51
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Onishi A, Kamitsuji S, Nishida M, Uemura Y, Takahashi M, Saito T, Yoshida Y, Kobayashi M, Kawate M, Nishimura K, Misaki K, Nobuhara Y, Nakazawa T, Hatachi S, Tsuji G, Morinobu A, Kumagai S. Genetic and clinical prediction models for the efficacy and hepatotoxicity of methotrexate in patients with rheumatoid arthritis: a multicenter cohort study. THE PHARMACOGENOMICS JOURNAL 2019; 20:433-442. [DOI: 10.1038/s41397-019-0134-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/13/2019] [Accepted: 11/21/2019] [Indexed: 12/12/2022]
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Safiri S, Kolahi AA, Hoy D, Smith E, Bettampadi D, Mansournia MA, Almasi-Hashiani A, Ashrafi-Asgarabad A, Moradi-Lakeh M, Qorbani M, Collins G, Woolf AD, March L, Cross M. Global, regional and national burden of rheumatoid arthritis 1990-2017: a systematic analysis of the Global Burden of Disease study 2017. Ann Rheum Dis 2019; 78:1463-1471. [PMID: 31511227 DOI: 10.1136/annrheumdis-2019-215920] [Citation(s) in RCA: 389] [Impact Index Per Article: 77.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To provide the level and trends of prevalence, incidence and disability adjusted life years (DALYs) for rheumatoid arthritis (RA) in 195 countries from 1990 to 2017 by age, sex, Socio-demographic Index (SDI; a composite of sociodemographic factors) and Healthcare Access and Quality (an indicator of health system performance) Index. METHODS Data from the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2017 were used. GBD 2017 modelled the burden of RA for 195 countries from 1990 to 2017, through a systematic analysis of mortality and morbidity data to estimate prevalence, incidence and DALYs. All estimates were presented as counts and age-standardised rates per 100 000 population, with uncertainty intervals (UIs). RESULTS Globally, the age-standardised point prevalence and annual incidence rates of RA were 246.6 (95% UI 222.4 to 270.8) and 14.9 (95% UI 13.3 to 16.4) in 2017, which increased by 7.4% (95% UI 5.3 to 9.4) and 8.2% (95% UI 5.9 to 10.5) from 1990, respectively. However, the age-standardised rate of RA DALYs per 100 000 population was 43.3 (95% UI 33.0 to 54.5) in 2017, which was a 3.6% (95% UI -9.7 to 0.3) decrease from the 1990 rate. The age-standardised prevalence and DALY rates increased with age and were higher in females; the rates peaked at 70-74 and 75-79 age groups for females and males, respectively. A non-linear association was found between age-standardised DALY rate and SDI. The global age-standardised DALY rate decreased from 1990 to 2012 but then increased and reached higher than expected levels in the following 5 years to 2017. The UK had the highest age-standardised prevalence rate (471.8 (95% UI 428.9 to 514.9)) and age-standardised incidence rate (27.5 (95% UI 24.7 to 30.0)) in 2017. Canada, Paraguay and Guatemala showed the largest increases in age-standardised prevalence rates (54.7% (95% UI 49.2 to 59.7), 41.8% (95% UI 35.0 to 48.6) and 37.0% (95% UI 30.9 to 43.9), respectively) and age-standardised incidence rates (48.2% (95% UI 41.5 to 55.1), 43.6% (95% UI 36.6 to 50.7) and 36.8% (95% UI 30.4 to 44.3), respectively) between 1990 and 2017. CONCLUSIONS RA is a major global public health challenge. The age-standardised prevalence and incidence rates are increasing, especially in countries such as Canada, Paraguay and Guatemala. Early identification and treatment of RA is vital especially among females, in order to reduce the ongoing burden of this condition. The quality of health data needs to be improved for better monitoring of disease burden.
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Affiliation(s)
- Saeid Safiri
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Damian Hoy
- School of Population Health, University of Queensland, Herston, Queensland, Australia
| | - Emma Smith
- Institute of Bone and Joint Research, Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
- Pain Management Research Institute, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Deepti Bettampadi
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Almasi-Hashiani
- Department of Epidemiology, School of Health, Arak University of Medical Sciences, Arak, Iran
| | - Ahad Ashrafi-Asgarabad
- Department of Epidemiology, School of Health, Bam University of Medical Sciences, Bam, Iran
| | - Maziar Moradi-Lakeh
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Gary Collins
- Centre for Statistics in Medicine, NDORMS, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Anthony D Woolf
- Bone and Joint Research Group, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Lyn March
- Institute of Bone and Joint Research, Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
| | - Marita Cross
- Institute of Bone and Joint Research, Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
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Michaud K, Vrijens B, Tousset E, Pedro S, Schumacher R, Dasic G, Chen C, Agarwal E, Suarez-Almazor ME. Real-World Adherence to Oral Methotrexate Measured Electronically in Patients With Established Rheumatoid Arthritis. ACR Open Rheumatol 2019; 1:560-570. [PMID: 31777840 PMCID: PMC6858035 DOI: 10.1002/acr2.11079] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 08/16/2019] [Indexed: 12/21/2022] Open
Abstract
Objective To assess methotrexate (MTX) adherence using the Medication Event Monitoring System (MEMS) and characterize associations with adherence in patients with rheumatoid arthritis (RA). Methods Eligible patients participated in Forward, the National Databank for Rheumatic Diseases, and recently (12 months or sooner) initiated oral MTX. MEMS was used to compile MTX weekly dosing over 24 weeks. The Beliefs about Medicines Questionnaire (BMQ) was completed, and baseline demographics and disease characteristics obtained. MTX adherence (percentage of weeks dose taken correctly), implementation (percentage of weeks dose taken correctly from initiation until last dose), and persistence (duration from initiation to last dose) were calculated. Analyses measured associations between patient characteristics and adherence, modeled using logistic generalized estimating equations and censored Poisson regression, and persistence modeled using Cox regression. Results Overall, 60 of 119 eligible patients were included in the analysis. MTX adherence, implementation, and persistence were 75%, 80%, and 83%, respectively, at 24 weeks. Demographics and disease characteristics were generally similar between patients with 1 week or less and 2 weeks or more of missed MTX. Unemployment, less disability, higher Patient Global scores, and no prior disease‐modifying antirheumatic drug (DMARD) use were associated with correct dosing. No significant differences in adherence were observed between patients receiving concomitant MTX versus MTX monotherapy, and biologic DMARD‐experienced versus biologic DMARD‐naïve patients. Higher scores in BMQ Specific Necessity (indicating a greater belief in the necessity of the medication) was associated with a decreased likelihood of dosing at an interval shorter than prescribed (odds ratio 0.89). Conclusion Even in a participatory group over a short period, MTX adherence was suboptimal and associated with certain demographics, medication experience, and beliefs about medicines. This suggests a need for screening and alternative treatment opportunities in nonadherent MTX patients with RA.
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Affiliation(s)
- Kaleb Michaud
- University of Nebraska Medical Center, Omaha, Nebraska and Forward, The National Databank for Rheumatic Diseases Wichita Kansas
| | - Bernard Vrijens
- AARDEX Group, Visé, Belgium, and University of Liège Liège Belgium
| | | | - Sofia Pedro
- Forward, The National Databank for Rheumatic Diseases Wichita Kansas
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Abstract
BACKGROUND Medication-based strategies to treat rheumatoid arthritis are crucial in terms of outcome. They aim at preventing joint destruction, loss of function and disability by early and consistent inhibition of inflammatory processes. OBJECTIVE Achieving consensus about evidence-based recommendations for the treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs in Germany. METHODS Following a systematic literature research, a structured process among expert rheumatologists was used to reach consensus. RESULTS The results of the consensus process can be summed up in 6 overarching principles and 10 recommendations. There are several new issues compared to the version of 2012, such as differentiated adjustments to the therapeutic regime according to time point and extent of treatment response, the therapeutic goal of achieving remission as assessed by means of the simplified disease activity index (SDAI) as well as the potential use of targeted synthetic DMARDs (JAK inhibitors) and suggestions for a deescalating in case of achieving a sustained remission. Methotrexate still plays the central role at the beginning of the treatment and as a combination partner in the further treatment course. When treatment response to methotrexate is inadequate, either switching to or combining with another conventional synthetic DMARD is an option in the absence of unfavourable prognostic factors. Otherwise biologic or targeted synthetic DMARDs are recommended according to the algorithm. Rules for deescalating treatment with glucocorticoids and-where applicable-DMARDs give support for the management of patients who have reached a sustained remission. DISCUSSION The new guidelines set up recommendations for RA treatment in accordance with the treat-to-target principle. Modern disease-modifying drugs, now including also JAK inhibitors, are available in an algorithm.
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55
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Homer D. Using video-based training for button-free auto-injection of subcutaneous methotrexate: A pilot study. Musculoskeletal Care 2019; 17:247-279. [PMID: 31373433 PMCID: PMC6851598 DOI: 10.1002/msc.1420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Dawn Homer
- Community Rheumatology Service, Modality Partnership, Enki Medical Practice, Handsworth, Birmingham, UK
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56
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Altering the natural history of rheumatoid arthritis: The role of immunotherapy and biologics in orthopaedic care. J Orthop 2019; 17:17-21. [PMID: 31879467 DOI: 10.1016/j.jor.2019.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/30/2019] [Indexed: 11/21/2022] Open
Abstract
Rheumatoid Arthritis (RA) is an idiopathic disease characterized by systemic inflammation, persistent synovitis, and the presence of autoantibodies. Because of the musculoskeletal deformity caused by RA, multiple orthopaedic procedures are regularly performed as part of the treatment. The changing rates of surgery and the rise in new efficacious medical therapy have improved the prognosis for patients with RA. This review will discuss the natural history of rheumatoid arthritis, common medications used to treat it, how disease progression has changed as a function of new biologic immunotherapy, and the role of orthopaedic intervention in this new landscape of advanced rheumatoid care.
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57
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Raebel MA, Shetterly SM, Bhardwaja B, Sterrett AT, Schroeder EB, Chorny J, Hagen TP, Silverman DJ, Astles R, Lubin IM. Technology-Enabled Outreach to Patients Taking High-Risk Medications Reduces a Quality Gap in Completion of Clinical Laboratory Testing. Popul Health Manag 2019; 23:3-11. [PMID: 31107176 DOI: 10.1089/pop.2019.0033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clinical laboratory quality improvement (QI) efforts can include population test utilization. The authors used a health care organization's Medical Data Warehouse (MDW) to characterize a gap in guideline-concordant laboratory testing recommended for safe use of antirheumatic agents, then tested the effectiveness of laboratory-led, technology-enabled outreach to patients at reducing this gap. Data linkages available through the Kaiser Permanente Colorado MDW and electronic health record were used to identify ambulatory adults taking antirheumatic agents who were due/overdue for alanine aminotransferase (ALT), aspartate aminotransferase (AST), complete blood count (CBC), or serum creatinine (SCr) testing. Outreach was implemented using an interactive voice response system to send patients text or phone call reminders. Interrupted time series analysis was used to estimate reminder effectiveness. Rates of guideline-concordant testing and testing timeliness in baseline vs. intervention periods were determined using generalized linear models for repeated measures. Results revealed a decrease in percentage of 3763 patients taking antirheumatic agents due/overdue for testing at any given time: baseline 24.3% vs. intervention 17.5% (P < 0.001). Among 3205 patients taking conventional antirheumatic agents, concordance for all ALT testing was baseline 52.8% vs. intervention 65.4% (P < 0.001) among patients chronically using these agents and baseline 20.6% vs. intervention 26.1% (P < 0.001) among patients newly starting these agents. The 95th percentiles for days to ALT testing were baseline 149 vs. intervention 117 among chronic users and baseline 134 vs. intervention 92 among new starts. AST, CBC, and SCr findings were similar. Technology-enabled outreach reminding patients to obtain laboratory testing improves health care system outcomes.
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Affiliation(s)
- Marsha A Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Bharati Bhardwaja
- Department of Pharmacy, Kaiser Permanente Colorado, Denver, Colorado
| | - Andrew T Sterrett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Emily B Schroeder
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Joseph Chorny
- Regional Laboratory, Colorado Permanente Medical Group, Denver, Colorado
| | - Tyson P Hagen
- Department of Rheumatology, Colorado Permanente Medical Group, Lafayette, Colorado
| | - David J Silverman
- Department of Rheumatology, Colorado Permanente Medical Group, Lafayette, Colorado
| | - Rex Astles
- Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ira M Lubin
- Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia
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58
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George MD, Baker JF. Perioperative management of immunosuppression in patients with rheumatoid arthritis. Curr Opin Rheumatol 2019; 31:300-306. [PMID: 30920454 PMCID: PMC6446585 DOI: 10.1097/bor.0000000000000589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Patients with rheumatoid arthritis are at increased risk of infection after surgery. Recent literature has provided more data and updated guidelines to guide the management of immunosuppression in the perioperative period. RECENT FINDINGS Studies over the past few years have confirmed that patients with rheumatoid arthritis are at increased risk of infection after surgery. Patients treated with biologics are at greater risk of postoperative infection, but this risk might be explained by the comorbidities and greater disease severity often seen in these patients. Recent observational studies have suggested that interruption of biologic therapies before surgery may not be associated with better outcomes. Glucocorticoids, however, have consistently been found to be risk factors for infection. Recent guidelines from the American College of Rheumatology/American Association of Hip and Knee Surgeons recommend continuing conventional disease-modifying drugs and holding biologics for one dosing interval before surgery. SUMMARY Prolonged interruption of conventional and biologic therapies before surgery does not appear to substantially reduce infection risk. Guidelines now recommend continuing conventional DMARDs and holding biologics for just one dosing interval before surgery. Glucocorticoids are strongly associated with the risk of postoperative infection and should be minimized before surgery.
