Pneumologie 63:329–334 (und Z Rheumatol. 2009;68:411–416)
Dixon WG, Kezouh A, Bernatsky S, Suissa S (2011) The influence of systemic glucocorticoid therapy upon the risk of non-serious infection in older patients with rheumatoid arthritis: a nested case – control study. Ann Rheum Dis 70:956–960
Dixon WG, Hyrich KL, Watson KD et al (2010) Drug-specific risk of tuberculosis in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the British Society for Rheumatology Biologics Register (BSRBR). Ann Rheum Dis 69:522–528
Doran MF, Crowson CS, Pond GR et al (2002) Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum 46:2287–2293
Doran MF, Crowson CS, Pond GR et al (2002) Predictors of infection in rheumatoid arthritis. Arthritis Rheum 46:2294–2300
Dorrington MG, Bowdish DME (2013) Immunosenescence and novel vaccination strategies for the elderly. Front Immunol 4:171
Feuchtenberger M, Kleinert S, Schwab S et al (2011) Vaccination survey in patients with rheumatoid arthritis: a cross-sectional study. Rheumatol Int 32:1533–1539
Galloway JB, Hyrich KL, Mercer LK et al (2011) Anti-TNF therapy is associated with an increased risk of serious infections in patients with rheumatoid arthritis especially in the first 6 months of treatment: updated results from the British Society for Rheumatology Biologics Register with special emphasis on risks in the elderly. Rheumatology 50:124–131
Gavazzi G, Krause KH (2002) Aging and infection. Lancet Infect Dis 2:659–666
Goldacker S, Gause AM, Warnatz K, Kommission Pharmakotherapie der DGRh (2013) Vaccination in adult patients with chronic inflammatory rheumatic diseases. Z Rheumatol 72:690–694
Gomez-Reino JJ, Carmona L, Valverde VR et al (2003) Treatment of rheumatoid arthritis with tumor necrosis factor inhibitors may predispose to significant increase in tuberculosis risk: a multicenter active-surveillance report. Arthritis Rheum 48:122–127
Goronzy JJ, Li G, Yang Z, Weyand CM (2013) The janus head of T cell aging – autoimmunity and immunodeficiency. Front Immunol 4:131
Harpaz R, Ortega-Sanchez IR, Seward JF et al (2008) Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 57:1–30 (quiz CE2–4)
Hazlewood GS, Naimark D, Gardam M et al (2013) Prophylaxis for latent tuberculosis infection prior to anti-TNF therapy in low-risk elderly patients with rheumatoid arthritis: a decision analysis. Arthritis Care Res (Hoboken). doi:10.1002/acr.22063
Kleinert S, Tony HP, Krueger K et al (2012) Screening for latent tuberculosis infection: performance of tuberculin skin test and interferon-γ release assays under real-life conditions. Ann Rheum Dis 71:1791–1795
Krause A, Krüger K (2013) Pneumokokkenimpfung bei immunsupprimierten Patienten. Z Rheumatol 72:942–946
Mariette X, Baron G, Tubach F et al (2012) Influence of replacing tuberculin skin test with ex vivo interferon gamma release assays on decision to administer prophylactic anti-tuberculosis antibiotics before anti-TNF therapy. Ann Rheum Dis 71:1783–1790
Leibovici L (1995) Bacteraemia in the very old. Features and treatment. Drugs Aging 6:456–464
Petri M (1998) Infection in systemic lupus erythematosus. Rheum Dis Clin North Am 24:423–456
Reber AI, Chirkova T, Kim JH et al (2012) Immunosenescence and challenges of vaccination against influenza in the aging population. Aging Dis 3:68–90
Ribeiro AC, Laurindo IM, Guedes LK et al (2013) Abatacept and reduced immune response to pandemic 2009 influenza A/H1N1 vaccination in patients with rheumatoid arthritis. Arthritis Care Res 65:476–480
