Risks of tuberculosis, meningitis, candidiasis, and fungal infections among patients receiving systemic treatments for psoriasis: a nationwide cohort study from BADBIR data.

Abstract

Systemic treatments for psoriasis confer differential risk profiles for infections such as tuberculosis, meningitis, candidiasis and other fungal infections. However, real-world comparative data including IL-17 and 23 inhibitors remain limited. We conducted a nationwide cohort study using data from British Association of Dermatologists Biologic and Immunomodulators Register (BADBIR) from 2007 to 2024. Adults with psoriasis receiving systemic treatments were included and followed from treatment initiation until treatment discontinuation, death, or last available follow-up data. Primary outcomes included tuberculosis, meningitis, candidiasis and other fungal infections. Incidence rates per 1000 person-years were calculated and incidence rate ratios (IRRs) were estimated using doubly robust interval-based Poisson regression model. Entropy balancing method was used to achieve covariate balance across treatment groups and multiple imputation was used to handle missing baseline data. A total of 40,930 treatment episodes from 18,635 patients contributing 118,018 person-years of follow-up were included in this analysis. During the follow-up, 22 tuberculosis cases, 29 meningitis cases, and 888 fungal infection cases including 450 candidiasis were reported. The overall incidence rates were 0.19 (95% CI 0.12 to 0.29) for tuberculosis, 0.25 (95% CI 0.16 to 0.35) for meningitis, and 7.53 (95% CI 7.05 to 8.05) for fungal infections per 1000 person-years. Most tuberculosis and meningitis cases were associated with TNF-α inhibitors, particularly adalimumab. Meningitis was predominantly viral and tuberculosis was largely pulmonary. 30-day mortality was observed in fewer than 5 cases in meningitis. IL-17 inhibitors alone exhibited increased risk of candidiasis compared to all other systemic treatment groups with IRRs ranging from 2.67 (95% CI 1.33 to 5.36) versus apremilast to 4.65 (95% CI 3.46 to 6.24) versus IL-12/23 inhibitor. Individual IL-17 inhibitors did not exhibit significant differences in the candidiasis risk. With fungal infections other than candidiasis, no statistically significant differences were observed between treatment groups. In this large cohort study, tuberculosis and meningitis were rare and longer-term follow-up is required to further characterise the risk with newer treatments. Candidiasis and fungal infections were more common with increased risks among patients receiving IL-17 inhibitors.