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Affiliation(s)
| | - Joshua F. Baker
- University of Pennsylvania, Division of Rheumatology
- Philadelphia Veterans Affairs Medical Center, Division of Rheumatology
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59
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Nedelcu RI, Balaban M, Turcu G, Brinzea A, Ion DA, Antohe M, Hodorogea A, Calinescu A, Badarau AI, Popp CG, Cioplea M, Nichita L, Popescu S, Diaconu C, Bleotu C, Pirici D, Popescu R, Popescu CM, Zurac SA. Efficacy of methotrexate as anti-inflammatory and anti-proliferative drug in dermatology: Three case reports. Exp Ther Med 2019; 18:905-910. [PMID: 31384322 DOI: 10.3892/etm.2019.7511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/17/2018] [Indexed: 12/27/2022] Open
Abstract
Methotrexate (MTX) is a folic acid analog with anti-proliferative (anti-neoplastic, cytotoxic), immunosuppressive and anti-inflammatory properties, which has been used in the treatment of various cutaneous disorders, such as psoriasis, keratoacanthoma, pityriasis rubra pilaris, atopic dermatitis, mycosis fungoides, bullous skin diseases, systemic sclerosis, morphea, lupus erythematosus, dermatomyositis and crusted scabies. Inhibition of cell proliferation is explained through its role in blocking DNA/RNA synthesis, by inhibiting dihydrofolate reductase, necessary for the production of pyrimidine and purine nucleotides. An anticancer effect can be related to α-oxoaldehyde metabolism (MTX increases methylglyoxal levels). Its anti-inflammatory property is based on the inhibition of 5-aminoimidazole-4-carboxamide ribonucleotide transformylase, thus increasing intracellular and extracellular adenosine, a purine nucleoside with anti-inflammatory effect. This drug can limit inflammation by scavenging free radicals and decreasing malondialdehyde-acetaldehyde protein-adduct production. Moreover, the anti-proliferative and anti-inflammatory effects can also be related to inhibition of the DNA methylation pathway, thus inhibiting methionine formation. The aim of the present study was to report various dermatological cases from our daily practice that demonstrate the efficacy of MTX in the treatment of cutaneous diseases, highlighting different mechanisms of action: its anti-inflammatory effect in psoriasis and its anti-proliferative, and anti-neoplastic effect in well-differentiated squamous cell carcinoma or in keratoacanthoma. Moreover, different administration pathways and doses are addressed. Assessment of the treatment plan, clinical improvement of cutaneous lesions, biologic evaluation, final aesthetic result, quality of life, as well as potential adverse effects and drug tolerance related to each case mentioned.
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Affiliation(s)
- Roxana-Ioana Nedelcu
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Derma 360° Clinic, 011273 Bucharest, Romania
| | - Mihaela Balaban
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Derma 360° Clinic, 011273 Bucharest, Romania
| | - Gabriela Turcu
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Derma 360° Clinic, 011273 Bucharest, Romania.,Department of Ambulatory, National Institute for Infectious Diseases 'Prof. Dr. Matei Balș', 020105 Bucharest, Romania
| | - Alice Brinzea
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Ambulatory, National Institute for Infectious Diseases 'Prof. Dr. Matei Balș', 020105 Bucharest, Romania.,Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Daniela Adriana Ion
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mihaela Antohe
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Derma 360° Clinic, 011273 Bucharest, Romania
| | - Anastasia Hodorogea
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Andreea Calinescu
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Anca Ioana Badarau
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | | | - Mirela Cioplea
- Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Luciana Nichita
- Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Silvia Popescu
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Carmen Diaconu
- Department of Cellular and Molecular Pathology, 'Stefan S. Nicolau' Institute of Virology, 030304 Bucharest, Romania
| | - Coralia Bleotu
- Department of Cellular and Molecular Pathology, 'Stefan S. Nicolau' Institute of Virology, 030304 Bucharest, Romania
| | - Daniel Pirici
- Department of Pathology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Raluca Popescu
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Catalin Mihai Popescu
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Sabina Andrada Zurac
- Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
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Zamora NV, Tayar JH, Lopez-Olivo MA, Christensen R, Suarez-Almazor ME. Baricitinib for rheumatoid arthritis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Jean H Tayar
- The University of Texas, MD Anderson Cancer Center; Department of General Internal Medicine; 1515 Holcombe Blvd Unit 1465 Houston Texas USA 77030
| | - Maria Angeles Lopez-Olivo
- The University of Texas, MD Anderson Cancer Center; Department of General Internal Medicine; 1515 Holcombe Blvd Unit 1465 Houston Texas USA 77030
| | - Robin Christensen
- Bispebjerg and Frederiksberg Hospital; Musculoskeletal Statistics Unit, The Parker Institute; Copenhagen Denmark
| | - Maria E Suarez-Almazor
- The University of Texas, MD Anderson Cancer Center; Department of General Internal Medicine; 1515 Holcombe Blvd Unit 1465 Houston Texas USA 77030
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Baker JF, George MD. Prevention of Infection in the Perioperative Setting in Patients with Rheumatic Disease Treated with Immunosuppression. Curr Rheumatol Rep 2019; 21:17. [PMID: 30847768 DOI: 10.1007/s11926-019-0812-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Patients with autoimmune rheumatic disease are at increased risk of infection after surgery. The goal of this manuscript is to review current evidence on important contributors to infection risk in these patients and the optimal management of immunosuppression in the perioperative setting. RECENT FINDINGS Recent studies have confirmed that patients with autoimmune rheumatic disease, including rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), are at increased risk of infection after surgery, with most evidence coming from studies of joint replacement surgery. Immunosuppression, disease activity, comorbidities, demographics, and surgeon and hospital volume are all important contributors to post-operative infection risk. Recently published guidelines regarding immunosuppression management before joint replacement recommend continuing the conventional disease-modifying drugs used to treat RA (e.g., methotrexate) without interruption, holding more potent conventional therapies for 1 week unless the underlying disease is severe, and holding biologic therapies for one dosing interval before surgery. Recent observational data suggests that holding biologics may not have a substantial impact on infection risk. These data also implicate glucocorticoids as a major contributor to post-operative infection risk. Observational data supports recent recommendations to continue many therapies in the perioperative period with only short interruptions of biologics and other potent immunosuppression. Even brief interruptions may not significantly lower risk, although the field continues to evolve. Clinicians should also consider other risk factors and should focus on minimizing glucocorticoids before surgery when possible to limit the risk of post-operative infection.
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Affiliation(s)
- Joshua F Baker
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia VA Medical Center, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA.
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Kwok TSH, Bell MJ. Immune checkpoint inhibitor-induced rheumatoid arthritis: insights into an increasingly common aetiology of polyarthritis. BMJ Case Rep 2019; 12:12/2/e227995. [PMID: 30819683 DOI: 10.1136/bcr-2018-227995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Nivolumab is an immune checkpoint inhibitor that is used in the treatment of a variety of cancers in the adjuvant or metastatic setting. Adverse effects include non-specific activation of T cells, leading to immune-related adverse events in downstream organs. We present a case of a 36-year-old man with unresectable oropharyngeal squamous cell carcinoma who developed nivolumab-induced rheumatoid arthritis. As immune checkpoint inhibitor use is becoming widespread in the medical oncology domain, the purpose of this case report is to increase awareness of an increasingly common cause of rheumatic disease and to alert clinicians to consider immunotherapy in their differential diagnosis of polyarthritis. This case also highlights the importance of working in an interdisciplinary manner to enhance cancer care for the patient as well as to increase awareness of the potential adverse effects of immunotherapy in patients with cancer.
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Affiliation(s)
| | - Mary Jane Bell
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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63
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Abstract
BACKGROUND Psoriatic arthritis is an inflammatory disease associated with joint damage, impaired function, pain, and reduced quality of life. Methotrexate is a disease-modifying anti-rheumatic drug (DMARD) commonly prescribed to alleviate symptoms, attenuate disease activity, and prevent progression of disease. OBJECTIVES To assess the benefits and harms of methotrexate for psoriatic arthritis in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the WHO International Clinical Trials Registry Platform, and www.clinicaltrials.gov for relevant records. We searched all databases from inception to 29 January 2018. We handsearched included articles for additional records and contacted study authors for additional unpublished data. We applied no language restrictions. SELECTION CRITERIA We included all randomised controlled trials (RCTs) and quasi-RCTs that compared methotrexate versus placebo, or versus another DMARD, for adults with psoriatic arthritis. We reported on the following major outcomes: disease response (measured by psoriatic arthritis response criteria (PsARC)), function (measured by the Health Assessment Questionnaire for Rheumatoid Arthritis (HAQ)), health-related quality of life, disease activity (measured by disease activity score (28 joints) with erythrocyte sedimentation rate (DAS28-ESR)), radiographic progression, serious adverse events, and withdrawals due to adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed search results, assessed risk of bias, extracted trial data, and assessed the quality of evidence using the GRADE approach. We undertook meta-analysis only when this was meaningful. MAIN RESULTS We included in this review eight RCTs conducted in an outpatient setting, in Italy, the United Kingdom, the United States of America, China, Russia, and Bangladesh. Five studies compared methotrexate versus placebo, and four studies compared methotrexate versus other DMARDs. The average age of participants varied across studies (26 to 52 years), as did the average duration of psoriatic arthritis (one to nine years). Doses of methotrexate varied from 7.5 mg to 25 mg orally per week, but most studies administered approximately 15 mg or less orally per week. Risk of bias was generally unclear or high across most domains for all studies. We considered only one study to have low risk of selection and detection bias. The main study informing results of the primary comparison (methotrexate vs placebo up to six months) was at low risk of bias for all domains except attrition bias and reporting bias.We restricted reporting of results to the comparison of methotrexate versus placebo for up to six months. Low-quality evidence (downgraded due to bias and imprecision) from a single study (221 participants; methotrexate dose 15 mg orally or less per week) informed results for disease response, function, and disease activity. Disease response, measured by the proportion who responded to treatment according to PsARC (response indicates improvement), was 41/109 in the methotrexate group and 24/112 in the placebo group (risk ratio (RR) 1.76, 95% confidence interval (CI) 1.14 to 2.70). This equates to an absolute difference of 16% more responders with methotrexate (4% more to 28% more), and a number needed to treat for an additional beneficial outcome (NNTB) of 6 (95% CI 5 to 25). Mean function, measured by the HAQ (scale 0 to 3; 0 meaning no functional impairment; minimum clinically important difference 0.22), was 1.0 points with placebo and 0.3 points better (95% 0.51 better to 0.09 better) with methotrexate; absolute improvement was 10% (3% better to 17% better), and relative improvement 30% (9% better to 51% better). Mean disease activity as measured by the DAS28-ESR (scale of 0 to 10; lower score means lower disease activity; minimum clinically important difference unknown) was 3.8 points in the methotrexate group and 4.06 points in the placebo group; mean difference was -0.26 points (95% CI -0.65 to 0.13); absolute improvement was 3% (7% better to 1% worse), and relative improvement 6% (16% better to 3% worse).Low-quality evidence (downgraded due to risk of bias and imprecision) from three studies (n = 293) informed our results for serious adverse events and withdrawals due to adverse events. Due to low event rates, we are uncertain if methotrexate results show increased risk of serious adverse events or withdrawals due to adverse events compared to placebo. Results show 1/141 serious adverse events in the methotrexate group and 4/152 in the placebo group: RR 0.26 (95% CI 0.03 to 2.26); absolute difference was 2% fewer events with methotrexate (5% fewer to 1% more). In all, 9/141 withdrawals in the methotrexate group were due to adverse events and 7/152 in the placebo group: RR 1.32 (95% CI 0.51 to 3.42); absolute difference was 1% more withdrawals (4% fewer to 6% more).One study measured health-related quality of life but did not report these results. No study measured radiographic progression. AUTHORS' CONCLUSIONS Low-quality evidence suggests that low-dose (15 mg or less) oral methotrexate might be slightly more effective than placebo when taken for six months; however we are uncertain if it is more harmful. Effects of methotrexate on health-related quality of life, radiographic progression, enthesitis, dactylitis, and fatigue; its benefits beyond six months; and effects of higher-dose methotrexate have not been measured or reported in a randomised placebo-controlled trial.
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Affiliation(s)
- Tom D Wilsdon
- Royal Adelaide Hospital and University of AdelaideDepartment of RheumatologyPort RdAdelaideAustralia5000
| | - Samuel L Whittle
- The Queen Elizabeth Hospital and University of AdelaideDepartment of Rheumatology28 Woodville RoadWoodvilleAustralia5011
| | - Tilenka RJ Thynne
- Flinders Medical Centre and Flinders UniversityDepartment of Clinical PharmacologyFlinders DriveBedford ParkAustralia5042
| | - Arduino A Mangoni
- Flinders Medical Centre and Flinders UniversityDepartment of Clinical PharmacologyFlinders DriveBedford ParkAustralia5042
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Ibrahim A, Ahmed M, Conway R, Carey JJ. Risk of Infection with Methotrexate Therapy in Inflammatory Diseases: A Systematic Review and Meta-Analysis. J Clin Med 2018; 8:jcm8010015. [PMID: 30583473 PMCID: PMC6352130 DOI: 10.3390/jcm8010015] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/12/2018] [Accepted: 12/15/2018] [Indexed: 02/07/2023] Open
Abstract
The aim of this study was to determine the risk of infection in adults with inflammatory rheumatic diseases (IRDs) treated with methotrexate. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing methotrexate versus placebo in adults using MEDLINE, EMBASE, and CENTRAL databases from 1980 to August 2017. The primary outcome was the risk of infection associated with methotrexate therapy. We chose a random effect model to summarize adverse event outcomes as risk ratios (RRs) and related 95% confidence intervals (95% CI). Twelve RCTs (total patients 1146) met the inclusion criteria for our main analysis, and ten for risk of serious infection (total patients 906). Overall, methotrexate was associated with increased risk of infection in rheumatoid arthritis (RA) (RR: 1.25; 95% CI, 1.01⁻1.56; p = 0.04; I² = 0%), but not in other non-RA IRD populations. There was no increased risk of total infections (RR: 1.14; 95% CI, 0.98⁻1.34; p = 0.10; I² = 0%) or serious infections (RR: 0.76; 95% CI, 0.11⁻5.15; p = 0.78; I² = 0%) in all included IRDs. Conclusively, methotrexate use in IRDs is associated with a higher risk of all infections in RA, but not in other non-RA (IRD) populations. There is no increased risk of serious infections.
