Biological agents in monotherapy for the treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease, which results in joint destruction and permanent disability. The advent of disease-modifying antirheumatic drugs (DMARDs) has made a profound impact on the outcome and prognosis of RA. Methotrexate (MTX) is a central agent in RA therapy, and is used either alone or in combination with biological DMARDs. However, a large proportion of RA patients (20%-40%) either do not respond to or are unable to tolerate MTX or the alternative agents used in place of MTX (including leflunomide, sulfasalazine, azathioprine, hydroxycholoquine and combination DMARDs). For these patients, monotherapy with biological DMARDs is a key treatment option that balances tolerability with improved clinical outcomes. This article reviews the data for four biological agents approved for use as monotherapy in Switzerland (adalimumab, certolizumab pegol, etanercept and tocilizumab) in order to formulate a consensus statement on their roles in biologic monotherapy of RA.

Infection risk after orthopedic surgery in patients with inflammatory rheumatic diseases treated with immunosuppressive drugs

OBJECTIVE

The influence of specific medications on the risk of postoperative infection in patients with rheumatoid arthritis and other inflammatory rheumatic diseases (IRDs) remains unclear. This retrospective study examined the risk of postoperative infection at the site of surgery in patients treated with immunosuppressive drugs (including biologic agents) undergoing different types of orthopedic surgery.

METHODS

The study included 50,359 cases of orthopedic surgery performed in our hospital between 2000 and 2008. The primary outcome was operation-related infection. IRD patients were compared with those with degenerative or posttraumatic disorders, and in IRD patients, the effect of immunosuppressive medication, specifically tumor necrosis factor α (TNFα) inhibitors and their preoperative management, was examined.

RESULTS

There were 373 operation-related infections (0.8%) of 47,887 cases in the degenerative/posttraumatic group and 49 (2.0%) of 2,472 in the IRD group (higher infection rate in the IRD group; odds ratio [OR] 2.58 [95% confidence interval (95% CI) 1.91-3.48], P < 0.001). In the IRD group, elbow and foot surgery had the highest infection rates. The risk of infection was significantly increased in patients taking multiple conventional disease-modifying antirheumatic drugs (DMARDs; OR 2.49 [95% CI 1.06-5.84], P = 0.036) or TNFα inhibitors (OR 2.54 [95% CI 1.08-5.97], P = 0.032). The risk was especially high (6 [12%] of 49) if the last dose of TNFα inhibitor was given <1 administration interval before surgery.

CONCLUSION

The risk of postoperative infection was elevated in patients with IRDs, especially those taking >1 conventional DMARD or TNFα inhibitors. It may be advisable to consider stopping TNFα inhibitors ≥1 administration interval before surgery, since the risk of postoperative infection appears to be higher if the operation occurs within this period.

Recommendations for the use of ultrasound in rheumatoid arthritis: literature review and SONAR score experience

Ultrasound (US) has become a useful tool in the detection of early disease, differential diagnosis, guidance of treatment decisions and treatment monitoring of rheumatoid arthritis (RA). In 2008, the Swiss Sonography in Arthritis and Rheumatism (SONAR) group was established to promote the use of US in inflammatory arthritis in clinical practice. A scoring system was developed and taught to a large number of Swiss rheumatologists who already contributed to the Swiss Clinical Quality Management (SCQM) database, a national patient register. This paper intends to give a Swiss consensus about best clinical practice recommendations for the use of US in RA on the basis of the current literature knowledge and experience with the Swiss SONAR score. Literature research was performed to collect data on current evidence. The results were discussed among specialists of the Swiss university centres and private practice, following a structured procedure. Musculoskelatal US was found to be very helpful in establishing the diagnosis and monitoring the evolution of RA, and to be a reliable tool if used by experienced examiners. It influences treatment decisions such as continuing, intensifying or stepping down therapy. The definite modalities of integrating US into the diagnosis and monitoring of RA treatments will be defined within a few years. There are, however, strong arguments to use US findings as of today in daily clinical care. Some practical recommendations about the use of US in RA, focusing on the diagnosis and the use of the SONAR score, are proposed.

