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Ibrahim F, Lorente-Cánovas B, Doré CJ, Bosworth A, Ma MH, Galloway JB, Cope AP, Pande I, Walker D, Scott DL. Optimizing treatment with tumour necrosis factor inhibitors in rheumatoid arthritis-a proof of principle and exploratory trial: is dose tapering practical in good responders? Rheumatology (Oxford) 2017; 56:2004-2014. [PMID: 28968858 PMCID: PMC5722050 DOI: 10.1093/rheumatology/kex315] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Indexed: 02/06/2023] Open
Abstract
Objectives RA patients receiving TNF inhibitors (TNFi) usually maintain their initial doses. The aim of the Optimizing Treatment with Tumour Necrosis Factor Inhibitors in Rheumatoid Arthritis trial was to evaluate whether tapering TNFi doses causes loss of clinical response. Methods We enrolled RA patients receiving etanercept or adalimumab and a DMARD with DAS28 under 3.2 for over 3 months. Initially (months 0–6) patients were randomized to control (constant TNFi) or two experimental groups (tapering TNFi by 33 or 66%). Subsequently (months 6–12) control subjects were randomized to taper TNFi by 33 or 66%. Disease flares (DAS28 increasing ⩾0.6 with at least one additional swollen joint) were the primary outcome. Results Two hundred and forty-four patients were screened, 103 randomized and 97 treated. In months 0–6 there were 8/50 (16%) flares in controls, 3/26 (12%) with 33% tapering and 6/21 (29%) with 66% tapering. Multivariate Cox analysis showed time to flare was unchanged with 33% tapering but was reduced with 66% tapering compared with controls (adjusted hazard ratio 2.81, 95% CI: 0.99, 7.94; P = 0.051). Analysing all tapered patients after controls were re-randomized (months 6–12) showed differences between groups: there were 6/48 (13%) flares with 33% tapering and 14/39 (36%) with 66% tapering. Multivariate Cox analysis showed 66% tapering reduced time to flare (adjusted hazard ratio 3.47, 95% CI: 1.26, 9.58; P = 0.016). Conclusion Tapering TNFi by 33% has no impact on disease flares and appears practical in patients in sustained remission and low disease activity states. Trail registration EudraCT, https://www.clinicaltrialsregister.eu, 2010-020738-24; ISRCTN registry, https://www.isrctn.com, 28955701
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Affiliation(s)
- Fowzia Ibrahim
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London
| | - Beatriz Lorente-Cánovas
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London
| | | | - Margaret H Ma
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London
| | - James B Galloway
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London
| | - Andrew P Cope
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London
| | - Ira Pande
- Rheumatology Department, Nottingham University Hospitals NHS Trust, Nottingham
| | - David Walker
- Musculoskeletal Services, Freeman Hospital, Newcastle, UK
| | - David L Scott
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London
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Safety of weekly adalimumab in the treatment of juvenile idiopathic arthritis and pediatric chronic uveitis. Clin Rheumatol 2017; 37:549-553. [DOI: 10.1007/s10067-017-3890-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/17/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
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Lamers-Karnebeek FB, Luime JJ, Ten Cate DF, Teerenstra S, Swen NWAA, Gerards AH, Hendrikx J, van Rooyen EM, Voorneman R, Haagsma C, Basoski N, de Jager M, Ghiti Moghadam M, Efde MN, Goekoop-Ruiterman YPM, van Riel PLCM, Jacobs JWG, Jansen TL. Limited value for ultrasonography in predicting flare in rheumatoid arthritis patients with low disease activity stopping TNF inhibitors. Rheumatology (Oxford) 2017; 56:1560-1565. [PMID: 28595367 DOI: 10.1093/rheumatology/kex184] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Indexed: 11/12/2022] Open
Abstract
Objective Ultrasonography (US) can be used for treatment decisions in RA patients. This study investigated the added value of US to clinical variables in predicting flare in RA patients with longstanding low disease activity when stopping TNF inhibitors (TNFi). Methods Cox models with and without using US added to clinical variables were developed in the Potential Optimization of Expediency of TNFi-UltraSonography study. RA patients (n = 259), using >1 year TNFi and csDMARD with DAS28 < 3.2 for 6 months prior to inclusion, were followed for 52 weeks after stopping TNFi. The added value of US was assessed in two ways: first, by the extent to which individual predictions for flare at 52 weeks with and without US differed; and second, by comparing how US information improved the prediction to classify patients at 52 weeks in the low risk (<33% flare), intermediate risk (33-50%) and high risk (50-100%) groups. Results Although US was predictive of flare at group level (multivariate hazard ratio = 1.7; 95% CI: 1.1, 2.5), individual predictions for flare at 52 weeks with and without US differed little (median difference 3.7%; interquartile range: -7.8 to 6.5%). With US, 15.9% of patients were designated low risk; without US, 14.6%. In fact, 12.0% of patients were US-classified as low risk with/without knowing US. Conclusion In RA patients with longstanding low disease activity, at time of stopping TNFi, US is a predictor for flare at group level, but at the patient level, US has limited added value when common clinical parameters are used already, though the predictive value of clinical predictors is modest as well.
