Loading ...

TOPLINE:

Discontinuing prophylactic trimethoprim-sulfamethoxazole (TMP-SMX) while patients with autoimmune or inflammatory disease (AIID) were receiving > 12.5 mg/d of prednisone-equivalent glucocorticoids significantly increased the risk for Pneumocystis jirovecii pneumonia (PJP).

METHODOLOGY:

• Researchers conducted a case-control study to assess the risk factors associated with PJP infection despite prophylaxis in a cohort of patients with AIID from South Korea.
• They included 1294 prophylactic episodes in 1148 patients with AIID who received immunosuppressants and prophylactic TMP-SMX.
• TMP-SMX was administered as either a single-strength tablet daily or a double-strength tablet thrice per week, with dose adjustments on the basis of the estimated glomerular filtration rate when needed (mean duration of TMP-SMX prophylaxis, 181.9 days).
• The clinical factors associated with the 1-year incidence of PJP as the primary outcome were evaluated from baseline to either loss to follow-up, PJP occurrence, or week 52.

TAKEAWAY:

• During the 1174 person-years of observation, 10 PJP cases were identified (incidence rate, 0.85 per 100 person-years; 95% CI, 0.41-1.57).
• The glucocorticoid dose at TMP-SMX discontinuation was significantly higher in patients with PJP than in those without the condition (median, 22.5 vs 10.0 mg prednisone-equivalent corticosteroids; P < .001).
• An optimal glucocorticoid cutoff of 12.5 mg prednisone-equivalent best distinguished PJP cases from the control cases (P < .001). Discontinuing TMP-SMX while being on a glucocorticoid dose above this significantly increased the PJP risk (adjusted hazard ratio, 13.84; P = .014).
• Of the 63 adverse events reported, the majority were mild to moderate in severity and required no intervention. Two severe cases of Stevens-Johnson syndrome were deemed to be probably related to TMP-SMX.

IN PRACTICE:

“In conclusion, discontinuation of TMP-SMX during GC [glucocorticoid] treatment at doses > 12.5 mg prednisone equivalent significantly increased the risk of PJP. This suggests that tapering the GC to 12.5 mg/d may be a reasonable consideration when withdrawing PJP prophylaxis,” the authors wrote.

SOURCE:

This study was led by Ju Yeon Kim, MD, Division of Rheumatology, Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, South Korea. It was published online on April 2, 2025, in Arthritis & Rheumatology.

LIMITATIONS:

The small number of PJP cases posed statistical challenges in fitting the multivariable model. The prophylactic effect of TMP-SMX may vary among individual autoimmune inflammatory diseases; however, this variability could not be thoroughly addressed because of limited patient numbers in specific disease subgroups. The risk for PJP is influenced by multiple interacting factors rather than a single determinant.

DISCLOSURES:

This study was supported by the National Research Foundation of Korea grant. The authors reported no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.