Long-term survival of GSB III elbow prostheses and risk factors for revisions

INTRODUCTION

Although replacement of the elbow joint is a complex procedure there is not much clinical evidence that contributes to surgical decision-making, mainly due to small clinical samples and short follow-up. Therefore, we performed a long-term analysis up to 30 years after implantation of a GSB III total elbow prosthesis to quantify long-term outcome and to identify possible risk factors for implant revision.

MATERIALS AND METHODS

All patients who received a primary GSB III total elbow prosthesis between 1978 and 1998 were included. Information about patient characteristics, the latest known implant status and possible risk factors were collected, Kaplan-Meier survival curves plotted, and 10- and 20-year survival calculated. The cohort was stratified for known risk factors such as diagnosis, age, or gender and included in a Cox regression analysis.

RESULTS

A total of 253 patients [mean age at operation 56.9 years (range from 17.5 to 84 years)] with 293 GSB III prostheses were included. The median follow-up was 9.1 years (0 months to 29.3 years). Whereas 81 prostheses did not need revision during the observation period, 76 had been implanted in patients who died before any revision was required, and 75 had not been revised by the last known follow-up. 61 prostheses were revised. This corresponds to a 10-year survival rate of 0.8 (95 % CI 0.74-0.85) and a 20-year rate of 0.67 (95 % CI 0.57-0.76). Prostheses in patients with post-traumatic conditions survived significantly shorter than those in patients with rheumatoid arthritis; previous operations lead to a 2.8 times greater risk of revision (p = 0.004). Neither age at implantation nor gender had a significant influence on prosthesis survival.

CONCLUSIONS

The results indicate a good long-term prognosis for this design. The prognosis has to be adjusted for the underlying disease. Previous operations such as joint reconstruction significantly increase the risk of revision.

The importance of early treatment for the prognosis of rheumatoid arthritis

Chronic synovial inflammation in rheumatoid arthritis (RA) leads to progressive damage to articular cartilage and bone, ultimately resulting in disability. Therefore, control of the articular inflammation is of great importance to prevent joint damage. A variety of disease-modifying antirheumatic drugs (DMARDs) are available for RA patients. Conventional synthetic DMARDs, and in particular biological DMARDs, have been shown to effectively inhibit joint destruction in RA. Longitudinal assessments of radiographic changes in patients with RA in clinical trials and in large patient registries have clearly shown that delays in the initiation of DMARD therapy results in significantly increased progression of joint damage. Patients started early on DMARDs had significantly lower radiographic damage progression than patients initiating DMARD treatment later. These effects were maintained for several years, suggesting that early in the development of RA a therapeutic window of opportunity exists in which DMARD therapy decisively influences the long-term prognosis. Therefore, to improve the clinical outcome of RA, our efforts should be directed towards diagnosing RA earlier and introducing DMARD therapy immediately after the diagnosis has been made.

Visfatin/pre-B-cell colony-enhancing factor (PBEF), a proinflammatory and cell motility-changing factor in rheumatoid arthritis

Adipokines such as adiponectin and visfatin/pre-B-cell colony-enhancing factor (PBEF) have been recently shown to contribute to synovial inflammation in rheumatoid arthritis (RA). In this study, we evaluated the pathophysiological implication of visfatin/PBEF in the molecular patterns of RA synovial tissue, focusing on RA synovial fibroblasts (RASFs), key players in RA synovium. Expression of visfatin/PBEF in synovial fluid and tissue of RA patients was detected by immunoassays and immunohistochemistry. RASFs were stimulated with different concentrations of visfatin/PBEF over varying time intervals, and changes in gene expression were evaluated at the RNA and protein levels using Affymetrix array, real-time PCR, and immunoassays. The signaling pathways involved were identified. The influence of visfatin/PBEF on fibroblast motility and migration was analyzed. In RA synovium, visfatin/PBEF was predominantly expressed in the lining layer, lymphoid aggregates, and interstitial vessels. In RASFs, visfatin/PBEF induced high amounts of chemokines such as IL-8 and MCP-1, proinflammatory cytokines such as IL-6, and matrix metalloproteinases such as MMP-3. Phosphorylation of p38 MAPK was observed after visfatin/PBEF stimulation, and inhibition of p38 MAPK showed strong reduction of visfatin-induced effects. Directed as well as general fibroblast motility was increased by visfatin/PBEF-induced factors. The results of this study indicate that visfatin/PBEF is involved in synovial fibroblast activation by triggering fibroblast motility and promoting cytokine synthesis at central sites in RA synovium.