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Affiliation(s)
| | - Jolanda J Luime
- Department of Rheumatology, Erasmus Medical Center, Rotterdam
| | | | - Steven Teerenstra
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, Nijmegen
| | | | - Andreas H Gerards
- Department of Rheumatology, Franciscus Gasthuis & Vlietland, Schiedam
| | - Jos Hendrikx
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen
| | - Emma M van Rooyen
- Department of Rheumatology, Radboud University Medical Center, Nijmegen
| | | | - Cees Haagsma
- Department of Rheumatology and Clinical Immunology, Ziekenhuisgroep Twente, Almelo
| | | | - Mike de Jager
- Department of Rheumatology, Albert Schweitzer Hospital, Dordrecht
| | - Marjan Ghiti Moghadam
- Department of Rheumatology, Arthritis Center Twente MST & University of Twente, Enschede
| | - Monique N Efde
- Department of Rheumatology, Viecuri Medicall Center, Venlo
| | | | - Piet L C M van Riel
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen
| | - Johannes W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim L Jansen
- Department of Rheumatology, Viecuri Medicall Center, Venlo
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Long-Term Effectiveness of Adalimumab in Patients with Rheumatoid Arthritis: An Observational Analysis from the Corrona Rheumatoid Arthritis Registry. Rheumatol Ther 2017; 4:375-389. [PMID: 28840531 PMCID: PMC5696289 DOI: 10.1007/s40744-017-0077-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Current recommendations for the management of rheumatoid arthritis (RA) focus on a treat-to-target approach with the objective of maximizing long-term health-related quality-of-life in patients with RA. Published studies from randomized clinical trials have reported limited data regarding the long-term efficacy and safety of adalimumab in patients with RA. This study aims to evaluate the long-term (10+ years) persistency and effectiveness of adalimumab in patients with RA in a real-world setting. METHODS Included in this study were biologic-naïve adults with RA initiating adalimumab during follow-up enrolled in the Corrona RA registry. More than 10 years of data on persistency of adalimumab and rheumatologist-supplied reasons for discontinuation were examined. Among patients who persisted on adalimumab over the years, clinical [e.g., clinical disease activity index scores (CDAI), physician global assessment, tender joint count, and swollen joint count] and patient-reported outcomes (PRO), such as physical function, pain, fatigue, and morning stiffness, were examined. RESULTS Of 1791 biologic-naive patients treated with adalimumab who had ≥1 follow-up registry visit, 64.1% were still on therapy at 1 year and 10.2% were still on therapy by the end of year 12. Among patients who persisted on adalimumab for at least 1 year (77.1% female, mean age 53.9 years), 67.0% were in low disease activity (LDA)/remission (CDAI ≤10) and had clinically meaningful improvements from baseline in all clinical assessments and PROs. Initial improvements in LDA/remission and in clinical and PRO assessments observed at year 1 were sustained in those patients who remained on adalimumab over 10 years of follow-up. Among patients who discontinued adalimumab, 61.6% were not in LDA/remission and 41.9% switched to another biologic within 12 months after discontinuing adalimumab. CONCLUSIONS Real-world data demonstrate a sustained effectiveness of adalimumab in the treatment of RA for patients who remained on therapy for 10 years. FUNDING Corrona, LLC and AbbVie.
