2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

Integrating different perspectives to define a concept of comprehensive remission in rheumatoid arthritis: The SUMAR project

INTRODUCTION AND OBJECTIVES

The SUMAR project aimed to establish a consensus on the concept of remission in patients with rheumatoid arthritis (RA) that takes into account the different perspectives of patients, health care professionals and health care managers.

MATERIALS AND METHODS

The scientific committee comprised a rheumatologist who acted as a national coordinator, 4 rheumatologists, 1 primary care physician, 1 nurse, 2 hospital pharmacists, 2 health care managers and 1 member of a patient advocacy group. The study was undertaken from 2020 to 2021 in three phases: (1) analysis of several perspectives on remission in RA with the participation of 275 patients, 160 rheumatologists and 31 health care managers; (2) an integrative definition of remission, which included two multidisciplinary workshops with 11 and 12 participants; and (3) extension and dissemination with up to 200 participants in 7 regional multidisciplinary meetings.

RESULTS

The concept of remission in the different settings and by the different stakeholders was heterogeneous. It was agreed that, in addition to inflammatory activity, remission should include pain and functionality as well as the duration of remission. For the participants, the definition of remission varied depending on the clinical scenario, without or with structural damage, seeking to "normalize" the outcomes in the former and avoid progression in the latter. The implementation of the concept of comprehensive remission was considered less feasible, and the main barriers to implementation were the lack of time for consultation and the variability in information technology systems across the different autonomous communities.

DISCUSSION AND CONCLUSIONS

This definition of remission is not only based on the concept of the presence or absence of inflammatory activity based on existing indexes, but also includes variables directly reported by the patient that are related to their health and quality of life.

Impact of obesity on clinical outcomes and treatment continuation in rheumatoid arthritis patients receiving non-TNF-targeted therapies

Background

Recent studies have shown the impact of obesity on achieving low disease activity or remission in rheumatoid arthritis (RA) patients treated with tumor necrosis factor inhibitors. However, there is limited research on the effects of obesity on clinical responses to non-TNF-targeted treatments.

Objectives

This study investigated the influence of body mass index (BMI) on clinical response to non-TNF-targeted treatments in RA patients.

Design

We used data from the KOrean nationwide BIOlogics & targeted therapy (KOBIO) registry, a multicenter, prospective, observational cohort that included RA patients in South Korea.

Methods

Patients who received at least one prescription for non-TNF-targeted treatments, including abatacept, tocilizumab, and Janus kinase inhibitors, were included. They were categorized into three BMI groups: under 25 kg/m2 (434 patients), between 25 and 30 kg/m2 (146 patients), and over 30 kg/m2 (22 patients). After 1 year of treatment, treatment continuation rates and clinical responses among these BMI groups were compared. Time on treatment for each category was analyzed using Kaplan-Meier curves and Cox regression, adjusting for confounders.

Results

The 1-year continuation rate of the targeted treatment was significantly lower in the obese group (81.8%) compared to the normal BMI (93.8%) and overweight (89.0%) groups (p = 0.033). Disease Activity Score of 28 joints-erythrocyte sedimentation rate score improvement was less in the obese group (2.06 ± 2.14) than in the normal BMI group (2.76 ± 1.55) (p = 0.045). Multivariable Cox proportional hazard analysis showed a higher discontinuation rate in the obese group (hazard ratio: 3.407, 95% confidence interval: 1.157-10.211; p = 0.029).

Conclusion

Higher BMI in RA patients was associated with poorer clinical response and higher discontinuation rates for non-TNF-targeted treatments.