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Affiliation(s)
- Ammar Ibrahim
- Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Mohammed Ahmed
- Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Richard Conway
- Department of Rheumatic Diseases, St. James's University Hospital, Dublin, Ireland.
| | - John J Carey
- Department of Rheumatic Diseases, Galway University Hospitals, Galway, Ireland.
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Raebel MA, Quintana LM, Schroeder EB, Shetterly SM, Pieper LE, Epner PL, Bechtel LK, Smith DH, Sterrett AT, Chorny JA, Lubin IM. Identifying Preanalytic and Postanalytic Laboratory Quality Gaps Using a Data Warehouse and Structured Multidisciplinary Process. Arch Pathol Lab Med 2018; 143:518-524. [PMID: 30525932 DOI: 10.5858/arpa.2018-0093-oa] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT.— The laboratory total testing process includes preanalytic, analytic, and postanalytic phases, but most laboratory quality improvement efforts address the analytic phase. Expanding quality improvement to preanalytic and postanalytic phases via use of medical data warehouses, repositories that include clinical, utilization, and administrative data, can improve patient care by ensuring appropriate test utilization. Cross-department, multidisciplinary collaboration to address gaps and improve patient and system outcomes is beneficial. OBJECTIVE.— To demonstrate medical data warehouse utility for characterizing laboratory-associated quality gaps amenable to preanalytic or postanalytic interventions. DESIGN.— A multidisciplinary team identified quality gaps. Medical data warehouse data were queried to characterize gaps. Organizational leaders were interviewed about quality improvement priorities. A decision aid with elements including national guidelines, local and national importance, and measurable outcomes was completed for each gap. RESULTS.— Gaps identified included (1) test ordering; (2) diagnosis, detection, and documentation, and (3) high-risk medication monitoring. After examination of medical data warehouse data including enrollment, diagnoses, laboratory, pharmacy, and procedures for baseline performance, high-risk medication monitoring was selected, specifically alanine aminotransferase, aspartate aminotransferase, complete blood count, and creatinine testing among patients receiving disease-modifying antirheumatic drugs. The test utilization gap was in monitoring timeliness (eg, >60% of patients had a monitoring gap exceeding the guideline recommended frequency). Other contributors to selecting this gap were organizational enthusiasm, regulatory labeling, and feasibility of a significant laboratory role in addressing the gap. CONCLUSIONS.— A multidisciplinary process facilitated identification and selection of a laboratory medicine quality gap. Medical data warehouse data were instrumental in characterizing gaps.
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Affiliation(s)
- Marsha A Raebel
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - LeeAnn M Quintana
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Emily B Schroeder
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Susan M Shetterly
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Lisa E Pieper
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Paul L Epner
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Laura K Bechtel
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - David H Smith
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Andrew T Sterrett
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Joseph A Chorny
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
| | - Ira M Lubin
- From the Institute for Health Research (Drs Raebel, Schroeder, and Sterrett and Mss Quintana, Shetterly, and Pieper), Kaiser Permanente Colorado, Denver; the Society to Improve Diagnosis in Medicine, Evanston, Illinois (Mr Epner); the Regional Laboratory, Kaiser Permanente Colorado, Aurora (Dr Bechtel); the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (Dr Smith); the Regional Laboratory, Colorado Permanente Medical Group, Aurora (Dr Chorny); and the Quality and Safety Systems Branch, Division of Laboratory Systems, Centers for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lubin)
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Abramkin AA, Lisitsyna TA, Veltishchev DY, Seravina OF, Kovalevskaya OB, Glukhova SI, Nasonov EL. FACTORS INFLUENCING THE EFFICIENCY OF THERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS: THE ROLE OF COMORBID MENTAL AND SOMATIC DISEASES. ACTA ACUST UNITED AC 2018. [DOI: 10.14412/1995-4484-2018-439-448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The response rate to therapy for rheumatoid arthritis (RA) rarely exceeds 60%. Mental disorders (MDs) of the anxiety-depressive spectrum (ADS) and cognitive impairment (CI) substantially affect the evaluation of the efficiency of RA therapy. Adequate psychopharmacotherapy is one of the possible approaches to optimizing the treatment of RA. The factors influencing the efficiency of RA therapy with standard disease-modifying antirheumatic drugs (DMARDs) and biological agents (BAs) in combination with adequate psychopharmacotherapy have not been previously identified. Objective: to determine the predictors of response to therapy in patients with RA receiving DMARDs and BAs with or without adequate psychopharmacotherapy for ADS disorders. Subjects and methods. The investigation included 128 patients (13% men and 87% women) with a reliable diagnosis of RA. At baseline, 75.1% of patients received DMARDs; 7.8% – BAs. ADS disorders were detected in 123 (96.1%) patients. Psychopharmacotherapy was offered to all the patients with MDs; 52 patients agreed to treatment and 71 refused. The following therapeutic groups were identified according to the performed therapy: 1) DMARDs (n = 39); 2) DMARDs + psychopharmacotherapy (n = 43); 3) DMARDs + BAs (n = 32); 4) DMARDs + BAs + psychopharmacotherapy (n = 9). The changes of MDs symptoms and the outcomes of RA were assessed in 83 (67.5%) patients at five-year follow-up. The efficiency of RA therapy was evaluated with DAS28 (EULAR criteria). Predictors of response to therapy were determined using linear regression modeling. Results and discussion. At 5 years, 22 (26.5%) and 37 (44.6%) patients were recorded to show good and moderate responses to therapy, respectively; 24 (28.9%) patients were non-respondents. The linear regression model included 14 factors (p<0.001). The high values of DAS28 (β=0.258) at the inclusion; belonging to therapeutic groups 2 (β=0.267), 3 (β=0.235), and 4 (β=0.210), the absence of diabetes mellitus (β=-0.230), and experience in using glucocorticoids (β=-0.230) were associated with a high likelihood of response to therapy; high body mass index (β=-0.200) and long RA duration (β=-0,181), a high level of rheumatoid factor (β=-0.176), a history of myocardial infarction (β=-0.153), schizotypic disorder (β=-0.132), and extra-articular manifestations of RA (β=-0.106), and older age (β=-0.102) were related to a low probability of response. The area under the ROC curve for the model was 0.99 (p><0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response. Keywords: rheumatoid arthritis; mental disorders; disease-modifying antirheumatic drugs; biological agents; efficiency of therapy; predictors; psychopharmacotherapy; therapy adherence><0.001). The high values of DAS28 (β=0.258) at the inclusion; belonging to therapeutic groups 2 (β=0.267), 3 (β=0.235), and 4 (β=0.210), the absence of diabetes mellitus (β=-0.230), and experience in using glucocorticoids (β=-0.230) were associated with a high likelihood of response to therapy; high body mass index (β=-0.200) and long RA duration (β=-0,181), a high level of rheumatoid factor (β=-0.176), a history of myocardial infarction (β=-0.153), schizotypic disorder (β=-0.132), and extra-articular manifestations of RA (β=-0.106), and older age (β=-0.102) were related to a low probability of response. The area under the ROC curve for the model was 0.99 (p<0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response. Keywords: rheumatoid arthritis; mental disorders; disease-modifying antirheumatic drugs; biological agents; efficiency of therapy; predictors; psychopharmacotherapy; therapy adherence><0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response.
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Dudics S, Langan D, Meka RR, Venkatesha SH, Berman BM, Che CT, Moudgil KD. Natural Products for the Treatment of Autoimmune Arthritis: Their Mechanisms of Action, Targeted Delivery, and Interplay with the Host Microbiome. Int J Mol Sci 2018; 19:ijms19092508. [PMID: 30149545 PMCID: PMC6164747 DOI: 10.3390/ijms19092508] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/12/2018] [Accepted: 08/18/2018] [Indexed: 12/16/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, debilitating illness characterized by painful swelling of the joints, inflammation of the synovial lining of the joints, and damage to cartilage and bone. Several anti-inflammatory and disease-modifying drugs are available for RA therapy. However, the prolonged use of these drugs is associated with severe side effects. Furthermore, these drugs are effective only in a proportion of RA patients. Hence, there is a need to search for new therapeutic agents that are effective yet safe. Interestingly, a variety of herbs and other natural products offer a vast resource for such anti-arthritic agents. We discuss here the basic features of RA pathogenesis; the commonly used animal models of RA; the mainstream drugs used for RA; the use of well-characterized natural products possessing anti-arthritic activity; the application of nanoparticles for efficient delivery of such products; and the interplay between dietary products and the host microbiome for maintenance of health and disease induction. We believe that with several advances in the past decade in the characterization and functional studies of natural products, the stage is set for widespread clinical testing and/or use of these products for the treatment of RA and other diseases.
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Affiliation(s)
- Steven Dudics
- Baltimore Veterans Affairs Medical Center, Baltimore, MD 21201, USA.
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - David Langan
- Baltimore Veterans Affairs Medical Center, Baltimore, MD 21201, USA.
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Rakeshchandra R Meka
- Baltimore Veterans Affairs Medical Center, Baltimore, MD 21201, USA.
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Shivaprasad H Venkatesha
- Baltimore Veterans Affairs Medical Center, Baltimore, MD 21201, USA.
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Brian M Berman
- Family and Community Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Chun-Tao Che
- Medicinal Chemistry and Pharmacognosy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Kamal D Moudgil
- Baltimore Veterans Affairs Medical Center, Baltimore, MD 21201, USA.
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Division of Rheumatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Zu Hoerste MM, Walscheid K, Tappeiner C, Zurek-Imhoff B, Heinz C, Heiligenhaus A. The effect of methotrexate and sulfasalazine on the course of HLA-B27-positive anterior uveitis: results from a retrospective cohort study. Graefes Arch Clin Exp Ophthalmol 2018; 256:1985-1992. [PMID: 30069748 DOI: 10.1007/s00417-018-4082-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/05/2018] [Accepted: 07/26/2018] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To investigate the effect of methotrexate (MTX) or sulfasalazine (SSZ) on the course of HLA-B27-positive, remitting acute anterior uveitis (AAU). METHODS Forty-six patients with HLA-B27-positive AAU with or without associated systemic rheumatic disease either receiving MTX (n = 20), SSZ (n = 13), or no systemic immunomodulating treatment (Ctrl; n = 13) were studied retrospectively. Best-corrected visual acuity (BCVA), AAU relapse rate, and occurrence of uveitis-related ocular complications were analyzed at baseline (BL) and at 12-month follow-up (FU). RESULTS Groups did not differ regarding age, gender, and presence of associated systemic diseases. BCVA at baseline was significantly worse in patients receiving MTX (logMAR 0.39 ± 0.4) than in those treated with SSZ (0.17 ± 0.2; P = 0.05) or in controls (Ctrl; 0.14 ± 0.2; P = 0.009). At the 12-month endpoint, MTX treatment was associated with significantly improved BCVA (0.18 ± 0.4 logMAR; P = 0.004). In contrast, BCVA did not significantly change in patients treated with SSZ (0.17 ± 0.3 logMAR) or in the controls (0.11 ± 0.2 logMAR). The annual uveitis relapse rate significantly decreased with MTX (BL 3.6 ± 2.4 relapses to FU 0.7 ± 0.8; P = 0.0001) and SSZ (BL 3.6 ± 1.9 to FU 1.8 ± 2.4, P < 0.01), but not in the controls (BL 1.9 ± 1.4 vs 1.9 ± 1.7 FU). The complication rate was slightly reduced with MTX (BL 1.75 ± 1.2 complications present versus FU 1.3 ± 1.2, P = 0.09) but not with SSZ (BL 0.9 ± 0.8 to FU 1.3 ± 1.4; P = 0.4) or in the controls (BL and FU 1.0 ± 0.95; P = 0.7). CONCLUSIONS MTX and SSZ reduced the uveitis relapse rate in HLA-B27-positive AAU patients, with MTX showing a beneficial effect on AAU-related macular edema.