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KUIJPER TMARTIJN, BUISMAN LEANDERR, HAZES JOHANNAM, WEEL ANGELIQUEE. Cost-effectiveness of Biological Disease-modifying Antirheumatic Drugs for the Treatment of Rheumatoid Arthritis: Implications for Clinical Practice. J Rheumatol 2017; 44:965-967. [DOI: 10.3899/jrheum.170334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Bouman CA, van Herwaarden N, van den Hoogen FH, Fransen J, van Vollenhoven RF, Bijlsma JW, Maas AVD, den Broeder AA. Long-term outcomes after disease activity-guided dose reduction of TNF inhibition in rheumatoid arthritis: 3-year data of the DRESS study - a randomised controlled pragmatic non-inferiority strategy trial. Ann Rheum Dis 2017; 76:1716-1722. [PMID: 28606961 DOI: 10.1136/annrheumdis-2017-211169] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/18/2017] [Accepted: 05/18/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Tumour necrosis factor inhibitors (TNFi) are effective in rheumatoid arthritis (RA), but disadvantages include adverse events (AEs) and high costs. This can be improved by disease activity-guided dose reduction (DR). We aimed to assess long-term outcomes of TNFi DR in RA by using 3-year data from the DRESS study (Dose REduction Strategy of Subcutaneous TNF inhibitors study). METHODS In the intervention phase (month 0-18) of the DRESS study (Dutch trial register, NTR 3216), patients were randomised to DR or usual care (UC). In the extension phase (month 18-36), treatment strategies in both groups converged to continuation of protocolised tight control and allowed dose optimisation. Intention-to-treat analyses were done on flare, disease activity (28 joint count-based disease activity score with C reactive protein (DAS28-CRP)), functioning (health assessment questionnaire-disability index (HAQ-DI)), quality of life (Euroqol 5 dimensions 5 levels questionnaire (EQ5D-5L)), medication use, radiographic progression (Sharp van der Heijde score (SvdH)) and AE. RESULTS 172/180 patients included in the DRESS study were included in the extension phase. Cumulative incidences of major flare were 10% and 12% (-2%, 95% CI -8 to 15) in DR and UC groups in the extension phase, and 17% and 14% (3%, 95% CI -9 to 13) from 0 to 36 months. Cumulative incidences of short-lived flares were 43% (33 to 52%)%) and 35% (23 to 49%)%) in DR and UC groups in the extension phase, and 83% (75 to 90%)%) and 44% (31 to 58%)%) from 0 to 36 months. Mean DAS28-CRP, HAQ-DI, EQ5D-5L and SvdH remained stable and not significantly different between groups. TNFi use remained low in the DR group and decreased in the UC group. Cumulative incidences of AE were not significantly different between groups. CONCLUSIONS Safety and efficacy of disease activity guided TNFi DR in RA are maintained up to 3 years, with a large reduction in TNFi use, but no other benefits. Implementation of DR would vastly improve the cost-effective use of TNFi.