Therapeutic potential of antibody-drug conjugates possessing bifunctional anti-inflammatory action in the pathogenies of rheumatoid arthritis

In an age where there is a remarkable upsurge in developing precision medicines, antibody-drug conjugates (ADCs) have emerged as a progressive therapeutic strategy. ADCs typically consist of monoclonal antibodies (mAb) conjugated to the cytotoxic payloads by utilizing a linker, combining the benefits of definitive target specificity of mAbs and potent killing impact of payload to achieve precise and efficient elimination of target cells. In addition to their well-established role in oncology, ADCs are currently demonstrating encouraging potential in addressing the unmet requirements in the treatment of autoimmune conditions such as rheumatoid arthritis (RA). Prevalent long-term autoimmune disease RA costs billions of dollars annually but still, there is a lack of precision-targeted therapeutics with minimal side effects. This review provides an overview of the RA pathogenesis, pre-existing therapies, and their limitations, the introduction of ADCs in RA treatment, the mechanism of ADCs, and a summary of ADCs in preclinical and clinical trials. Based on the literature we also propose a strategy in ADC synthesis, which may increase the efficiency in targeting multifactorial diseases like RA. We propose to utilize DMARDs (Disease-modifying anti-rheumatic drugs), the first-line treatment for RA, as a payload for ADC synthesis. DMARDs are the only class of medication that limits the disease progression, but their efficacy is limited due to off-target toxicities. Hence, utilizing them as payload will help to deliver them directly at the targeted site, reducing their off-target toxicity, which in turn will increase their efficiency in targeting disease. Also, as mAbs are not sufficient to achieve remission, they are given in combinations with DMARDs. Hence, synthesizing ADCs may reduce the multiple and higher dosages given to patients, which in turn may enhance patient compliance.

2024 update of the recommendations of the French Society of Rheumatology for the diagnosis and management of patients with rheumatoid arthritis

The French Society of Rheumatology recommendations for managing rheumatoid arthritis (RA) has been updated by a working group of 21 rheumatology experts, 4 young rheumatologists and 2 patient association representatives on the basis of the 2023 version of the European Alliance of Associations for Rheumatology (EULAR) recommendations and systematic literature reviews. Two additional topics were addressed: people at risk of RA development and RA-related interstitial lung disease (RA-ILD). Four general principles and 19 recommendations were issued. The general principles emphasize the importance of a shared decision between the rheumatologist and patient and the need for comprehensive management, both drug and non-drug, for people with RA or at risk of RA development. In terms of diagnosis, the recommendations stress the importance of clinical arthritis and in its absence, the risk factors for progression to RA. In terms of treatment, the recommendations incorporate recent data on the cardiovascular and neoplastic risk profile of Janus kinase inhibitors. With regard to RA-ILD, the recommendations highlight the importance of clinical screening and the need for high-resolution CT scan in the presence of pulmonary symptoms. RA-ILD management requires collaboration between rheumatologists and pulmonologists. The treatment strategy is based on controlling disease activity with methotrexate or targeted therapies (mainly abatacept or rituximab). The prescription for anti-fibrotic treatment should be discussed with a pulmonologist with expertise in RA-ILD.

Unraveling the Role of the Blood-Brain Barrier in the Pathophysiology of Depression: Recent Advances and Future Perspectives

Depression is a highly prevalent psychological disorder characterized by persistent dysphoria, psychomotor retardation, insomnia, anhedonia, suicidal ideation, and a remarkable decrease in overall well-being. Despite the prevalence of accessible antidepressant therapies, many individuals do not achieve substantial improvement. Understanding the multifactorial pathophysiology and the heterogeneous nature of the disorder could lead the way toward better outcomes. Recent findings have elucidated the substantial impact of compromised blood-brain barrier (BBB) integrity on the manifestation of depression. BBB functions as an indispensable defense mechanism, tightly overseeing the transport of molecules from the periphery to preserve the integrity of the brain parenchyma. The dysfunction of the BBB has been implicated in a multitude of neurological disorders, and its disruption and consequent brain alterations could potentially serve as important factors in the pathogenesis and progression of depression. In this review, we extensively examine the pathophysiological relevance of the BBB and delve into the specific modifications of its components that underlie the complexities of depression. A particular focus has been placed on examining the effects of peripheral inflammation on the BBB in depression and elucidating the intricate interactions between the gut, BBB, and brain. Furthermore, this review encompasses significant updates on the assessment of BBB integrity and permeability, providing a comprehensive overview of the topic. Finally, we outline the therapeutic relevance and strategies based on BBB in depression, including COVID-19-associated BBB disruption and neuropsychiatric implications. Understanding the comprehensive pathogenic cascade of depression is crucial for shaping the trajectory of future research endeavors.