Use of abatacept in rheumatoid arthritis

Abatacept (CTLA-Ig), a modulator of T-lymphocyte activation, has been approved by the Swiss health regulatory agency Swissmedic for the treatment of active rheumatoid arthritis (RA). This article summarises the key trial findings for this biologic agent in RA in different situations such as early erosive rheumatoid arthritis (RA), biologic-naïve RA, RA before and after the use of methotrexate or TNF-inhibitors and includes safety information from these trials. Based on these data, recommendations for clinical practice in Switzerland are made by a panel of experts.

Evolution of radiographic joint damage in rituximab-treated versus TNF-treated rheumatoid arthritis cases with inadequate response to TNF antagonists

Background

Observational studies have suggested that patients with rheumatoid arthritis (RA) who experience inadequate response to anti-tumour necrosis factor (anti-TNF) agents respond more favourably to rituximab (RTX) than to an alternative anti-TNF agent. However, the relative effectiveness of these agents on long-term outcomes, particularly in radiographic damage, remains unclear.

Objective

To compare the effectiveness of RTX against anti-TNF agents in preventing joint damage in patients with RA who have experienced inadequate response to at least one prior anti-TNF agent.

Methods

This is a prospective cohort study within the Swiss registry of patients with RA who discontinued at least one anti-TNF agent and subsequently received either RTX or an alternative anti-TNF agent. The primary outcome, progression of radiographic joint erosions (Ratingen erosion score)over time, and the secondary outcome, functional disability (Health Assessment Questionnaire Disability Index), were analysed using regression models for longitudinal data and adjusted for potential confounders.

Results

Of the 371 patients included, 104 received RTX and 267 received an alternative anti-TNF agent. During the 2.6-year median follow-up period, the rates of Ratingen erosion score progression were similar between patients taking RTX and patients taking an alternative anti-TNF agent (p=0.67). The evolution of the Health Assessment Questionnaire score was statistically significantly better in the RTX group (p=0.016), but the magnitude of the effect was probably not clinically relevant.

Conclusion

This observational study suggests that RTX is as effective as an alternative anti-TNF agent in preventing erosions in patients with RA who have previously experienced inadequate response to anti-TNF agents.

Down-regulation of microRNA-34a* in rheumatoid arthritis synovial fibroblasts promotes apoptosis resistance

OBJECTIVE

To investigate the expression and effect of the microRNA-34 (miR-34) family on apoptosis in rheumatoid arthritis synovial fibroblasts (RASFs).

METHODS

Expression of the miR-34 family in synovial fibroblasts with or without stimulation with Toll-like receptor (TLR) ligands, tumor necrosis factor α (TNFα), interleukin-1β (IL-1β), hypoxia, or 5-azacytidine was analyzed by real-time polymerase chain reaction (PCR). Promoter methylation was studied by combined bisulfite restriction analysis. The effects of overexpression and silencing of miR-34a and miR-34a* on apoptosis were analyzed by annexin V/propidium iodide staining. Production of X-linked inhibitor of apoptosis protein (XIAP) was assessed by real-time PCR and immunohistochemistry analysis. Reporter gene assay was used to study the signaling pathways of miR-34a*.

