Frailty & immunomodulator infection risk

Frailty & immunomodulator infection risk

July 14, 2020

Issue 13

Clinical Question

Are frail IBD patients more susceptible to infections with immunomodulators?

Editor’s Bottom Line

Frailty is associated with an increased risk of infection among IBD patients treated with TNF inhibitors and immunosuppressants. Recognition of frailty, and strategies to reduce frailty, may help to reduce infectious complications of therapy.


Kochar B, Cai W, Cagan A, et al. Pretreatment Frailty Is Independently Associated With Increased Risk of Infections After Immunosuppression in Patients With Inflammatory Bowel Diseases. Gastroenterol. 2020;158(8):2104–11.


Frailty is “a multifactorial vulnerability to stress that increases the risk of adverse health outcomes.” To determine the impact that frailty has on the incidence of infections with the use of anti-tumor necrosis factor (TNF) agents and immunosuppressing drugs, researchers retrospectively examined data from 1,299 IBD patients treated with an anti-TNF agent and 2,676 IBD patients receiving an immunosuppressant. Individuals had been treated at Partners HealthCare System in Massachusetts between 1996 and 2010. The authors used a validated definition of frailty and an algorithm to identify frail or fit patients using International Classification of Disease (ICD)-10 codes.

Five percent of those who received anti-TNF therapy and 7% of those given an immunosuppressant met the criteria for frailty in the two years prior to starting treatment with an anti-TNF or immunosuppressant. Frail patients using an anti-TNF or an immunosuppressant were a median 41 and 44 years of age, respectively, compared to a median of 35 and 38 years of age for fit patients using an anti-TNF or immunosuppressant, respectively. Frail patients in this group had a mean of three comorbidities, compared to a mean of one comorbid condition among fit patients. Frail IBD patients in general were more likely to be female and white.

Results showed that 19% and 17% of frail patients receiving an anti-TNF agent or immunosuppressant, respectively, experienced an infection following treatment, compared with 9% and 7%, respectively, of fit patients (P<0.01). The rate of infection-related hospitalizations after treatment initiation was 13% among frail IBD patients receiving immunosuppressant drugs, compared to 5% for fit patients (P<0.01). The rate of such hospitalizations was numerically but not significantly higher among frail anti-TNF users.

Analyses adjusting for the impact of age, comorbidities, and concomitant medications found frail patients were twice as likely as fit patients to experience an infection with anti-TNF use (Adjusted Odds Ratio [AOR], 2.05; 95% Confidence Interval [CI], 1.07–3.93] and 1.8 times more likely to have an infection after immunosuppressant use (AOR, 1.81; 95% CI, 1.22–2.70).


Study Design: Retrospective cohort
Funding: Not disclosed
Allocation: Not applicable
Setting: Single-center database
Level of Evidence: 2b (Oxford Levels of Evidence)