Roseman C, Truedsson L, Kapetanovic MC (2012) The effect of smoking and alcohol consumption on markers of systemic inflammation, immunoglobulin levels and immune response following pneumococcal vaccination in patients with arthritis. Arthritis Res Ther 14:R170
Sarrazin C, Berg T, Ross RS et al (2010) Update der S3-Leitlinie Prophylaxe, Diagnostik und Therapie der Hepatitis C-Virus-Infektion, AWMF-Register-Nr.:021/012. Z Gastroenterol 48:289–351
Smitten AL, Choi HK, Hochberg MC et al (2007) The risk of herpes zoster in patients with rheumatoid arthritis in the United States and the United Kingdom. Arthritis Rheum 57:1431–1438
Ständige Impfkommission(STIKO) am Robert-Koch-Institut (2005) Hinweise zu Impfungen für Patienten mit Immundefizienz/Stand: November 2005. Epidemiologisches Bulletin 39/2005. http://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2005/Sonderausgaben/Sonderdruck_STlKO-Hinweise_Nov-2005.pdf;jsessionid=DC2B1B546D4D01640A4DFEB5FC4783D7.2_cid372?__blob=publicationFile. Zugegriffen 10.03.2014
Staples PJ, Gerding DN, Decker JL, Gordon RS Jr (1974) Incidence of infection in systemic lupus erythematosus. Arthritis Rheum 17:1–10
Strangfeld A, Eveslage M, Schneider M et al (2011) Treatment benefit or survival of the fittest: what drives the time-dependent decrease in serious infection rates under TNF inhibition and what does this imply for the individual patient? Ann Rheum Dis 70:1914–1920
Strangfeld A, Listing J, Herzer P et al (2009) Risk of herpes zoster in patients with rheumatoid arthritis treated with anti – TNF- agents. JAMA 301:737–744
Thomas S, Hall A (2004) What does epidemiology tell us about risk factors for herpes zoster? Lancet Infect Dis 4:26–33
Tubach F, Salmon D, Ravaud P et al (2009) Risk of tuberculosis is higher with anti – tumor necrosis factor monoclonal antibody therapy than with soluble tumor necrosis factor receptor therapy the three-year prospective. Arthritis Rheum 60:1884–1894
Warnatz K, Goldacker S, Gause AM, die Kommission Pharmakotherapie der DGRh (2013) Impfempfehlungen der Kommission für Pharmakotherapie der DGRh. Z Rheumatol 72:687–689
Warnatz K, Goldacker S, die Kommission Pharmakotherapie der DGRh (2013) Z Rheumatol 9:909
Weng NP (2006) Aging of the immune system: how much can the adaptive immune system adapt? Immunity 24:495–499
Widdifield J, Bernatsky S, Paterson JM et al (2013) Serious infections in a population-based cohort of 86,039 seniors with rheumatoid arthritis. Arthritis Care Res 65:353–361
Winthrop KL, Weinblatt ME, Daley CL (2012) You can’t always get what you want, but if you try sometimes (with two tests – TST and IGRA – for tuberculosis) you get what you need. Ann Rheum Dis 71:1757–1760
Zink A, Manger B, Kaufmann J et al (2013) Evaluation of the RABBIT risk score for serious infections. Ann Rheum Dis (Elektronisch publiziert vor Drucklegung)
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Interessenkonflikt. Die Autoren weisen auf folgende Beziehungen hin: A. Strangfeld: Vortragshonorare von Pfizer, BMS, MSD, UCB, Abbvie und Roche. K. Krüger: Vorträge und/oder Beratung bei Abbvie, BMS, Medac, MSD, Pfizer, Roche und UCB. C. Kneitz: Vorträge und/oder Beratung bei Abbvie, Berlin-Chemie, Chugai, Roche, MSD, Pfizer, BMS und UCB. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Kneitz, C., Strangfeld, A. & Krüger, K. Prophylaxe und Behandlung von Infektionen beim älteren Rheumapatienten. Z. Rheumatol. 73, 225–232 (2014). https://doi.org/10.1007/s00393-013-1243-5
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DOI: https://doi.org/10.1007/s00393-013-1243-5