Treatment of rheumatoid arthritis-associated interstitial lung disease: An appraisal of the 2023 ACR/CHEST guideline

Purpose of review

To summarize the current treatment landscape of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) in the context of the recent 2023 American College of Rheumatology/American College of Chest Physicians guideline for ILD treatment in systemic autoimmune rheumatic diseases.

Recent findings

The guideline conditionally recommends mycophenolate, azathioprine, and rituximab for first-line RA-ILD therapy, with cyclophosphamide and short-term glucocorticoids as additional options. For RA-ILD progression after first line, mycophenolate, rituximab, nintedanib, tocilizumab, cyclophosphamide, and pirfenidone are conditionally recommended, while long-term glucocorticoids are conditionally recommended against. Only three randomized controlled trials (RCTs) enrolled patients with RA-ILD (total n=217). All other recommendations for RA-ILD were based on RCTs for other diseases or observational data. Antifibrotics might be particularly effective for patients with RA-ILD and the usual interstitial pneumonia pattern (RA-UIP). There is uncertainty of the utility of azathioprine and glucocorticoids in RA-UIP since these medications had worse outcomes compared to placebo in an RCT of patients with idiopathic pulmonary fibrosis. RA-ILD treatment decisions should consider articular activity, ILD activity, comorbidities, and potential for infection.

Summary

We summarized the current treatment landscape for RA-ILD. Since only three RCTs included patients with RA-ILD, most guideline recommendations were conditional and based on low-quality evidence. This highlights the urgent need for additional high-quality RCT data for efficacy and safety of anti-inflammatory and antifibrotic medications for RA-ILD.

Tofacitinib Safety and Effectiveness in Canadian Patients with Rheumatoid Arthritis by Cardiovascular Risk Enrichment: Subanalysis of the CANTORAL Study

INTRODUCTION

ORAL Surveillance, a post-authorisation safety study of patients with rheumatoid arthritis (RA) enriched for cardiovascular (CV) risk, demonstrated increased risk of major adverse CV events (MACE) and malignancies (excluding non-melanoma skin cancer [NMSC]) for tofacitinib versus tumour necrosis factor inhibitors (TNFi). This analysis of a real-world Canadian observational study evaluated tofacitinib safety/effectiveness in patients meeting or not meeting CV risk criteria.

METHODS

CANTORAL included patients with moderate-to-severe RA initiating tofacitinib (10/2017-07/2020; N = 504). Interim data (data-cut: 07/2021) were stratified as CV risk-enriched (CV+ ; patients ≥ 50 years with ≥ 1 additional CV risk factor) or not CV risk-enriched (CV-; ≥ 50 years without additional CV risk factors and 18-49 years with/without CV risk factors). Safety and persistence were evaluated to month (M) 36. Effectiveness outcomes to M18 included Clinical Disease Activity Index (CDAI)-defined low disease activity (LDA)/remission (CANTORAL co-primary endpoints) and Disease Activity Score in 28 joints, C-reactive protein (DAS28-4[CRP]) < 3.2/ < 2.6.

RESULTS

Overall, 272/232 patients were included in CV+ /CV- cohorts (full analysis set) (435/356 patient-years [safety analysis set]). Incidence rates (events/100 patient-years) in CV+ /CV- cohorts were 138.5/112.5 for treatment-emergent adverse events (AEs); 17.0/5.6 for serious AEs; 1.2/0.3 for deaths; 5.5/1.7 for serious infections; 1.4/1.1 for herpes zoster; 1.6/0.0 for MACE; 2.1/0.3 for malignancies (excluding NMSC); 0.7/0.6 for NMSC; 0.5/0.0 for venous thromboembolic events. Persistence was generally comparable between cohorts. In CV+ /CV- cohorts, at M6, CDAI LDA and remission rates were 51.5%/54.6% and 12.0%/19.6%; DAS28-4(CRP) < 3.2/ < 2.6 rates were 44.0%/39.3% and 31.5%/28.8%, respectively; effectiveness was generally maintained to M18.