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Affiliation(s)
- Chantal Am Bouman
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | - Frank Hj van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Rheumatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jaap Fransen
- Department of Rheumatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ronald F van Vollenhoven
- Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Rheumatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Johannes Wj Bijlsma
- Department of Rheumatology & Clinical Immunology, Utrecht University Medical Centre, Utrecht, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Rheumatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Schmitz EMH, Benoy-De Keuster S, Meier AJL, Scharnhorst V, Traksel RAM, Broeren MAC, Derijks LJJ. Therapeutic drug monitoring (TDM) as a tool in the switch from infliximab innovator to biosimilar in rheumatic patients: results of a 12-month observational prospective cohort study. Clin Rheumatol 2017; 36:2129-2134. [PMID: 28593609 DOI: 10.1007/s10067-017-3686-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/10/2017] [Accepted: 05/15/2017] [Indexed: 12/14/2022]
Abstract
The objective of this study is to apply therapeutic drug monitoring (TDM) as an objective tool to monitor the switch from infliximab innovator (INX) to infliximab biosimilar (INB) in our diverse rheumatic cohort in daily clinical practice. All rheumatic patients on INX treatment (Remicade®) and ≥18 years were switched to INB (Inflectra®) as part of routine care, but in a controlled setting. Patients were monitored by taking blood samples just before the first infusion of INB (T1), and after the second (T2), fourth (T3), and seventh (T4) infusion of INB. T4 reflects the patients' status after ∼12 months. Infliximab trough levels, antibodies-to-infliximab (ATI), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and validated disease activity scores (if possible) were measured. Our population consisted of 27 patients with seven different rheumatic diseases who had received INX for 143 (58-161) months (median (IQR)). Half of the patients (52%) received concomitant immunosuppressives. We found widely varying infliximab levels, with only 56% within the proposed therapeutic range of 1-5 μg/mL. One patient had very high ATI levels (>880 au/mL), and two had low ATI levels (≤30 au/mL). After switching to INB, seven patients (26%) discontinued the therapy, partially due to subjective reasons. No difference in infliximab levels, CRP levels, and disease activity scores was found between the four time points (p ≥ 0.2460). In conclusion, no pharmacokinetic or clinical differences were found between INX and INB in our diverse rheumatic cohort. TDM is a helpful tool to monitor patients switching from INX to INB.
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Affiliation(s)
- E M H Schmitz
- Clinical Laboratory, Máxima Medical Center, Veldhoven, the Netherlands.,Expert Center Clinical Chemistry, Eindhoven, the Netherlands.,Clinical Laboratory, Catharina Hospital, Eindhoven, the Netherlands.,Laboratory of Chemical Biology and Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - S Benoy-De Keuster
- Department of Rheumatology, Máxima Medical Center, Eindhoven and Veldhoven, the Netherlands
| | - A J L Meier
- Department of Rheumatology, Máxima Medical Center, Eindhoven and Veldhoven, the Netherlands
| | - V Scharnhorst
- Expert Center Clinical Chemistry, Eindhoven, the Netherlands.,Clinical Laboratory, Catharina Hospital, Eindhoven, the Netherlands.,Laboratory of Chemical Biology and Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - R A M Traksel
- Department of Rheumatology, Máxima Medical Center, Eindhoven and Veldhoven, the Netherlands
| | - M A C Broeren
- Clinical Laboratory, Máxima Medical Center, Veldhoven, the Netherlands.,Expert Center Clinical Chemistry, Eindhoven, the Netherlands
| | - L J J Derijks
- Clinical Pharmacy, Máxima Medical Center, P.O. Box 7777, 5500 MB, Veldhoven, The Netherlands.