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Affiliation(s)
- Melissa Meyer Zu Hoerste
- Department of Ophthalmology and Ophtha-Lab at St. Franziskus Hospital, Hohenzollernring 74, 48145, Muenster, Germany
| | - Karoline Walscheid
- Department of Ophthalmology and Ophtha-Lab at St. Franziskus Hospital, Hohenzollernring 74, 48145, Muenster, Germany.
| | - Christoph Tappeiner
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beatrix Zurek-Imhoff
- Department of Ophthalmology and Ophtha-Lab at St. Franziskus Hospital, Hohenzollernring 74, 48145, Muenster, Germany
| | - Carsten Heinz
- Department of Ophthalmology and Ophtha-Lab at St. Franziskus Hospital, Hohenzollernring 74, 48145, Muenster, Germany.,University of Duisburg-Essen, Duisburg, Germany
| | - Arnd Heiligenhaus
- Department of Ophthalmology and Ophtha-Lab at St. Franziskus Hospital, Hohenzollernring 74, 48145, Muenster, Germany.,University of Duisburg-Essen, Duisburg, Germany
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Sergeant JC, Hyrich KL, Anderson J, Kopec-Harding K, Hope HF, Symmons DPM, Barton A, Verstappen SMM. Prediction of primary non-response to methotrexate therapy using demographic, clinical and psychosocial variables: results from the UK Rheumatoid Arthritis Medication Study (RAMS). Arthritis Res Ther 2018; 20:147. [PMID: 30005689 PMCID: PMC6044018 DOI: 10.1186/s13075-018-1645-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/13/2018] [Indexed: 12/04/2022] Open
Abstract
Background Methotrexate (MTX) remains the disease-modifying anti-rheumatic drug of first choice in rheumatoid arthritis (RA) but response varies. Predicting non-response to MTX could enable earlier access to alternative or additional medications and control of disease progression. We aimed to identify baseline predictors of non-response to MTX and combine these into a prediction algorithm. Methods This study included patients recruited to the Rheumatoid Arthritis Medication Study (RAMS), a UK multi-centre prospective observational study of patients with RA or undifferentiated polyarthritis, commencing MTX for the first time. Non-response to MTX at 6 months was defined as “no response” using the European League Against Rheumatism (EULAR) response criteria, discontinuation of MTX due to inefficacy or starting biologic therapy. The association of baseline demographic, clinical and psychosocial predictors with non-response was assessed using logistic regression. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots. Results Of 1050 patients, 449 (43%) were classified as non-responders. Independent multivariable predictors of MTX non-response (OR (95% CI)) were rheumatoid factor (RF) negativity (0.62 (0.45, 0.86) for RF positivity versus negativity), higher Health Assessment Questionnaire score (1.64 (1.25, 2.15)), higher tender joint count (1.06 (1.02, 1.10)), lower Disease Activity score in 28 joints (0.29 (0.23, 0.39)) and higher Hospital Anxiety and Depression Scale anxiety score (1.07 (1.03, 1.12)). The optimism-corrected AUC was 0.74. Conclusions This is the first model for MTX non-response to be developed in a large contemporary study of patients commencing MTX in which demographic, clinical and psychosocial predictors were considered. Patient anxiety was a predictor of non-response and could be addressed at treatment commencement. Electronic supplementary material The online version of this article (10.1186/s13075-018-1645-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jamie C Sergeant
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - James Anderson
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Kamilla Kopec-Harding
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Holly F Hope
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Deborah P M Symmons
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Anne Barton
- NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Arthritis Research UK Centre for Genetics and Genomics, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK. .,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
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Betancourt BY, Biehl A, Katz JD, Subedi A. Pharmacotherapy Pearls in Rheumatology for the Care of Older Adult Patients: Focus on Oral Disease-Modifying Antirheumatic Drugs and the Newest Small Molecule Inhibitors. Rheum Dis Clin North Am 2018; 44:371-391. [PMID: 30001781 DOI: 10.1016/j.rdc.2018.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Providing safe and effective pharmacotherapy to geriatric patients with rheumatologic disorders is challenging. Multidisciplinary care involving rheumatologists, primary care physicians, and other specialties can optimize benefit and reduce adverse outcomes. Oral disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the small molecule inhibitors tofacitinib and apremilast have distinctive monitoring requirements and specific adverse reaction profiles. This article provides clinically relevant pearls for use of these interventions in older patients.
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Affiliation(s)
- Blas Y Betancourt
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA.
| | - Ann Biehl
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, FDA, 10001 New Hampshire Avenue, Hillandale Building, 4th Floor Silver Spring, MD 20993, USA
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
| | - Ananta Subedi
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
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71
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Felson DT, Neogi T. Emerging Treatment Models in Rheumatology: Challenges for Osteoarthritis Trials. Arthritis Rheumatol 2018; 70:1175-1181. [PMID: 29609224 DOI: 10.1002/art.40515] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/27/2018] [Indexed: 12/14/2022]
Abstract
At a time when advancing understanding of osteoarthritis (OA) has created opportunities for new treatments, development of treatments has remained considerably behind advances in other rheumatic diseases. We describe elements of trial design and measurements that have inhibited success and offer suggestions that may help break the log jam. Among the problems with trials that include pain as an outcome measure are reliance on a single, non-optimal pain outcome, overestimation of likely effects of treatments on pain, and failure to identify patient subgroups most likely to respond to specific treatments. With regard to the use of structure modification as an outcome measure, demonstrating structure modification is often highly challenging, even with the use of magnetic resonance imaging. Many OA patients have advanced disease that is unlikely to respond to treatments that prevent cartilage loss. Further, prevention of cartilage loss and reduction of pain correlate weakly at best, and in at least some patients, reduction in pain may actually increase joint damage, making it impossible to demonstrate dual treatment effects on structure and pain in such scenarios. For structure outcomes, treatment effects on pain-sensitive structures such as bone and synovium may be more achievable than preventing cartilage loss. We suggest that changes in trial design related to some of these issues may increase the chances that new exciting and effective OA treatments will become available.
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Affiliation(s)
- David T Felson
- Boston University School of Medicine, Boston, Massachusetts
| | - Tuhina Neogi
- Boston University School of Medicine, Boston, Massachusetts
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72
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Chou PC, Chu HY. Clinical Efficacy of Acupuncture on Rheumatoid Arthritis and Associated Mechanisms: A Systemic Review. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2018; 2018:8596918. [PMID: 29849731 PMCID: PMC5925010 DOI: 10.1155/2018/8596918] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/07/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The objective of this review is to investigate the detailed existing scientific information about the clinical efficacy of acupuncture on rheumatoid arthritis (RA) conditions and to reveal the proposed mechanisms. METHODS We searched the PubMed, EMBASE, Cochrane, AMED (Allied and Complementary Medicine), NCCAM (The National Center for Complementary and Alternative Medicine), and CNKI (China National Knowledge Infrastructure) databases to identify relevant monographs and related references from 1974 to 2018. Chinese journals and theses/dissertations were hand searched. RESULTS 43 studies were recruited. Each research was analyzed for study design, subject characteristics, intervention, selected acupoints, assessment parameters, proposed mechanisms, and results/conclusions. CONCLUSIONS In our review, we concluded that acupuncture alone or combined with other treatment modalities is beneficial to the clinical conditions of RA without adverse effects reported and can improve function and quality of life and is worth trying. Several important possible mechanisms were summarized including anti-inflammatory effect, antioxidative effect, and regulation of immune system function. However, there is still inconsistency regarding the clinical efficacy and lack of well-designed human/animal double-blinded RCTs. Future discussion for further agreement on taking traditional Chinese medicine (TCM) theory into consideration as much as possible is a top priority.
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Affiliation(s)
- Pei-Chi Chou
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Heng-Yi Chu
- Department of Rehabilitation, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Świerkot J, Batko B, Wiland P, Jędrzejewski M, Stajszczyk M. Methotrexate treatment for rheumatoid arthritis in Poland: Retrospective analysis of patients in routine clinical practice. Reumatologia 2018; 56:3-9. [PMID: 29686436 PMCID: PMC5911651 DOI: 10.5114/reum.2018.74741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 02/21/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate methotrexate (MTX) treatment administered by Polish rheumatologists in everyday practice. MATERIAL AND METHODS The study was based on a retrospective analysis of a cohort of 1957 patients with rheumatoid arthritis (RA). It was conducted among 100 rheumatologists, each of whom received 20 questionnaires and completed them based on the data from their rheumatoid arthritis patients. RESULTS Methotrexate was taken by 91% of patients, and 80% of them continued the treatment either as a monotherapy (65%) or concomitantly with other disease-modifying anti-rheumatic drugs. In 60% of the cases, therapy was initiated within six months of diagnosis. Dose modifications were observed in 76% of cases and were contingent on different factors, e.g. lack of efficacy, presence of adverse events. The most prevalent adverse events were nausea and vomiting, weakness, and elevated liver enzyme activity. The most common initial dose of MTX was 10 or 15 mg/week. An increase in dose to the maximum of 25 mg/week was observed in 36% of cases, with continuation for 27% of patients. Treatment interruption was noted in 21% of patients, predominantly due to MTX intolerance; however, in 13% of cases, it was due to patient choice. CONCLUSIONS Methotrexate is the most common agent used to treat rheumatoid arthritis. Dose modifications are often applied to maximise efficacy and reduce adverse reactions, which could lead to withdrawal. Methotrexate is an effective drug for treatment of RA when used according to current recommendations. To optimise MTX therapy, regular medical visits are required.
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Affiliation(s)
- Jerzy Świerkot
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | - Bogdan Batko
- Department of Rheumatology, J. Dietl Specialist Hospital, Krakow, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | | | - Marcin Stajszczyk
- Department of Rheumatology and Autoimmune Diseases, Silesian Rheumatology Centre, Ustron, Poland
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Latremoliere A, Costigan M. Combining Human and Rodent Genetics to Identify New Analgesics. Neurosci Bull 2018; 34:143-155. [PMID: 28667479 PMCID: PMC5799129 DOI: 10.1007/s12264-017-0152-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/01/2017] [Indexed: 12/26/2022] Open
Abstract
Most attempts at rational development of new analgesics have failed, in part because chronic pain involves multiple processes that remain poorly understood. To improve translational success, one strategy is to select novel targets for which there is proof of clinical relevance, either genetically through heritable traits, or pharmacologically. Such an approach by definition yields targets with high clinical validity. The biology of these targets can be elucidated in animal models before returning to the patients with a refined therapeutic. For optimal treatment, having biomarkers of drug action available is also a plus. Here we describe a case study in rational drug design: the use of controlled inhibition of peripheral tetrahydrobiopterin (BH4) synthesis to reduce abnormal chronic pain states without altering nociceptive-protective pain. Initially identified in a population of patients with low back pain, the association between BH4 production and chronic pain has been confirmed in more than 12 independent cohorts, through a common haplotype (present in 25% of Caucasians) of the rate-limiting enzyme for BH4 synthesis, GTP cyclohydrolase 1 (GCH1). Genetic tools in mice have demonstrated that both injured sensory neurons and activated macrophages engage increased BH4 synthesis to cause chronic pain. GCH1 is an obligate enzyme for de novo BH4 production. Therefore, inhibiting GCH1 activity eliminates all BH4 production, affecting the synthesis of multiple neurotransmitters and signaling molecules and interfering with physiological function. In contrast, targeting the last enzyme of the BH4 synthesis pathway, sepiapterin reductase (SPR), allows reduction of pathological BH4 production without completely blocking physiological BH4 synthesis. Systemic SPR inhibition in mice has not revealed any safety concerns to date, and available genetic and pharmacologic data suggest similar responses in humans. Finally, because it is present in vivo only when SPR is inhibited, sepiapterin serves as a reliable biomarker of target engagement, allowing potential quantification of drug efficacy. The emerging development of therapeutics that target BH4 synthesis to treat chronic pain illustrates the power of combining human and mouse genetics: human genetic studies for clinical selection of relevant targets, coupled with causality studies in mice, allowing the rational engineering of new analgesics.
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Affiliation(s)
- Alban Latremoliere
- Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.
| | - Michael Costigan
- Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.
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Thompson PL, Nidorf SM. Anti-inflammatory therapy with canakinumab for atherosclerotic disease: lessons from the CANTOS trial. J Thorac Dis 2018; 10:695-698. [PMID: 29607136 DOI: 10.21037/jtd.2018.01.119] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Peter L Thompson
- Heart Research Institute, Harry Perkins Institute of Medical Research, University of Western Australia and Genesis HeartCare Western Australia, Perth, Australia
| | - S Mark Nidorf
- Heart Research Institute, Harry Perkins Institute of Medical Research, University of Western Australia and Genesis HeartCare Western Australia, Perth, Australia
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Drug-Induced Gastrointestinal and Hepatic Disease Associated with Biologics and Nonbiologic Disease-Modifying Antirheumatic Drugs. Rheum Dis Clin North Am 2018; 44:29-43. [DOI: 10.1016/j.rdc.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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77
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Kostic M. Cost-Effectiveness Analysis of Etanercept in Combination with Methotrexate for Rheumatoid Arthritis - Markov Model Based on Data from Serbia. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2017. [DOI: 10.1515/sjecr-2016-0070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Abstract
Biological therapeutic strategies have shown positive benefits for chronic and progressive rheumatoid arthritis (RA) in clinical and radiological outcomes. Despite these results, the use of biological drugs in the treatment of RA is limited by high costs. The aim of this study was to compare the cost effectiveness of etanercept in combination with methotrexate and methotrexate alone in patients with RA in the socioeconomic environment of a Balkan country.
We conducted a cost-effectiveness study using a Markov model from a societal perspective with a time horizon of 480 months. The cycle duration was set to one month. The basic transition probabilities and data on therapeutic efficacy were estimated from the available literature, while costs were calculated using the medical documents of patients with RA treated at the Clinical Center Kragujevac.
Our results indicated that treatment of patients with RA using methotrexate alone is more cost effective, with a cost-effectiveness ratio of 1.446.640,78 RSD/QALY, than treatment with a combination of methotrexate and etanercept, with a cost-effectiveness ratio of 5.882.714,57 RSD/QALY.
The use of etanercept to treat RA is not cost effective in the socioeconomic environment of Serbia. The cost-effectiveness ratio of biological drugs would be more favourable if special strategies for the pricing policy of biological drugs were established on the basis of local pharmacoeconomic studies.