CONCLUSIONS

In concordance with studies of background risk, AEs were more common in patients with CV risk enrichment, particularly those aged ≥ 65 years. Tofacitinib effectiveness/persistence were generally similar regardless of CV risk enrichment. These findings support individualised treatment benefit-risk assessment, including CV assessment/management, to optimise RA outcomes.

Heart Failure in Rheumatoid Arthritis: Clinical Implications

PURPOSE OF REVIEW

This review focuses on the association between RA and heart failure, highlighting the role of inflammation and the prevalence of heart failure with preserved ejection fraction (HFpEF) in this population.

RECENT FINDINGS

The incidence of heart failure in RA patients is two to three times higher than in the general population, with inflammation playing a significant role independent of traditional cardiovascular risk factors. HFpEF accounts for about half of heart failure cases and is increasingly recognized in RA patients, although it remains underdiagnosed. Atypical presentations and non-specific symptoms further complicate diagnosis. Early control of inflammation has been shown to reduce the risk of heart failure development and progression, improving both morbidity and mortality outcomes. Rheumatoid arthritis (RA) is a systemic inflammatory disease affecting approximately 1% of the population, with cardiovascular disease being the leading cause of premature death in these patients.

A prospective randomized-controlled non-blinded comparative study of the JAK inhibitor (baricitinib) with TNF-α inhibitors and conventional DMARDs in a sample of Egyptian rheumatoid arthritis patients

To evaluate the efficacy of baricitinib compared to TNF-α Inhibitors and conventional DMARDs (cDMARDs) in patients with RA. Our study included 334 RA patients classified into 3 groups: the first receiving baricitinib, the second receiving TNF-α Inhibitors, and the third receiving cDMARDs. Patients were evaluated at baseline, week 12, and week 24 using TJC, SJC, VAS, DAS28, CDAI, and HAQ-DI. Larsen score was measured at baseline and 24 weeks. The response to therapy was assessed at weeks 12 and 24 using ACR 20, ACR 50, and ACR 70 response criteria. Emerging treatment side effects were monitored. Patients receiving baricitinib showed significant improvement regarding all outcome measures at weeks 12 and 24. In addition, baricitinib was comparable to TNF Inhibitors in all outcome measures except the ACR 70 at week 12, which was higher in the baricitinib group. Furthermore, baricitinib group showed significantly better outcome measures and response to therapy in comparison to cDMARDs group. The most common side effects in the baricitinib group were infection, GIT, and CVS complications. The most common side effects in the TNF inhibitors group were infection and skin complications. The cDMARDs had the least side effects, mostly GIT complications. Baricitinib is an effective drug for treating RA refractory to cDMARDs, improving disease activity measures and functional status and reducing the progression of structural joint damage. It has a comparable efficacy and safety profile to TNF Inhibitors. Multicenter studies are recommended to support our results. Key Points • Baricitinib is an effective therapeutic choice for rheumatoid arthritis refractory to cDMARDs. • Patients treated with baricitinib showed improvement in all outcome measures and functional status. • Bricitinib delayed the progression of radiographic joint damage more effectively than cDMARDs. • The efficacy and safety of baricitinib for treating rheumatoid arthritis is comparable to that of TNF inhibitors.

Rheumatoid arthritis: a review of the key clinical features and ongoing challenges of the disease