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Pelzek AJ, Grönwall C, Rosenthal P, Greenberg JD, McGeachy M, Moreland L, Rigby WFC, Silverman GJ. Persistence of Disease-Associated Anti-Citrullinated Protein Antibody-Expressing Memory B Cells in Rheumatoid Arthritis in Clinical Remission. Arthritis Rheumatol 2017; 69:1176-1186. [PMID: 28118534 DOI: 10.1002/art.40053] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 01/17/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE In rheumatoid arthritis (RA), autoreactive B cells are pathogenic drivers and sources of anti-citrullinated protein antibodies (ACPAs) that are a diagnostic biomarker and predictor of worse long-term prognosis. Yet, the immunobiologic significance of persistent ACPA production at the cellular level is poorly understood. This study was undertaken to investigate the representation of ACPA-expressing switched-memory B cells in RA. METHODS In a cross-sectional study of RA patients, we investigated the presence of continued defects in immune homeostasis as a function of disease activity. Using an enzyme-linked immunosorbent assay (ELISA) and a sensitive multiplex bead-based immunoassay, we characterized fine binding antibody specificities in sera, synovial fluid (SF), and B cell culture supernatants. In this manner, we determined the frequency and epitope reactivity patterns of ACPAs produced by SF B cells and switched-memory blood B cells and compared the latter to serum ACPA levels and disease activity scores. RESULTS Cultured B cells from SF were shown to spontaneously secrete ACPAs, while constitutive IgG autoantibody production by peripheral blood mononuclear cells (PBMCs) was substantially less frequent. After in vitro stimulation, PBMCs secreted IgG ACPA that was overwhelmingly from switched-memory B cells, across all patient groups treated with methotrexate and/or a tumor necrosis factor inhibitor. Intriguingly, the frequencies of ACPA-expressing switched-memory B cells significantly correlated with serum IgG anti-cyclic citrullinated peptide 3 (r = 0.57, P = 0.003). Moreover, treatment-induced clinical remission had little or no effect on the circulating burden of switched-memory ACPA-expressing B cells, in part explaining the continued dysregulation of humoral immunity. CONCLUSION Our findings rationalize why therapeutic cessation most often results in disease reactivation and clinical flare. Hence, a clinical disease activity score is not a reliable indicator of the resolution of pathologic recirculating B cell autoimmunity.
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Affiliation(s)
- Adam J Pelzek
- New York University School of Medicine, New York, New York
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Mallick A, Fautrel B, Sagez F, Sordet C, Javier RM, Petit H, Chatelus E, Rahal N, Gottenberg JE, Sibilia J. Stratégies d’arrêt ou de réduction des biomédicaments dans la polyarthrite rhumatoïde en rémission. Rev Med Interne 2017; 38:256-263. [DOI: 10.1016/j.revmed.2016.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/21/2016] [Indexed: 11/17/2022]
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bDMARD Dose Reduction in Rheumatoid Arthritis: A Narrative Review with Systematic Literature Search. Rheumatol Ther 2017; 4:1-24. [PMID: 28255897 PMCID: PMC5443724 DOI: 10.1007/s40744-017-0055-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Indexed: 12/20/2022] Open
Abstract
Introduction Although bDMARDs are effective in the treatment of RA, they are associated with dose-dependent side effects, patient burden, and high costs. Recently, many studies have investigated the possibility of discontinuing or tapering bDMARDs when patients have reached their treatment goal. The aim of this review is to provide a narrative overview of the existing evidence on bDMARD dose reduction and to provide answers to specific dose-reduction-related questions that are of interest to clinicians. Methods We systematically searched for relevant studies in four scientific databases. Furthermore, we screened the references of reviews and relevant studies. Results Our searches resulted in 45 original studies of bDMARD dose reduction in RA patients (15 RCTs and 30 observational studies). Current evidence shows that bDMARD dose reduction can be considered in all RA patients who achieve stable (e.g., ≥6 months) low disease activity or remission. The best strategies seem to be disease-activity-guided dose optimization and fixed dose reduction, since direct bDMARD discontinuation (without restarting) results in a high flare rate, worse physical functioning, and more joint damage. When tapering the bDMARD treatment of a patient, disease activity should be monitored closely, and if a flare occurs, the dose should be increased to the lowest effective dose. Current evidence shows that restarting bDMARD treatment is effective and safe. Unfortunately, no clear predictors of successful dose reduction have been identified so far. Conclusion The current evidence and rising healthcare costs urge that dose reduction should be considered for eligible patients. However, the decision to start dose reduction should be made in shared decision-making. Future research should focus not only on a better understanding of the effects of dose reduction on clinical outcomes but also on the perspectives of patients and physicians as well as the implementation of this new treatment principle. Electronic supplementary material The online version of this article (doi:10.1007/s40744-017-0055-5) contains supplementary material, which is available to authorized users.