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Affiliation(s)
- Marina Kostic
- University of Kragujevac , Serbia , Faculty of Medical Sciences, Department of Pharmacology and Toxicology
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78
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Tavakolpour S. Towards personalized medicine for patients with autoimmune diseases: Opportunities and challenges. Immunol Lett 2017; 190:130-138. [DOI: 10.1016/j.imlet.2017.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 08/03/2017] [Indexed: 02/06/2023]
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79
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Giat E, Ehrenfeld M, Shoenfeld Y. Cancer and autoimmune diseases. Autoimmun Rev 2017; 16:1049-1057. [DOI: 10.1016/j.autrev.2017.07.022] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
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Ruiz Garcia V, Burls A, Cabello JB, Vela Casasempere P, Bort‐Marti S, Bernal JA. Certolizumab pegol (CDP870) for rheumatoid arthritis in adults. Cochrane Database Syst Rev 2017; 9:CD007649. [PMID: 28884785 PMCID: PMC6483724 DOI: 10.1002/14651858.cd007649.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Tumour necrosis factor (TNF)-alpha inhibitors are beneficial for the treatment of rheumatoid arthritis (RA) for reducing the risk of joint damage, improving physical function and improving the quality of life. This review is an update of the 2014 Cochrane Review of the treatment of RA with certolizumab pegol. OBJECTIVES To assess the clinical benefits and harms of certolizumab pegol (CZP) in people with RA who have not responded well to conventional disease-modifying anti-rheumatic drugs (DMARDs). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL: Cochrane Library 2016, Issue 9), MEDLINE, Embase, Web of Knowledge, reference lists of articles, clinicaltrials.gov and ICTRP of WHO. The searches were updated from 2014 (date of the last search for the previous version) to 26 September 2016. SELECTION CRITERIA Randomised controlled trials that compared certolizumab pegol with any other agent, including placebo or methotrexate (MTX), in adults with active RA, regardless of current or prior treatment with conventional disease-modifying anti-rheumatic drugs (DMARDs), such as MTX. DATA COLLECTION AND ANALYSIS Two review authors independently checked search results, extracted data and assessed trial quality. We resolved disagreements by discussion or referral to a third review author. MAIN RESULTS We included 14 trials in this update, three more than previously. Twelve trials (5422 participants) included measures of benefit. We pooled 11 of them, two more than previously. Thirteen trials included information on harms, (5273 participants). The duration of follow-up varied from 12 to 52 weeks and the range of doses of certolizumab pegol varied from 50 to 400 mg given subcutaneously. In Phase III trials, the comparator was placebo plus MTX in seven trials and placebo in five. In the two Phase II trials the comparator was only placebo.The approved dose of certolizumab pegol, 200 mg every other week, produced clinically important improvements at 24 weeks for the following outcomes:- American College of Rheumatology (ACR) 50% improvement (pain, function and other symptoms of RA): 25% absolute improvement (95% confidence interval (CI) 20% to 33%); number need to treat for an additional beneficial outcome (NNTB) of 4 (95% CI 3 to 5); risk ratio (RR) 3.80 (95% CI 2.42 to 5.95), 1445 participants, 5 studies.- The Health Assessment Questionnaire (HAQ): -12% absolute improvement (95% CI -9% to -14%); NNTB of 8 (95% CI 7 to 11); mean difference (MD) - 0.35 (95% CI -0.43 to -0.26; 1268 participants, 4 studies) (scale 0 to 3; lower scores mean better function).- Proportion of participants achieving remission (Disease Activity Score (DAS) < 2.6) absolute improvement 10% (95% CI 8% to 16%); NNTB of 8 (95% CI 6 to 12); risk ratio (RR) 2.94 (95% CI 1.64 to 5.28), 2420 participants, six studies.- Radiological changes: erosion score (ES) absolute improvement -0.29% (95% CI -0.42% to -0.17%); NNTB of 6 (95% CI 4 to 10); MD -0.67 (95% CI -0.96 to -0.38); 714 participants, two studies (scale 0 to 230), but not a clinically important difference.-Serious adverse events (SAEs) were statistically but not clinically significantly more frequent for certolizumab pegol (200 mg every other week) with an absolute rate difference of 3% (95% CI 1% to 4%); number needed to treat for an additional harmful outcome (NNTH) of 33 (95% CI 25 to 100); Peto odds ratio (OR) 1.47 (95% CI 1.13 to 1.91); 3927 participants, nine studies.There was a clinically significant increase in all withdrawals in the placebo groups (for all doses and at all follow-ups) with an absolute rate difference of -29% (95% CI -16% to -42%), NNTH of 3 (95% CI 2 to 6), RR 0.47 (95% CI 0.39 to 0.56); and there was a clinically significant increase in withdrawals due to adverse events in the certolizumab groups (for all doses and at all follow-ups) with an absolute rate difference of 2% (95% CI 0% to 3%); NNTH of 58 (95% CI 28 to 329); Peto OR 1.45 (95% CI 1.09 to 1.94) 5236 participants Twelve studies.We judged the quality of evidence to be high for ACR50, DAS remission, SAEs and withdrawals due to adverse events, and moderate for HAQ and radiological changes, due to concerns about attrition bias. For all withdrawals we judged the quality of evidence to be moderate, due to inconsistency. AUTHORS' CONCLUSIONS The results and conclusions did not change from the previous review. There is a moderate to high certainty of evidence from randomised controlled trials that certolizumab pegol, alone or combined with methotrexate, is beneficial in the treatment of RA for improved ACR50 and health-related quality of life, an increased chance of remission of RA, and reduced joint damage as seen on x-ray. Fewer people stopped taking their treatment, but most of these who did stopped due to serious adverse events. Adverse events were more frequent with active treatment. We found a clinically but not statistically significant risk of serious adverse events.
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Affiliation(s)
- Vicente Ruiz Garcia
- La Fe University HospitalHospital at Home Unit, Tower C, Floor 1 Office 5 & CASPe SpainAv Fernando Abril Martorell nº 106ValenciaSpain46026
| | - Amanda Burls
- City University LondonSchool of Health SciencesMyddleton StreetLondonUKEC1V 0HB
| | - Juan B Cabello
- Hospital General Universitario de AlicanteDepartment of Cardiology & CASP SpainPintor Baeza 12AlicanteAlicanteSpain03010
| | - Paloma Vela Casasempere
- Hospital General Universitario AlicanteDepartment of RheumatologyMaestro Alonso, 109AlicanteSpain03010
| | | | - José A Bernal
- Hospital General Universitario AlicanteDepartment of RheumatologyMaestro Alonso, 109AlicanteSpain03010
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Affiliation(s)
- Tom D Wilsdon
- Flinders Medical Centre and Flinders University; Department of Clinical Pharmacology; Flinders Drive Bedford Park South Australia Australia 5042
| | - Samuel L Whittle
- The Queen Elizabeth Hospital and University of Adelaide; Department of Rheumatology; 28 Woodville Road Woodville South Australia Australia 5011
| | - Tilenka RJ Thynne
- Flinders Medical Centre and Flinders University; Department of Clinical Pharmacology; Flinders Drive Bedford Park South Australia Australia 5042
| | - Arduino A Mangoni
- Flinders Medical Centre and Flinders University; Department of Clinical Pharmacology; Flinders Drive Bedford Park South Australia Australia 5042
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Abstract
BACKGROUND Rheumatoid arthritis is a systemic auto-immune disorder that causes widespread and persistent inflammation of the synovial lining of joints and tendon sheaths. Presently, there is no cure for rheumatoid arthritis and treatment focuses on managing symptoms such as pain, stiffness and mobility, with the aim of achieving stable remission and improving mobility. Celecoxib is a selective non-steroidal anti-inflammatory drug (NSAID) used for treatment of people with rheumatoid arthritis. OBJECTIVES To assess the benefits and harms of celecoxib in people with rheumatoid arthritis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trials registers (ClinicalTrials.gov and the World Health Organization trials portal) to May 18, 2017. We also searched the reference and citation lists of included studies. SELECTION CRITERIA We included prospective randomized controlled trials (RCTs) that compared oral celecoxib (200 mg and 400 mg daily) versus no intervention, placebo or a traditional NSAID (tNSAID) in people with confirmed rheumatoid arthritis, of any age and either sex. We excluded studies with fewer than 50 participants in each arm or had durations of fewer than four weeks treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included eight RCTs with durations of 4 to 24 weeks, published between 1998 and 2014 that involved a total of 3988 adults (mean age = 54 years), most of whom were women (73%). Participants had rheumatoid arthritis for an average of 9.2 years. All studies were assessed at high or unclear risk of bias in at least one domain. Overall, evidence was assessed as moderate-to-low quality. Five studies were funded by pharmaceutical companies. Celecoxib versus placeboWe included two studies (N = 873) in which participants received 200 mg daily or 400 mg daily or placebo. Participants who received celecoxib showed significant clinical improvement compared with those receiving placebo (15% absolute improvement; 95% CI 7% to 25%; RR 1.53, 95% CI 1.25 to 1.86; number needed to treat to benefit (NNTB) = 7, 95% CI 5 to 13; 2 studies, 873 participants; moderate to low quality evidence).Participants who received celecoxib reported less pain than placebo-treated people (11% absolute improvement; 95% CI 8% to 14%; NNTB = 4, 95% CI 3 to 6; 1 study, 706 participants) but results were inconclusive for improvement in physical function (MD -0.10, 95% CI 0.29 to 0.10; 1 study, 706 participants).In the celecoxib group, 15/293 participants developed ulcers, compared with 4/99 in the placebo group (Peto OR 1.26, 95% CI 0.44 to 3.63; 1 study, 392 participants; low quality evidence). Nine (of 475) participants in the celecoxib group developed short-term serious adverse events, compared with five (of 231) in the placebo group (Peto OR 0.87 (0.28 to 2.69; 1 study, 706 participants; low quality evidence).There were fewer withdrawals among people who received celecoxib (163/475) compared with placebo (130/231) (22% absolute change; 95% CI 16% to 27%; RR 0.61, 95% CI 0.52 to 0.72; 1 study, 706 participants).Cardiovascular events (myocardial infarction, stroke) were not reported. However, regulatory agencies warn of increased cardiovascular event risk associated with celecoxib. Celecoxib versus tNSAIDsSeven studies (N = 2930) compared celecoxib and tNSAIDs (amtolmetin guacyl, diclofenac, ibuprofen, meloxicam, nabumetone, naproxen, pelubiprofen); one study included comparisons of both placebo and tNSAIDs (N = 1149).There was a small improvement, which may not be clinically significant, in numbers of participants achieving ACR20 criteria response in the celecoxib group compared to tNSAIDs (4% absolute improvement; 95% CI 0% less improvement to 8% more improvement; RR 1.10, 95% CI 0.99 to 1.23; 4 studies, 1981 participants). There was a lack of evidence of difference between participants in the celecoxib and tNSAID groups in terms of pain or physical function. Results were assessed at moderate-to-low quality evidence (downgraded due to risk of bias and inconsistency).People who received celecoxib had a lower incidence of gastroduodenal ulcers ≥ 3 mm (34/870) compared with those who received tNSAIDs (116/698). This corresponded to 12% absolute change (95% CI 11% to 13%; RR 0.22, 95% CI 0.15 to 0.32; 5 studies, 1568 participants; moderate quality evidence). There were 7% fewer withdrawals among people who received celecoxib (95% CI 4% to 9%; RR 0.73, 95% CI 0.62 to 0.86; 6 studies, 2639 participants).Results were inconclusive for short-term serious adverse events and cardiovascular events (low quality evidence). There were 17/918 serious adverse events in people taking celecoxib compared to 42/1236 among people who received placebo (Peto OR 0.71; 95% CI 0.39 to 1.28; 5 studies, 2154 participants). Cardiovascular events were reported in both celecoxib and placebo groups in one study (149 participants). AUTHORS' CONCLUSIONS Celecoxib may improve clinical symptoms, alleviate pain and contribute to little or no difference in physical function compared with placebo. Celecoxib was associated with fewer numbers of participant withdrawals. Results for incidence of gastroduodenal ulcers (≥ 3 mm) and short-term serious adverse events were uncertain; however, there were few reported events for either.Celecoxib may slightly improve clinical symptoms compared with tNSAIDs. Results for reduced pain and improved physical function were uncertain. Particpants taking celecoxib had lower incidence of gastroduodenal ulcers (≥ 3 mm) and there were fewer withdrawals from trials. Results for cardiovascular events and short-term serious adverse events were also uncertain.Uncertainty about the rate of cardiovascular events between celecoxib and tNSAIDs could be due to risk of bias; another factor is that these were small, short-term trials. It has been reported previously that both celecoxib and tNSAIDs increase cardiovascular event rates. Our confidence in results about harms is therefore low. Larger head-to-head clinical trials comparing celecoxib to other tNSAIDs is needed to better inform clinical practice.
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Affiliation(s)
- Mahir Fidahic
- University of TuzlaMedical facultyUniverzitetska 1TuzlaCanton TuzlaBosnia and Herzegovina75000
| | - Antonia Jelicic Kadic
- Cochrane Croatia, University of Split School of MedicineSoltanska 2SplitCroatia
- University Hospital SplitDepartment of PediatricsSpinciceva 1SplitCroatia21 000
| | - Mislav Radic
- University Hospital Split, School of Medicine, Cochrane CroatiaDivision of Rheumatology and Clinical ImmunologyŠoltanska 2SplitCroatia21000
| | - Livia Puljak
- University of Split School of MedicineCochrane CroatiaSoltanska 2SplitCroatia21000
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Schlaeger JM, Roach K, Golas M, Takayama M, Wilkie DJ. Treatment-Seeking Behaviors of Persons With Rheumatoid Arthritis. J Holist Nurs 2017; 36:179-191. [PMID: 28506103 DOI: 10.1177/0898010117693539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Describe perceptions of patients with rheumatoid arthritis (RA) regarding disease-related pain, tendency to tell others about their pain, and treatments used since diagnosis. DESIGN Cross sectional, exploratory. METHOD A total of 63 participants responded to telephone interview about their treatments and tendency to tell others about their RA pain. They also responded to McGill Pain Questionnaire and Health Assessment Questionnaire (HAQ) items. Participants marked pain location on mailed body outlines. FINDINGS RA diagnosis occurred an average of 11 years prior. Mean HAQ Standard Disability Index score was 1.26. Previous week symptoms were joint pain (97%), joint swelling (83%), decreased movement/function (83%), fatigue (70%), muscle weakness (65%). Mean morning stiffness duration was 120 ± 137 minutes. Mean pain intensity was 1.15 ± 0.6 at its least and 3.8 ± 1.1 at its worst. 65% were not satisfied with pain levels. 57% stated a tendency not to tell others about their pain; 43% tended to tell. 78% used medications and alternative therapies, none solely used alternative therapies, and 22% only used medications. CONCLUSIONS RA patients reported high rates of alternative therapy use. Dissatisfaction with pain levels indicates need for improved pain management. Not talking about pain lends insights into the importance of teaching patients to communicate their pain to others.