Rheumatoid arthritis (RA) is an autoimmune inflammatory condition that primarily affects the joints and periarticular soft tissue. The development of joint swelling is traditionally regarded as the starting point of the disease. Emerging evidence indicates that RA patients often experience a preclinical stage characterized by immunological and inflammatory changes before developing the disease. The review discusses ongoing efforts to predict the transition from this preclinical phase to clinical RA and describes studies aimed at preventing the onset of RA in individuals at risk. Over the past two decades, there have been significant advancements in RA management and outcomes. An increasing number of patients can now achieve disease remission, and in some cases, this remission persists without ongoing treatment, which is effectively a cure. As new therapies and evolving scientific evidence emerge, recommendations for RA management are continuously evolving. Despite these improvements in the management of RA, many patients still do not respond to multiple conventional or more advanced therapies, including biologic and targeted synthetic disease modifying anti-rheumatic drugs, or experience disease flares when treatments are tapered or discontinued. This situation underscores the need for reliable biomarkers to guide therapy more effectively, improve personalized treatment approaches and monitoring strategies (i.e. precision medicine). In conclusion, this review provides a comprehensive overview of RA, covering new research on the 'pre-clinical' phase of the disease, as well as its epidemiology, pathogenesis, clinical manifestations, diagnosis, imaging, and management strategies. It highlights key clinical aspects of RA and addresses ongoing challenges in disease management, particularly in the areas of prevention and treatment.

Management strategies in rheumatoid arthritis

Management of rheumatoid arthritis (RA) has evolved from simply the direct translation of drug efficacy results from clinical trials to patient care, to a more complex longitudinal process that considers not only drug efficacy but also the safety gestalt of a treatment and patient profiles and preferences, as well as health-economic factors. With numerous DMARDs available to treat RA, knowledge about trial efficacy becomes less important than data that inform an appropriate clinical strategy for their optimal selection and use. Overly ambitious approaches targeting the 'maximum' level of success could, for example, be prone to failure and create frustration, and lead to a large number of patients then being considered as 'difficult to treat'. Safety profiles might be more informative than efficacy profiles for precision medicine approaches. Contemporary RA management strategies might therefore take a more holistic approach, beyond merely efficacy, to the setting of targets that lead to improved compliance rather than aspirational successes, with consideration of each patient's multimorbidity profile and preferences, as well as the safety profile of each treatment. Ultimately, the goal remains unchanged: maximizing health-related quality of life; however, with a focus on optimal balance rather than superlatives.

A novel inhibitor of class IIa histone deacetylases attenuates collagen-induced arthritis

BACKGROUND AND PURPOSE

Most inhibitors of histone deacetylases (HDACs) are not selective and are cytotoxic. Some have anti-inflammatory activity in disease models, but cytotoxicity prevents long-term uses in non-fatal diseases. Inhibitors selective for class IIa HDACs are much less cytotoxic and may have applications in management of chronic inflammatory diseases.

EXPERIMENTAL APPROACH

LL87 is a novel HDAC inhibitor examined here for HDAC enzyme selectivity. It was also investigated in macrophages for cytotoxicity and for inhibition of lipopolysaccharide (LPS)-stimulated cytokine secretion. In a rat model of collagen-induced arthritis, LL87 was investigated for effects on joint inflammation in Dark Agouti rats. Histological, immunohistochemical, micro-computed tomography and molecular analyses characterise developing arthritis and anti-inflammatory efficacy.

KEY RESULTS

LL87 was significantly more inhibitory against class IIa than class I or IIb HDAC enzymes. In macrophages, LL87 was not cytotoxic and reduced both LPS-induced secretion of pro-inflammatory cytokines, and IL6-induced class IIa HDAC activity. In rats, LL87 attenuated paw swelling and clinical signs of arthritis, reducing collagen loss and histological damage in ankle joints. LL87 decreased immune cell infiltration, especially pro-inflammatory macrophages and osteoclasts, into synovial joints and significantly reduced expression of pro-inflammatory cytokines and tissue-degrading proteases.

CONCLUSION AND IMPLICATIONS

A novel inhibitor of class IIa HDACs has been shown to have an anti-inflammatory and anti-arthritic profile distinct from current therapies. It is efficacious in reducing macrophage infiltration and joint inflammation in a chronic model of rat arthritis.