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Bouman CAM, van der Maas A, van Herwaarden N, Sasso EH, van den Hoogen FHJ, den Broeder AA. A multi-biomarker score measuring disease activity in rheumatoid arthritis patients tapering adalimumab or etanercept: predictive value for clinical and radiographic outcomes. Rheumatology (Oxford) 2017; 56:973-980. [DOI: 10.1093/rheumatology/kex003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Indexed: 11/13/2022] Open
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Yasuda S, Ohmura K, Kanazawa H, Kurita T, Kon Y, Ishii T, Fujieda Y, Jodo S, Tanimura K, Minami M, Izumiyama T, Matsumoto T, Amasaki Y, Suzuki Y, Kasahara H, Yamauchi N, Kato M, Kamishima T, Tsutsumi A, Takemori H, Koike T, Atsumi T. Maintenance treatment using abatacept with dose reduction after achievement of low disease activity in patients with rheumatoid arthritis (MATADOR) – A prospective, multicenter, single arm pilot clinical trial. Mod Rheumatol 2017; 27:930-937. [DOI: 10.1080/14397595.2017.1286714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Shinsuke Yasuda
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazumasa Ohmura
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Kanazawa
- Department of Rheumatology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Takashi Kurita
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yujiro Kon
- Department of Internal Medicine, Takikawa Municipal Hospital, Takikawa, Japan
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuichiro Fujieda
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
| | - Satoshi Jodo
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
| | | | - Michio Minami
- Department of Rheumatology and Orthopaedic Surgery, Hokkaido Orthopaedic Memorial Hospital, Sapporo, Japan
| | | | - Takumi Matsumoto
- Division of Rheumatology, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | | | | | | | | | - Masaru Kato
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | | | - Akito Tsutsumi
- Department of Internal Medicine, Takikawa Municipal Hospital, Takikawa, Japan
| | - Hiromitsu Takemori
- Department of Rheumatology, Aomori Prefectural Central Hospital, Aomori, Japan
| | | | - Tatsuya Atsumi
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Lenert A, Lenert P. Tapering biologics in rheumatoid arthritis: a pragmatic approach for clinical practice. Clin Rheumatol 2016; 36:1-8. [PMID: 27896522 DOI: 10.1007/s10067-016-3490-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
Abstract
Optimal rheumatoid arthritis (RA) therapy in daily clinical practice is based on the treat-to-target strategy. Quicker escalation of therapy and earlier introduction of biological disease-modifying anti-rheumatic drugs have led to improved outcomes in RA. However, chronic immunosuppressive therapy is associated with adverse events and higher costs. In addition, our patients frequently express a desire for lower dosing and drug holidays. Current clinical practice guidelines from the American College of Rheumatology and European League Against Rheumatism suggest that rheumatologists consider tapering treatment after achieving remission. However, the optimal approach for tapering therapy in RA, specifically de-escalation of biologics, remains unknown. This clinical review discusses biologic tapering strategies in RA. We draw our recommendations for everyday clinical practice from the most recent observational, pragmatic, and controlled clinical trials on de-escalation of biologics in RA. For each biologic, we highlight clinically relevant outcomes, such as flare rates, recapture of the disease control with retreatment, radiographic progression, side effects, and functional impact. We discuss the use of musculoskeletal ultrasound to select patients for successful tapering. In conclusion, we provide the reader with a practical guide for tapering biologics in the rheumatology clinic.
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Affiliation(s)
- Aleksander Lenert
- Division of Rheumatology, Department of Internal Medicine, University of Kentucky, Kentucky Clinic J507, 740 South Limestone St, Lexington, KY, 40536, USA.