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Affiliation(s)
| | | | - Mary Golas
- University of Illinois at Chicago, Chicago.,Jesse Brown VA Medical Center Chicago, Chicago
| | - Miho Takayama
- Tokyo Ariake University of Medical and Health Sciences, Japan
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Bello AE, Perkins EL, Jay R, Efthimiou P. Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis. Open Access Rheumatol 2017; 9:67-79. [PMID: 28435338 PMCID: PMC5386601 DOI: 10.2147/oarrr.s131668] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methotrexate (MTX) remains the cornerstone therapy for patients with rheumatoid arthritis (RA), with well-established safety and efficacy profiles and support in international guidelines. Clinical and radiologic results indicate benefits of MTX monotherapy and combination with other agents, yet patients may not receive optimal dosing, duration, or route of administration to maximize their response to this drug. This review highlights best practices for MTX use in RA patients. First, to improve the response to oral MTX, a high initial dose should be administered followed by rapid titration. Importantly, this approach does not appear to compromise safety or tolerability for patients. Treatment with oral MTX, with appropriate dose titration, then should be continued for at least 6 months (as long as the patient experiences some response to treatment within 3 months) to achieve an accurate assessment of treatment efficacy. If oral MTX treatment fails due to intolerability or inadequate response, the patient may be "rescued" by switching to subcutaneous delivery of MTX. Consideration should also be given to starting with subcutaneous MTX given its favorable bioavailability and pharmacodynamic profile over oral delivery. Either initiation of subcutaneous MTX therapy or switching from oral to subcutaneous administration improves persistence with treatment. Upon transition from oral to subcutaneous delivery, MTX dosage should be maintained, rather than increased, and titration should be performed as needed. Similarly, if another RA treatment is necessary to control the disease, the MTX dosage and route of administration should be maintained, with titration as needed.
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Affiliation(s)
| | | | - Randy Jay
- Arizona Arthritis & Rheumatology Associates, Phoenix, AZ
| | - Petros Efthimiou
- Division of Rheumatology, New York Methodist Hospital, Brooklyn, NY, USA
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Ikeda K, Watanabe K, Hirai T, Tanji K, Miyashita T, Nakajima S, Uomori K, Morimoto S, Takamori K, Ogawa H, Takasaki Y, Sekigawa I. Mizoribine Synchronized Methotrexate Therapy should be Considered when Treating Rheumatoid Arthritis Patients with an Inadequate Response to Various Combination Therapies. Intern Med 2017; 56:1147-1152. [PMID: 28502927 PMCID: PMC5491807 DOI: 10.2169/internalmedicine.56.7886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The objective of this study was to confirm the efficacy of low-dose mizoribine (MZR), an inhibitor of inosine monophosphate dehydrogenase, as part of synchronized methotrexate (MTX) therapy for rheumatoid arthritis (RA) patients with an inadequate response to various combination therapies of MTX, other synthetic disease-modifying anti-rheumatic drugs (DMARDs) and biological DMARDs. Methods Low-dose MZR was administered to 56 uncontrolled RA patients being treated with MTX and various biological DMARDs. The observation period was 12 months, and the disease activity was evaluated based on the Disease Activity Score in 28 joints (DAS28)-ESR, Simplified Disease Activity Index (SDAI) and serum MMP-3 level. Results All of the disease activity indices were significantly improved within three months, and the serum MMP-3 levels were also significantly decreased around four months after starting low-dose MZR therapy. No patients experienced any adverse effects. Conclusion The present preliminary findings suggest that low-dose MZR therapy with MTX should be considered for the treatment of RA patients with an inadequate response to various combination therapies including MTX, other synthetic DMARDs and biological DMARDs or in whom increasing the dose of MTX is difficult for reasons such as adverse effects and complications.
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Affiliation(s)
- Keigo Ikeda
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Kozo Watanabe
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Takuya Hirai
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Kana Tanji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Tomoko Miyashita
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
| | - Shihoko Nakajima
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Kaori Uomori
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Shinji Morimoto
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Kenji Takamori
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Hideoki Ogawa
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshinari Takasaki
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Iwao Sekigawa
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
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Noack M, Ndongo-Thiam N, Miossec P. Evaluation of Anti-inflammatory Effects of Steroids and Arthritis-Related Biotherapies in an In Vitro Coculture Model with Immune Cells and Synoviocytes. Front Immunol 2016; 7:509. [PMID: 27909436 PMCID: PMC5112278 DOI: 10.3389/fimmu.2016.00509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/02/2016] [Indexed: 12/02/2022] Open
Abstract
Background During rheumatoid arthritis (RA), steroids and biotherapies are used alone and combined. Efficacy has been established in clinical trials but their differential effects at the cellular level are less documented. The aim was to study these cellular effects using an in vitro model with synoviocytes interacting with peripheral blood mononuclear cells (PBMC) to reproduce the interactions in the RA synovium. Methods Activated-PBMC were cocultured with RA synoviocytes during 48 h. A dose–response of methylprednisolone (MP) was tested and different biotherapies (Infliximab, Etanercept, Adalimumab, Tocilizumab, Abatacept, and Rituximab) were added alone or in combination with MP. Cytokine production (IL-17, IL-6, IL-1β, IFN-γ and IL-10) was measured by ELISA. Results Addition of MP to cocultures inhibited the production of all cytokines. The response to the biotherapies alone was treatment-dependent. IL-17 production was inhibited only by Tocilizumab (p = 0.004), while IL-6 was decreased only by Infliximab (p ≤ 0.002). IL-1β level was affected in all conditions (p ≤ 0.03). IFN-γ production was mainly decreased by Infliximab (p = 0.004) and IL-10 by Infliximab and Tocilizumab (p ≤ 0.004). The combination MP and biotherapies did not induce an additional effect on pro-inflammatory cytokine inhibition. The combination MP and biotherapies induced a higher IL-10 secretion than MP alone, mainly with Rituximab. Conclusion Steroids inhibited the secretion of all cytokines, and low doses were as potent. The anti-inflammatory effect of biotherapies was dependent on their mechanism of action. MP and biotherapy combination did not enhance the inhibitory effect on pro-inflammatory cytokines but could have a beneficial effect by increasing IL-10 production.
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Affiliation(s)
- Mélissa Noack
- Immunogenomics and Inflammation Research Unit, EA 4130, Edouard Herriot Hospital, Hospices Civils de Lyon and University Claude Bernard Lyon 1 , Lyon , France
| | - Ndiémé Ndongo-Thiam
- Immunogenomics and Inflammation Research Unit, EA 4130, Edouard Herriot Hospital, Hospices Civils de Lyon and University Claude Bernard Lyon 1 , Lyon , France
| | - Pierre Miossec
- Immunogenomics and Inflammation Research Unit, EA 4130, Edouard Herriot Hospital, Hospices Civils de Lyon and University Claude Bernard Lyon 1 , Lyon , France
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Mechanism of action of methotrexate in rheumatoid arthritis, and the search for biomarkers. Nat Rev Rheumatol 2016; 12:731-742. [PMID: 27784891 DOI: 10.1038/nrrheum.2016.175] [Citation(s) in RCA: 253] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The treatment and outcomes of patients with rheumatoid arthritis (RA) have been transformed over the past two decades. Low disease activity and remission are now frequently achieved, and this success is largely the result of the evolution of treatment paradigms and the introduction of new therapeutic agents. Despite the rapid pace of change, the most commonly used drug in RA remains methotrexate, which is considered the anchor drug for this condition. In this Review, we describe the known pharmacokinetic properties and putative mechanisms of action of methotrexate. Consideration of the pharmacodynamic perspective could inform the development of biomarkers of responsiveness to methotrexate, enabling therapy to be targeted to specific groups of patients. Such biomarkers could revolutionize the management of RA.
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Hazlewood GS, Barnabe C, Tomlinson G, Marshall D, Devoe DJA, Bombardier C. Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis: A network meta-analysis. Cochrane Database Syst Rev 2016; 2016:CD010227. [PMID: 27571502 PMCID: PMC7087436 DOI: 10.1002/14651858.cd010227.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Methotrexate is considered the preferred disease-modifying anti-rheumatic drug (DMARD) for the treatment of rheumatoid arthritis, but controversy exists on the additional benefits and harms of combining methotrexate with other DMARDs. OBJECTIVES To compare methotrexate and methotrexate-based DMARD combinations for rheumatoid arthritis in patients naïve to or with an inadequate response (IR) to methotrexate. METHODS We systematically identified all randomised controlled trials with methotrexate monotherapy or in combination with any currently used conventional synthetic DMARD , biologic DMARDs, or tofacitinib. Three major outcomes (ACR50 response, radiographic progression and withdrawals due to adverse events) and multiple minor outcomes were evaluated. Treatment effects were summarized using Bayesian random-effects network meta-analyses, separately for methotrexate-naïve and methotrexate-IR trials. Heterogeneity was explored through meta-regression and subgroup analyses. The risk of bias of each trial was assessed using the Cochrane risk of bias tool, and trials at high risk of bias were excluded from the main analysis. The quality of evidence was evaluated using the GRADE approach. A comparison between two treatments was considered statistically significant if its credible interval excluded the null effect, indicating >97.5% probability that one treatment was superior. MAIN RESULTS 158 trials with over 37,000 patients were included. Methotrexate-naïve: Several treatment combinations with methotrexate were statistically superior to oral methotrexate for ACR50 response: methotrexate + sulfasalazine + hydroxychloroquine ("triple therapy"), methotrexate + several biologics (abatacept, adalimumab, etanercept, infliximab, rituximab, tocilizumab), and tofacitinib. The estimated probability of ACR50 response was similar between these treatments (range 56-67%, moderate to high quality evidence), compared with 41% for methotrexate. Methotrexate combined with adalimumab, etanercept, certolizumab, or infliximab was statistically superior to oral methotrexate for inhibiting radiographic progression (moderate to high quality evidence) but the estimated mean change over one year with all treatments was less than the minimal clinically important difference of five units on the Sharp-van der Heijde scale. Methotrexate + azathioprine had statistically more withdrawals due to adverse events than oral methotrexate, and triple therapy had statistically fewer withdrawals due to adverse events than methotrexate + infliximab (rate ratio 0.26, 95% credible interval: 0.06 to 0.91). Methotrexate-inadequate response: In patients with an inadequate response to methotrexate, several treatments were statistically significantly superior to oral methotrexate for ACR50 response: triple therapy (moderate quality evidence), methotrexate + hydroxychloroquine (low quality evidence), methotrexate + leflunomide (moderate quality evidence), methotrexate + intramuscular gold (very low quality evidence), methotrexate + most biologics (moderate to high quality evidence), and methotrexate + tofacitinib (high quality evidence). There was a 61% probability of an ACR50 response with triple therapy, compared to a range of 27% to 64% for the combinations of methotrexate + biologic DMARDs that were statistically significantly superior to oral methotrexate. No treatment was statistically significantly superior to oral methotrexate for inhibiting radiographic progression. Methotrexate + cyclosporine and methotrexate + tocilizumab (8 mg/kg) had a statistically higher rate of withdrawals due to adverse events than oral methotrexate and methotrexate + abatacept had a statistically lower rate of withdrawals due to adverse events than several treatments. AUTHORS' CONCLUSIONS We found moderate to high quality evidence that combination therapy with methotrexate + sulfasalazine+ hydroxychloroquine (triple therapy) or methotrexate + most biologic DMARDs or tofacitinib were similarly effective in controlling disease activity and generally well tolerated in methotrexate-naïve patients or after an inadequate response to methotrexate. Methotrexate + some biologic DMARDs were superior to methotrexate in preventing joint damage in methotrexate-naïve patients, but the magnitude of these effects was small over one year.
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Affiliation(s)
- Glen S Hazlewood
- University of CalgaryDepartment of Medicine and Department of Community Health Sciences3330 Hospital Drive NWCalgaryONCanadaT2N 1N1
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of TorontoInstitute of Health, Policy, Management and EvaluationTorontoONCanadaM5T 3M6
| | - Cheryl Barnabe
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of CalgaryDepartment of Medicine3330 Hospital Dr NWCalgaryABCanadaT2N 4N1
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - George Tomlinson
- University of TorontoDepartment of Medicine and Institute of Health Policy, Management and EvaluationEaton North, 6th Floor, Room 232B200 Elizabeth StreetTorontoONCanadaM5G 2C4
| | - Deborah Marshall
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Daniel JA Devoe
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Claire Bombardier
- University Health NetworkToronto General Research InstituteTorontoONCanadaM6J 3S3
- University of TorontoDepartment of Medicine and Institute of Health Policy, Management, and EvaluationTorontoONCanadaM5G 2C4
- Mount Sinai HospitalDivision of RheumatologyTorontoONCanadaM5T 3L9
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O'Connor A, Thorne C, Kang H, Tin D, Pope JE. The rapid kinetics of optimal treatment with subcutaneous methotrexate in early inflammatory arthritis: an observational study. BMC Musculoskelet Disord 2016; 17:364. [PMID: 27558249 PMCID: PMC4997744 DOI: 10.1186/s12891-016-1213-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Methotrexate (MTX) is standard treatment for RA. Absorption is better in subcutaneous MTX (scMTX), which may impact speed of onset. In RA, earlier time to remission improves long-term results. Our objectives were to determine rapidity of response of subcutaneous methotrexate in early rheumatoid arthritis. Methods The change in several disease activity measures (including DAS28) from 0 to 6 weeks (early period) and 6 to 12 weeks (late period) was compared. The proportion achieving DAS28/CDAI/SDAI remission and/or low disease activity state was also compared. Results One hundred three patients were included from a single site between 2008 and 2014. All received MTX (98.0 % scMTX, 98 % 25 mg/week). There were no dropouts. There was a significantly greater early change in DAS28 (−1.9 vs. −0.2, p < 0.00); this effect was seen for several outcome measures. By 6 weeks, 59 % had achieved either DAS28 remission or low disease activity state, with 74 % achieving either state by 12 weeks. There were a larger proportion of patients achieving CDAI and DAS28 remission in the early versus late period (p < 0.0002 for both). There was significant improvement when using combination MTX and HCQ, however sample size was small (n = 9). The use of intra-articular steroids with MTX yielded the most disease measures that demonstrated early significant improvement. Conclusion Subcutaneous MTX is rapid, as the change in many disease activity scores was significantly greater between 0–6 weeks compared to 6–12 weeks. Combination MTX + HCQ gave added value, although generalizability is limited by combination cohort sample size. Intra-articular steroid injections may contribute to the early effect. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1213-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna O'Connor
- Schulich School of Medicine & Dentistry, University of Western Ontario, 268 Grosvenor St, London, ON, N6A 4V2, Canada
| | | | - Hyeon Kang
- University of Toronto, Toronto, ON, Canada
| | - Diane Tin
- Southlake Regional Health Centre, Newmarket, Canada
| | - Janet E Pope
- Schulich School of Medicine & Dentistry, University of Western Ontario, 268 Grosvenor St, London, ON, N6A 4V2, Canada. .,University of Toronto, Toronto, ON, Canada. .,Rheumatology, St. Joseph's Health Care, London, ON, Canada.