RESULTS

Basal expression levels of miR-34a* were found to be reduced in synovial fibroblasts from RA patients compared to osteoarthritis patients, whereas levels of miR-34a, miR-34b/b*, and miR-34c/c* did not differ. Neither TNFα, IL-1β, TLR ligands, nor hypoxia altered miR-34a* expression. However, we demonstrated that the promoter of miR-34a/34a* was methylated and showed that transcription of the miR-34a duplex was induced upon treatment with demethylating agents. Enforced expression of miR-34a* led to an increased rate of FasL- and TRAIL-mediated apoptosis in RASFs. Moreover, levels of miR-34a* were highly correlated with expression of XIAP, which was found to be up-regulated in RA synovial cells. Finally, we identified XIAP as a direct target of miR-34a*.

CONCLUSION

Our data provide evidence of a methylation-specific down-regulation of proapoptotic miR-34a* in RASFs. Decreased expression of miR- 34a* results in up-regulation of its direct target XIAP, thereby contributing to resistance of RASFs to apoptosis.

Th17 cells generated in the absence of TGF-β induce experimental allergic encephalitis upon adoptive transfer

The discovery of IL-17-producing helper T cells (Th17) has led to new concepts of T-cell differentiation and immunity. Importantly, Th17 cells are thought to be important drivers of autoimmunity. TGF-β and IL-6 in combination were shown to induce differentiation of murine naive CD4 T cells into IL-17-producing cells in vitro. By contrast, human Th17 differentiation was shown to be independent of TGF-β and could be induced by IL-6 in conjunction with IL-21 or with IL-1. Ghoreschi et al. have elegantly demonstrated that mouse Th17 cell differentiation can also occur in the absence of TGF-β. A combination of IL-23, IL-1 and IL-6 can give rise to IL-17-producing cells, which are characterized by the expression of T-bet. Intriguingly, the adoptive transfer of such in vitro differentiated Th17 cells into lymphocyte-deficient mice resulted in the induction of experimental allergic encephalitis, which was more severe than in mice receiving Th17 cells differentiated in the presence of TGF-β. Collectively, the results suggest that a subpopulation of Th17 cells differentiated in the absence of TGF-β, expressing T-bet and RORγt, occur in vivo and may be responsible for autoimmunity.

[The rheumatic hand - diagnostics in practice]

Many rheumatic diseases show changes and are visible in the hands. The pattern of distribution in the relevant joints, soft-tissue changes, skin manifestations, neurological and vascular symptoms and clinical findings provide fundamental information. Imaging and lab results provide diagnostic support. In this review, common diseases are presented in terms of their clinical expressions in the hands: osteoarthritis, rheumatoid arthritis, gout, calcium pyrophosphate dihydrate deposition disease, psoriatic arthritis, reactive arthritis, systemic sclerosis, dermatomyositis/polymyositis and systemic lupus erythematosus. Furthermore, we discuss pathological findings of the hands as a result of diabetic cheiroarthropathia, endocarditis, secondary hypertrophic osteo-arthropathy and chronic regional pain syndrom.

Delays in assessment of patients with rheumatoid arthritis: variations across Europe

OBJECTIVE

The first 3 months after symptom onset represent an important therapeutic window for rheumatoid arthritis (RA). This study investigates the extent and causes of delay in assessment of patients with RA in eight European countries.

METHOD

Data on the following levels of delay were collected from 10 centres (Berlin, Birmingham, Heraklion, Lund, Prague, Stockholm, Umeå, Vienna, Warsaw and Zurich): (1) from onset of RA symptoms to request to see healthcare professional (HCP); (2) from request to see HCP to assessment by that HCP; (3) from initial assessment by HCP to referral to rheumatologist; and (4) from referral to rheumatologist to assessment by that rheumatologist.

RESULTS

Data were collected from 482 patients with RA. The median delay across the 10 centres from symptom onset to assessment by the rheumatologist was 24 weeks, with the percentage of patients seen within 12 weeks of symptom onset ranging from 8% to 42%. There were important differences in the levels underlying the total delays at individual centres.

CONCLUSIONS

This research highlights the contribution of patients, professionals and health systems to treatment delay for patients with RA in Europe. Although some centres have strengths in minimising certain types of delay, interventions are required in all centres to ensure timely treatment for patients.