| | - Petar Lenert
- Division of Immunology, Department of Internal Medicine, The University of Iowa, C428-2GH, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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Safety and efficacy of etanercept and adalimumab in children aged 2 to 4 years with juvenile idiopathic arthritis. Clin Rheumatol 2016; 35:2925-2931. [PMID: 27709443 DOI: 10.1007/s10067-016-3439-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 09/24/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
The TNF inhibitors etanercept (ETA) and adalimumab (ADA) are approved for treating patients older than 2 years with polyarticular juvenile idiopathic arthritis (JIA). Because long-term experience of treating children younger than 4 years is limited, we evaluated the efficacy and safety of ETA or ADA in patients aged 2-4 years. This prospective, long-term, observational registry study documented baseline demographics, clinical characteristics, disease activity parameters, and safety of patients treated with ETA or ADA. Efficacy was determined using the JADAS-10, the JADAS criteria for minimal disease activity (MDA) and remission, and the PedACR response criteria after 3, 6, 12, 18, and 24 months. Between January 2001 and March 2015, 85 patients with polyarticular JIA aged 2-4 years started anti-TNF-α treatment. Seventy-four (54 girls) patients were treated with ETA and 11 (7 girls) with ADA. After 6/12/24 months of treatment, JADAS-MDA was reached by 55/58/58 % of ETA patients and 50/71/66 % of ADA patients. Furthermore, JADAS-Remission was achieved by 35/44/50 % of ETA patients and 16/28/66 % of ADA patients. PedACR 50/70/90 response was achieved by 64/54/41 % of ETA patients and 56/33/22 % of ADA patients at the last treatment observation. Discontinuation because of remission or inefficacy was recorded in 24 (29 %) and 28 (33 %) patients, respectively. Seventy-nine adverse events and four serious adverse events were reported. Administration of ETA and ADA in JIA patients younger than 4 years was efficacious, well tolerated, and safe. Patients younger than 4 years may show marked improvement following anti-TNF-alpha therapy.
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El Miedany Y, El Gaafary M, Youssef S, Ahmed I, Bahlas S, Hegazi M, Nasr A. Optimizing therapy in inflammatory arthritis: prediction of relapse after tapering or stopping treatment for rheumatoid arthritis patients achieving clinical and radiological remission. Clin Rheumatol 2016; 35:2915-2923. [DOI: 10.1007/s10067-016-3413-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/10/2016] [Accepted: 09/10/2016] [Indexed: 12/22/2022]
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Rintelen B, Zwerina J, Herold M, Singer F, Hitzelhammer J, Halder W, Eichbauer-Sturm G, Puchner R, Stetter M, Leeb BF. Validity of data collected in BIOREG, the Austrian register for biological treatment in rheumatology: current practice of bDMARD therapy in rheumatoid arthritis in Austria. BMC Musculoskelet Disord 2016; 17:358. [PMID: 27550175 PMCID: PMC4994324 DOI: 10.1186/s12891-016-1207-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 08/05/2016] [Indexed: 12/19/2022] Open
Abstract
Background The purpose of the present study was to check the validity of data collected in BIOREG, the Austrian register for biological treatment in rheumatology, and to elucidate eventual differences with respect to disease activity (DA) in patients with rheumatoid arthritis (RA) on established biological DMARDs (bDMARDs) before inclusion into the register (EST) and beginners at the time point of inclusion (NEW) after 1 year of treatment. Methods RA patients with a complete follow-up of 1 year in BIOREG were divided into EST and NEW and compared with respect to DA, remission rates, concomitant synthetic DMARDs (csDMARDs) and glucocorticoid therapy (GC) at baseline and after 1-year follow-up. Safety concerns are listed. Descriptive statistics are applied. Results For 346 RA patients (284 EST, 62 NEW) out of 970 RA patients included into BIOREG, a full data set for a 1-year follow-up was available. No differences in DA were observed after 1 year as expressed by DAS28 or RADAI-5, and small differences as expressed by remission rates according to DAS28, RADAI-5 or Boolean criteria (namely approximately 1/2, 1/3 to 1/4 and 1/4 to 1/5 of the patients respectively). Sixty-four adverse events (AEs) were noted in 56 (20 %) of EST and 20 in 19 (31 %) of NEW patients. Malignancy occurred in four patients. After 1 year, 48 % of EST patients but only 16 % of NEW patients were on bDMARD monotherapy. Conclusion Regarding DA, the date collected in BIOREG appeared to be valid. After 1 year of bDMARD therapy, all patients, whether EST or NEW, achieved a similar level of DA. AEs occurred more frequently during the early phase of bDMARD treatment. Austrian rheumatologists initiate bDMARD therapy in patients with lower disease levels than in other European countries, leading to high remission rates.