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Kammermeier J, Morris MA, Garrick V, Furman M, Rodrigues A, Russell RK. Management of Crohn's disease. Arch Dis Child 2016; 101:475-80. [PMID: 26553907 PMCID: PMC4853609 DOI: 10.1136/archdischild-2014-307217] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/09/2015] [Accepted: 10/12/2015] [Indexed: 02/07/2023]
Abstract
Crohn's disease (CD) is rapidly increasing in children so an up to date knowledge of diagnosis, investigation and management is essential. Exclusive enteral nutrition is the first line treatment for active disease. The vast majority of children will need immunosuppressant treatment and around 20% will need treatment with biologics. Recent guidelines have helped make best use of available therapies.
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Affiliation(s)
| | - Mary-Anne Morris
- Department of Paediatrics, Norfolk and Norwich University Hospital, Norwich, UK
| | - Vikki Garrick
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Mark Furman
- Centre for Paediatric Gastroenterology, Royal Free Hospital, London, UK
| | - Astor Rodrigues
- Department of Paediatric Gastroenterology, John Radcliffe Hospital, Oxford, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
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Truchetet ME, Poursac N, Barnetche T, Shipley E, Gottenberg JE, Bannwarth B, Richez C, Schaeverbeke T. Abatacept monotherapy compared with abatacept plus disease-modifying anti-rheumatic drugs in rheumatoid arthritis patients: data from the ORA registry. Arthritis Res Ther 2016; 18:72. [PMID: 27029339 PMCID: PMC4815200 DOI: 10.1186/s13075-016-0956-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 02/12/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Retention rate, efficacy, and safety of abatacept (ABA) was compared between patients with rheumatoid arthritis receiving ABA as monotherapy to those in combination ABA + conventional synthetic DMARD (csDMARD). METHODS The patients were obtained from the ORA registry. The retention rate was analysed in two ways: (1) therapeutic strategy retention, in which the addition of a csDMARD was considered to indicate failure of the monotherapy strategy; and (2) ABA retention, which was assessed by the discontinuation of ABA regardless of other treatment modifications. Efficacy and safety were compared between ABA initiated alone and ABA used in combination with a csDMARD. RESULTS The retention rate at month 6 (M6) was evaluated in 569 patients. A significant difference was identified in the retention rate between the ABA monotherapy strategy and the ABA + csDMARD strategy (58.5 % [110/188] vs. 68 % [258/381], respectively, p = 0.031). No significant difference was identified in the ABA retention rate initiated either as a monotherapy or in combination with csDMARDs (75 % [142/188] vs. 76 % [291/381], respectively, p = 0.824). Data regarding ABA efficacy were available for 444 patients. There was no significant difference in the responder proportion after 6 months of treatment between ABA monotherapy and ABA + csDMARD treatment (60.2 % [88/146] vs. 60 % [179/298], respectively, p = 0.967). CONCLUSIONS This "real-life" analysis, which is relevant for bedside practice, emphasised the satisfactory efficacy and safety of ABA used in monotherapy, which provides an acceptable alternative when csDMARDs are undesirable.
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Affiliation(s)
- Marie-Elise Truchetet
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France. .,Groupe Epidemiologie Clinique des Maladies Inflammatoires d'Aquitaine (GECMIA) Study Group, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France.
| | - Nicolas Poursac
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
| | - Thomas Barnetche
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
| | - Emilie Shipley
- Département de Rhumatologie, Hôpital de Dax, 18 Avenue Paul Doumer, 40100, Dax, France
| | - Jacques-Eric Gottenberg
- Hôpitaux Universitaires de Strasbourg et Universités de Strasbourg, 1 Place de L Hôpital, 67000, Strasbourg, France
| | - Bernard Bannwarth
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
| | - Christophe Richez
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France.,Groupe Epidemiologie Clinique des Maladies Inflammatoires d'Aquitaine (GECMIA) Study Group, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
| | - Thierry Schaeverbeke
- Département de Rhumatologie, Hôpital Pellegrin, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France.,Groupe Epidemiologie Clinique des Maladies Inflammatoires d'Aquitaine (GECMIA) Study Group, CHU de Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
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Bianchi G, Caporali R, Todoerti M, Mattana P. Methotrexate and Rheumatoid Arthritis: Current Evidence Regarding Subcutaneous Versus Oral Routes of Administration. Adv Ther 2016; 33:369-78. [PMID: 26846283 PMCID: PMC4833794 DOI: 10.1007/s12325-016-0295-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Indexed: 11/30/2022]
Abstract
Abstract Methotrexate (MTX) is still considered the drug of choice in rheumatoid arthritis (RA) management. Comparing subcutaneous (MTX SC) and oral (MTX OR) routes of administration is important to optimize the everyday therapeutic strategy in the real-life setting. This review summarizes scientific evidence currently available on this topic. As shown by pharmacokinetic studies, at the same dose level, bioavailability of MTX SC is significantly higher and less variable than that of MTX OR. This difference is even more pronounced for medium-to-high dosages (i.e., >15 mg/week). With regard to clinical response (Disease Activity Score-28, American College of Rheumatology Criteria), randomized, double-blind studies and retrospective or longitudinal analyses in real-life settings showed that MTX SC is more effective than MTX OR. This is true both in MTX-naive patients with early RA, and in patients who switch from MTX OR to MTX SC due to previous treatment failure, lack of efficacy and/or adverse events. Finally, MTX SC has a better tolerability profile than MTX OR, with fewer gastroenterological side effects. Delaying the use of more expensive biological therapies by switching from MTX OR to MTX SC in non-responders might provide cost savings, with relevant implications in the management of patients with RA. Funding Alfa Wassermann. Electronic supplementary material The online version of this article (doi:10.1007/s12325-016-0295-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Roberto Caporali
- Division of Rheumatology, IRCCS San Matteo, University of Pavia, Pavia, Italy
| | - Monica Todoerti
- Division of Rheumatology, IRCCS San Matteo, University of Pavia, Pavia, Italy
| | - Paolo Mattana
- Division of Medical Service, Alfa Wassermann, Bologna, Italy
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Krause D, Gabriel B, Herborn G, Braun J, Rau R. Response to methotrexate predicts long-term patient-related outcomes in rheumatoid arthritis. Clin Rheumatol 2016; 35:1123-7. [PMID: 26920753 DOI: 10.1007/s10067-016-3216-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/25/2016] [Accepted: 02/15/2016] [Indexed: 10/22/2022]
Abstract
This study was conducted to investigate the predictive value of the initial response to methotrexate (MTX) on long-term patient-related outcomes (PROs) in rheumatoid arthritis (RA). All RA patients starting MTX treatment between 1980 and 1987 in our department were enrolled in a prospective observational study. After an average of 18 years, patient-related outcomes were assessed in three dimensions according to the International Classification of Functioning, Disability and Health (ICF). Statistical analyses employed multivariable models with baseline values for age, gender, disease duration, rheumatoid factor positivity, disease activity, response to MTX after 1 year and continuous use of MTX as covariates. The 271 patients enrolled had a mean disease duration of 8.5 years, a mean number of swollen joints of 18 (out of 32), and a mean erythrocyte sedimentation rate of 55 mm/h. After 18 years, PRO was available in 89 patients (33 %). A clinical improvement of at least 20 % 1 year after the initiation of MTX was associated with a favourable outcome in all three dimensions of the ICF, independent of continuation of MTX (p < 0.05). The initial response to MTX is an independent predictor of PRO in RA as assessed after an average of 18 years.
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Affiliation(s)
- Dietmar Krause
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University, Bochum, Germany.
| | | | - Gertraud Herborn
- Department of Rheumatology, Evangelisches Fachkrankenhaus, Ratingen, Germany
| | | | - Rolf Rau
- Department of Rheumatology, Evangelisches Fachkrankenhaus, Ratingen, Germany
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Hensvold AH, Joshua V, Li W, Larkin M, Qureshi F, Israelsson L, Padyukov L, Lundberg K, Defranoux N, Saevarsdottir S, Catrina AI. Serum RANKL levels associate with anti- citrullinated protein antibodies in early untreated rheumatoid arthritis and are modulated following methotrexate. Arthritis Res Ther 2015; 17:239. [PMID: 26337028 PMCID: PMC4559929 DOI: 10.1186/s13075-015-0760-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/18/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Receptor activator of nuclear factor kappa B ligand (RANKL) is a key regulator of bone metabolism. Anti-citrullinated protein antibodies (ACPA) have been suggested to cause bone destruction by osteoclast activation. We investigated the relationship between RANKL and ACPA in patients with early untreated rheumatoid arthritis (RA). METHODS Patients with newly diagnosed untreated RA (n = 183) were analyzed at baseline and 3 months after initiating methotrexate (MTX) treatment. Serum RANKL (total RANKL), ACPA (anti-CCP2) and ACPA specificities (anti-citrullinated (cit)-vimentin, anti-cit-enolase and anti-cit-fibrinogen) were determined by enzyme-linked immunosorbent assay (ELISA). Synovial RANKL expression was evaluated by immunohistochemistry in a small group of patients (n = 15). The relationship between anti-cit-vim antibodies and bone destruction was further validated in 1116 RA patients included in the EIRA cohort. Pearson's chi-square test, Wilcoxon rank sum test, Wilcoxon signed rank test and linear regression models were used. RESULTS Serum RANKL concentration was significantly higher (p <0.05) in ACPA-positive (median: 689 pmol/L, IQR 342-1253) compared with ACPA-negative (median: 159 pmol/L, IQR 96-243) patients and this difference was also seen for synovial RANKL expression. Serum RANKL associated with ACPA (p <0.05) and bone erosions in rheumatoid factor (RF)-negative patients (n = 59). Among ACPA specificites, anti-cit-vimentin (amino acids 60-75) was associated with higher RANKL concentration and higher prevalence of bone erosion (p <0.05). Significant reductions in both serum RANKL and ACPA levels were observed after 3 months of MTX treatment (p <0.05). CONCLUSIONS RANKL was elevated in ACPA-positive and in anti-cit-vimentin-positive patients with early untreated RA and associated with bone erosions. These findings give further support for an early direct pathogenic link between ACPA and bone destruction in RA.
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Affiliation(s)
- Aase Haj Hensvold
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden.
| | - Vijay Joshua
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden.
| | - Wanying Li
- Crescendo Bioscience, 341 Oyster Point Boulevard, South San Francisco, CA, 94080, USA.
| | - Michaela Larkin
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden.
| | - Ferhan Qureshi
- Crescendo Bioscience, 341 Oyster Point Boulevard, South San Francisco, CA, 94080, USA.
| | - Lena Israelsson
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden.
| | - Leonid Padyukov
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden.
| | - Karin Lundberg
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden.
| | - Nadine Defranoux
- Crescendo Bioscience, 341 Oyster Point Boulevard, South San Francisco, CA, 94080, USA.
| | - Saedis Saevarsdottir
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden. .,Institute of Environmental Medicine, Karolinska Institutet, Solnavägen 1, 171 77, Stockholm, Sweden.
| | - Anca Irinel Catrina
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, L8:04 CMM, 171 76, Stockholm, Sweden.
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de Thurah A, Nørgaard M, Stengaard-Pedersen K. Methotrexate utilization in Rheumatoid arthritis. A register-based cohort-study of treatment re-starts after gabs of at least 90 days. SPRINGERPLUS 2015; 4:227. [PMID: 26110100 PMCID: PMC4474972 DOI: 10.1186/s40064-015-0975-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/10/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To examine restart of MTX treatment among patients with rheumatoid arthritis (RA) who discontinues treatment, and investigate predictors of restart. METHODS A cohort study was conducted based on data from medical databases. MTX drug discontinuation was defined as a gap ≥ 90 days from the expiration of one MTX prescription to the redemption of a new one. Kaplan Meier estimates were used to compute the cumulative probability of restarting MTX treatment and Cox proportional hazard to estimate the hazard of return to treatment. A case-crossover analysis compared the frequency of events that could potentially have a transient effect on MTX restart. RESULTS Among 788 patients, who started MTX, 299 patients experienced a gap ≥ 90 days. Within 1.4 years 50 % of these patients returned to treatment, and a total of 66 % restarted treatment during follow-up. Concurrent treatment with corticosteroid and disease-modifying antirheumatic drugs (DMARDs) tended to be negatively associated with MTX restart (OR: 0.7(95 % CI: 0.5-1.2) and (OR: 0.7 (95 % CI: 0.4-1.0)). Older patients were less inclined to restart treatment than middle-aged patients (Adjustet HR 0.7 (0.4-1.2)). Patients with a CRP > 300 nmol/L less often restarted MTX than patients with a CRP < 75 nmol/L (adjHR: 0.6 (95 % CI 0.3-1.2)), and men were more inclined to MTX restart than women (adjHR 1.30 (95 % CI 0.9-2.0)). CONCLUSION It is important to support patients in remaining continuous users of MTX. A large proportion of RA patients who discontinued MTX later restarted treatment, but especially patients with high disease activity, old age or co-morbidity were less inclined to restart treatment.
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Affiliation(s)
- Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, Denmark ; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Institute of Clinical Medicine, University Hospital, Aarhus, Denmark
| | - Kristian Stengaard-Pedersen
- Department of Rheumatology, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, Denmark ; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Singh JA, Noorbaloochi S, Thorne C, Hazlewood GS, Suarez-Almazor ME, Tanjong Ghogomu E, Wells GA, Tugwell P. Subcutaneous or intramuscular methotrexate for rheumatoid arthritis. Hippokratia 2015. [DOI: 10.1002/14651858.cd011730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical Center; Department of Medicine; Faculty Office Tower 805B 510 20th Street South Birmingham AL USA 35294
| | - Shahrzad Noorbaloochi
- Minneapolis VA Medical Center and University of Minnesota; Department of Medicine; One Veterans Drive Minneapolis MN USA 55417
| | - Carter Thorne
- Southlake Regional Health Centre; 43 Lundy's Lane Newmarket ON Canada L3Y 3R7
| | - Glen S Hazlewood
- University of Toronto; Department of Health, Policy, Management and Evaluation; 60 Murray St., Suite 2-029 Toronto ON Canada M5T 3L9
| | - Maria E Suarez-Almazor
- The University of Texas, M.D. Anderson Cancer Center; Department of General Internal Medicine; 1515 Holcombe Blvd Unit 1465 Houston TX USA 77030
| | - Elizabeth Tanjong Ghogomu
- University of Ottawa; Bruyère Research Institute; 43 Bruyère St Annex E, room 302 Ottawa ON Canada K1N 5C8
| | - George A Wells
- University of Ottawa; Department of Epidemiology and Community Medicine; Room H1281 40 Ruskin Street Ottawa ON Canada K1Y 4W7
| | - Peter Tugwell
- Faculty of Medicine, University of Ottawa; Department of Medicine; Ottawa ON Canada K1H 8M5
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Tillu G, Chopra A, Sarmukaddam S, Tharyan P. Ayurveda interventions for rheumatoid arthritis. Hippokratia 2015. [DOI: 10.1002/14651858.cd011569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Girish Tillu
- Savitribai Phule University of Pune; Interdisciplinary School of Health Sciences; Pune Maharatra India 411007
| | - Arvind Chopra
- Centre for Rheumatic Diseases, Pune; No 11, Hermes Elegante, 1988, Convent Street, Camp, Pune Pune Maharashtra India 411001
| | - Sanjeev Sarmukaddam
- Centre for Rheumatic Diseases, Pune; No 11, Hermes Elegante, 1988, Convent Street, Camp, Pune Pune Maharashtra India 411001
| | - Prathap Tharyan
- Christian Medical College; South Asian Cochrane Network & Center, Prof. BV Moses Center for Evidence-Informed Health Care and Health Policy; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
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Abstract
BACKGROUND Rituximab is a selective, B-cell depleting, biologic agent for treating refractory rheumatoid arthritis (RA). It is a chimeric monoclonal antibody targeted against CD 20 that is promoted as therapy for patients who fail to respond to other biologics. There is evidence to suggest that rituximab is effective and well tolerated when used in combination with methotrexate for RA. OBJECTIVES To evaluate the benefits and harms of rituximab for the treatment of RA. SEARCH METHODS We conducted a search (until January 2014) in electronic databases (The Cochrane Library, MEDLINE, EMBASE, CINAHL, Web of Science), clinical trials registries, and websites of regulatory agencies. Reference lists from comprehensive reviews were also screened. SELECTION CRITERIA All controlled trials comparing treatment with rituximab as monotherapy or in combination with any disease modifying anti-rheumatic drug (DMARD) (traditional or biologic) versus placebo or other DMARD (traditional or biologic) in adult patients with active RA. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias and abstracted data from each study. MAIN RESULTS We included eight studies with 2720 patients. For six studies selection bias could not be evaluated and two studies were considered to have low risk of bias. The level of evidence ranged from low to high, but was rated as moderate for most outcomes. We have prioritised reporting of rituximab (two 1000 mg doses) in combination with methotrexate since this is the approved dose and most commonly used combination. We also reported data on other combinations and doses as supplementary information in the results section of the review.American College of Rheumatology (ACR) 50 response rates were statistically significantly improved with rituximab (two 1000 mg doses) in combination with methotrexate compared with methotrexate alone at 24 to 104 weeks. The RR for achieving an ACR 50 at 24 weeks was 3.3 (95% CI 2.3 to 4.6); 29% of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate achieved the ACR 50 compared to 9% of controls. The absolute treatment benefit (ATB) was 21% (95% CI 16% to 25%) with a number needed to treat (NNT) of 6 (95% CI 4 to 9).At 52 weeks, the RR for achieving clinical remission (Disease Activity Score (DAS) 28 joints < 2.6) with rituximab (two 1000 mg doses) in combination with methotrexate compared with methotrexate monotherapy was 2.4 (95% CI 1.7 to 3.5); 22% of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate achieved clinical remission compared to 11% of controls. The ATB was 11% (95% CI 2% to 20%) with a NNT of 7 (95% CI 4 to 13).At 24 weeks, the RR for achieving a clinically meaningful improvement (CMI) in the Health Assessment Questionnaire (HAQ) (> 0.22) for patients receiving rituximab combined with methotrexate compared to patients on methotrexate alone was 1.6 (95% CI 1.2 to 2.1). The ATB was 24% (95% CI 12% to 36%) with an NNT of 5 (95% CI 3 to 13). At 104 weeks, the RR for achieving a CMI in HAQ (> 0.22) was 1.4 (95% CI 1.3 to 1.6). The ATB was 24% (95% CI 16% to 31%) with a NNT of 5 (95% CI 3 to 7).At 24 weeks, the RR for preventing radiographic progression in patients receiving rituximab (two 1000 mg doses) in combination with methotrexate was 1.2 (95% CI 1.0 to 1.4) compared to methotrexate alone; 70% of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate had no radiographic progression compared to 59% of controls. The ATB was 11% (95% CI 2% to 19%) and the NNT was 10 (95% CI 5 to 57). Similar benefits were observed at 52 to 56 weeks and 104 weeks.Statistically significantly more patients achieved a CMI on the physical and mental components of the quality of life, measured by the Short Form (SF)-36, in the rituximab (two 1000 mg doses) in combination with methotrexate-treated group compared with methotrexate alone at 24 to 52 weeks (RR 2.0, 95% CI 1.1 to 3.4; NNT 4, 95% CI 3 to 8 and RR 1.4, 95% CI 1.1 to 1.9; NNT 8, 95% CI 5 to 19, respectively); 34 and 13 more patients out of 100 showed an improvement in the physical component of the quality of life measure compared to methotrexate alone (95% CI 5% to 84%; 95% CI 7% to 8%, respectively).There was no evidence of a statistically significant difference in the rates of withdrawals because of adverse events or for other reasons (that is, withdrawal of consent, violation, administrative, failure to return) in either group. However, statistically significantly more people receiving the control drug withdrew from the study compared to those receiving rituximab (two 1000 mg doses) in combination with methotrexate at all times (RR 0.40, 95% CI 0.32 to 0.50; RR 0.61, 95% CI 0.40 to 0.91; RR 0.48, 95% CI 0.28 to 0.82; RR 0.58, 95% CI 0.45 to 0.75, respectively). At 104 weeks, 37% withdrew from the control group and 20% withdrew from the rituximab (two 1000 mg doses) in combination with methotrexate group. The absolute risk difference (ARD) was -20% (95% CI -34% to -5%) with a number needed to harm (NNH) of 7 (95% CI 5 to 11).A greater proportion of patients receiving rituximab (two 1000 mg doses) in combination with methotrexate developed adverse events after their first infusion compared to those receiving methotrexate monotherapy and placebo infusions (RR 1.6, 95% CI 1.3 to 1.9); 26% of those taking rituximab plus methotrexate reported more events associated with their first infusion compared to 16% of those on the control regimen with an ARD of 9% (95% CI 5% to 13%) and a NNH of 11 (95% CI 21 to 8). However, no statistically significant differences were noted in the rates of serious adverse events. AUTHORS' CONCLUSIONS Evidence from eight studies suggests that rituximab (two 1000 mg doses) in combination with methotrexate is significantly more efficacious than methotrexate alone for improving the symptoms of RA and preventing disease progression.
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Affiliation(s)
- Maria Angeles Lopez‐Olivo
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | | | - Lynda McGahan
- L. McGahan Consulting33 Meadowlands Dr.OttawaONCanadaK2G 2R3
| | - Eduardo N Pollono
- University of South FloridaDepartment of Cardiovascular Sciences2 Tampa General Circle, 5rd FloorTampaFloridaUSA33606
| | - Maria E Suarez‐Almazor
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
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Ruiz Garcia V, Jobanputra P, Burls A, Cabello JB, Vela Casasempere P, Bort-Marti S, Kynaston-Pearson FJB. Certolizumab pegol (CDP870) for rheumatoid arthritis in adults. Cochrane Database Syst Rev 2014:CD007649. [PMID: 25231904 DOI: 10.1002/14651858.cd007649.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tumour necrosis factor (TNF)-alpha inhibitors are beneficial for the treatment of rheumatoid arthritis (RA) in terms of reducing the risk of joint damage, improving physical function and improving quality of life. This Cochrane review is an update of a review of the treatment of RA with certolizumab pegol that was first published in 2011. OBJECTIVES To assess the clinical benefits and harms of certolizumab pegol (CDP870) in patients with RA who have not responded well to conventional disease-modifying anti-rheumatic drugs (DMARDs). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 5), MEDLINE, EMBASE, Scopus, TOXLINE, Web of Knowledge; websites of the US Food and Drug Administration (FDA) and European Medicines Evaluation Agency (EMEA); reference lists of articles; and searched http/clinicaltrials.gov. The searches were updated from 2009 (date of last search for the original review) to 5 June 2014. SELECTION CRITERIA Randomised controlled trials that compared certolizumab pegol with any other agent including placebo or methotrexate (MTX) in adult patients with active RA despite current or prior treatment with conventional disease-modifying anti-rheumatic drugs (DMARDs), such as MTX. DATA COLLECTION AND ANALYSIS Two authors independently assessed search results, trial quality and extracted data. Disagreements were resolved by discussion or referral to a third author. MAIN RESULTS Eleven trials were included in this update. Ten (4324 patients) were included in the pooled analysis for benefits, five more than previously, and 10 (3711 patients) in the pooled analysis for harms, four more trials (1930 patients) than previously. The duration of follow-up varied from 12 to 52 weeks and the range of doses of certolizumab pegol varied from 50 to 400 mg given subcutaneously (sc). In phase III trials, the control was placebo plus MTX in five trials and placebo in four trials. The risk of bias of the included studies was assessed as low but there may have been a risk of attrition bias.Statistically significant improvements were observed at 24 weeks with the approved dose of 200 mg certolizumab pegol every other week, in 1) American College of Rheumatology (ACR) 50% improvement: 27% absolute improvement (95% CI 20% to 33%), NNT of 4 (95% CI 3 to 8), risk ratio (RR) 3.80 (95% CI 2.42 to 5.95); 2) the Health Assessment Questionnaire (HAQ): -12% absolute improvement (95% CI -9% to -14%), NNT of 6 (95% CI 5 to 8), mean difference (MD) - 0.35 (95% CI -0.43 to -0.26) (scale 0 to 3); 3) Disease Activity Score (DAS) remission improvement: absolute improvement 11% (95% CI 8% to 15%), NNT of 9 (95% CI 4 to 20), RR 8.47 (95% CI 4.15-17.28); and 4) radiological changes: erosion score (ES) absolute improvement -0.29% (95% CI -0.42% to -0.17%), NNT of 6 (95% CI 4 to 10), MD -0.67 (95% CI -0.96 to -0.38) (scale 0 to 230). Serious adverse events were statistically significantly more frequent for certolizumab pegol (200 mg every other week) with an absolute rate difference of 4% (95% CI 2% to 6%), NNTH of 32 (95% CI 17 to 88), Peto odds ratio (OR) 1.77 (95% CI 1.27 to 2.46). There was a statistically significant increase in all withdrawals in the placebo groups (for all doses and all follow-ups) with an absolute rate difference of -34% (95% CI -18% to -50%), NNTH of 4 (95% CI 3 to 5), NNTH of 4 (95% CI 3 to 5), RR 0.42 (95% CI 0.36 to 0.50); and there was a statistically significant increase in all withdrawals due to adverse events in the certolizumab groups (for all doses and all follow-up) with an absolute rate difference of 2% (95% CI 1% to 3%), NNTH of 55 (95% CI 27 to 238), Peto OR 1.66 (95% CI 1.15 to 2.37).The risk of bias was low and the quality of evidence was downgraded to moderate because of high rates of dropouts (> 20%) in most of the trials. We did not find any problems with inconsistency, indirectness, imprecision or publication bias. AUTHORS' CONCLUSIONS The results and conclusions did not change from the previous review. There is moderate-level evidence from randomised controlled trials that certolizumab pegol alone or combined with methotrexate is beneficial in the treatment of RA. Adverse events were more frequent with active treatment. We found a potential risk of serious adverse events.
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Affiliation(s)
- Vicente Ruiz Garcia
- Unidad de Hospitalización a Domicilio Torre C planta 1 Despacho nº 5 & CASP Spain, Hospital Universitari i Politècnic La Fe, Avinguda de Fernando Abril Martorell nº 106, Valencia, Valencia, Spain, 46026
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