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Affiliation(s)
- Bernhard Rintelen
- Lower Austrian State Hospital Stockerau, 2nd Department for internal medicine, Lower Austrian Center for Rheumatology, Landstrasse 18, Stockerau, 2000, Austria. .,Karl Landsteiner Institute for Clinical Rheumatology, Landstrasse 18, Stockerau, 2000, Austria.
| | - Jochen Zwerina
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital Vienna, Heinrich-Collinstrasse 30, Vienna, 1140, Austria
| | - Manfred Herold
- Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Franz Singer
- BIOREG, Schloßhoferstrasse 4/4/12, Vienna, 1221, Austria
| | - Johann Hitzelhammer
- Health Center Vienna Mariahilf, Wiener Gebietskrankenkasse, Mariahilfer Strasse 85-87, Vienna, 1060, Austria
| | | | | | - Rudolf Puchner
- Office based rheumatologist, Freiung 19, Wels, 4070, Austria
| | - Miriam Stetter
- Department for Internal Medicine, Lower Austrian State Hospital Amstetten, Krankenhausstrasse 21, Amstetten, 3300, Austria
| | - Burkhard F Leeb
- Lower Austrian State Hospital Stockerau, 2nd Department for internal medicine, Lower Austrian Center for Rheumatology, Landstrasse 18, Stockerau, 2000, Austria.,Karl Landsteiner Institute for Clinical Rheumatology, Landstrasse 18, Stockerau, 2000, Austria.,Medical University of Graz, Auenbruggerplatz 2, Graz, 8010, Austria
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Galvao TF, Zimmermann IR, da Mota LMH, Silva MT, Pereira MG. Withdrawal of biologic agents in rheumatoid arthritis: a systematic review and meta-analysis. Clin Rheumatol 2016; 35:1659-68. [DOI: 10.1007/s10067-016-3285-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/14/2016] [Accepted: 04/16/2016] [Indexed: 12/11/2022]
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Relative expression and correlation of tumor necrosis factor-α, interferon-γ, and interleukin-17 in the rheumatoid synovium. Clin Rheumatol 2016; 35:1691-7. [DOI: 10.1007/s10067-016-3249-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 03/23/2016] [Accepted: 03/26/2016] [Indexed: 01/15/2023]
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Chan CKY, Holroyd CR, Mason A, Zarroug J, Edwards CJ. Are there dangers in biologic dose reduction strategies? Autoimmun Rev 2016; 15:742-6. [PMID: 26970488 DOI: 10.1016/j.autrev.2016.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 12/25/2022]
Abstract
Biologic dose reduction strategies, for patients with inflammatory rheumatic diseases, have been assessed in multiple studies to assess outcomes compared to ongoing maintenance dosing. Whilst cessation in established disease usually leads to disease flare, dose tapering approaches for those achieving low disease activity often appear to be successful in the short term. However, tapering can be associated with a higher risk of losing disease control and rates of recapture of disease control using the original biologic dose vary between studies. Over relatively short periods of follow-up, a number of studies have shown no statistical difference in radiographic progression in patients tapering or discontinuing biologics. However, a Cochrane review found that radiographic and functional outcomes may be worse after TNF inhibitor discontinuation, and over long-term disease follow-up flares have been associated with radiographic progression and worse patient reported outcomes. To date, no studies of biological therapy dose reduction have specifically investigated the risk of increased immunogenicity or the effects on cardiovascular risk and other co-morbidities, although these remain important potential risks. In addition, whether there are greater dangers in certain dose reduction approaches such as a reduction in dose at the same frequency or a spacing of doses is not established.
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Affiliation(s)
| | | | - Alice Mason
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jalaa Zarroug
- MSK Research Unit, NIHR Wellcome Trust Clinical Research Facility, University of Southampton, UK
| | - Christopher J Edwards
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; MSK Research Unit, NIHR Wellcome Trust Clinical Research Facility, University of Southampton, UK.
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