Real-world clinical outcomes and rationale for initiating abatacept as a first-line biologic for patients with anticitrullinated protein antibody- and rheumatoid factor-positive rheumatoid arthritis

Aim: In rheumatoid arthritis (RA), seropositivity for both anticitrullinated protein antibody (ACPA) and rheumatoid factor (RF) is associated with disease severity and therapeutic response. Biologic (b) disease-modifying antirheumatic drugs (DMARDs) such as abatacept are recommended after inadequate response or contraindication to conventional synthetic DMARDs. This retrospective cohort study aimed to describe changes in Clinical Disease Activity Index (CDAI) measures over 12 months among patients with ACPA+ and RF+ RA with an inadequate response to methotrexate treated with abatacept as a first-line bDMARD. Patients & methods: Patient data were abstracted from medical records by treating rheumatologists. Analyses included McNemar tests for paired proportions or paired t-tests to assess longitudinal changes in CDAI scores, and Kaplan-Meier methods for time-to-event outcomes. Serious AEs and rationale for initiating treatment were recorded. Results: Overall, 296 patients were included. Mean CDAI scores improved (decreased) by 34.0, 61.0 and 74.0% (all p < 0.001) from baseline to 3-6 months, 6-12 months and ≥12 months after abatacept initiation, respectively. Of 279 patients not in CDAI low disease activity (LDA) or remission at baseline, 24.7% of patients achieved it within 6 months, 56.3% within 12 months and 71.0% at any point during follow-up after abatacept initiation. Median time to CDAI LDA/remission was 10.2 months. Serious AEs were reported in 2.4% of patients. Common reasons reported by rheumatologists for initiating abatacept were effectiveness/efficacy (52.7%), safety (31.4%) and patient preference (25.3%). Conclusion: In this analysis of patients with ACPA+ and RF+ RA treated with abatacept as a first-line bDMARD in a clinical practice setting, clinical outcomes and remission rates were improved at all time points, providing real-world evidence to further support the use of abatacept in this patient population.

Chinese guidelines for the diagnosis and treatment of rheumatoid arthritis: 2024 update

Rheumatoid arthritis (RA) is an autoimmune disease with destructive arthritis as its main clinical manifestation, which is a major cause of disability. It is very important to formulate and update a guideline for the diagnosis and treatment of RA that adhere to international guideline development standards and can be applied to clinical practice in China. This guideline is endorsed and developed by the National Clinical Research Center for Dermatologic and Immunologic Diseases, collaborated with Rheumatologists Branch of Chinese Medical Doctor Association, Rheumatology Rehabilitation Branch of Chinese Association of Rehabilitation Medicine, Rheumatology Branch of Chinese Research Hospital Association, and Rheumatology Branch of Beijing Association of Holistic Integrative Medicine, based on grading of recommendations assessment, development and evaluation (GRADE) and reporting items for practice guidelines in healthcare (RIGHT). Evidence-based recommendation were developed for 10 clinical scenario that are most relevant to Chinese rheumatologists, aiming to improve and standardize the diagnosis and treatment of RA in China, which may finally improve the quality of life and prognosis of patients.

Safety and Efficacy of Baricitinib, Upadacitinib, and Sarilumab Implementation in Moderately-to-Severely Active Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Current Evidence

This study aims to assess the efficacy and safety of newly approved Janus kinase (JAK) and interleukin-6 (IL-6) inhibitors in patients with moderately-to-severely active rheumatoid arthritis (RA) with inadequate response to or intolerance of conventional disease-modifying antirheumatic drugs. We conducted a systematic review and meta-analysis of all placebo-controlled randomized trials assessing baricitinib, sarilumab, and upadacitinib treatment in RA, published in PubMed and CENTRAL (Cochrane Central Register of Controlled Trials) databases up to October 2023. The study outcomes involved the American College of Rheumatology (ACR) 20%, 50%, and 70% responses, Health Assessment Questionnaire-Disability Index (HAQ-DI), Disease Activity Score in 28 joints (DAS28), serious adverse events, and adverse events leading to drug discontinuation. Twelve randomized controlled trials enrolling 5875 patients were selected for final analysis. Pooled analysis revealed that the implementation of baricitinib (RR = 1.77; 95% CI = 1.58-1.97; I2 = 21%), sarilumab (RR = 1.60; 95% CI = 1.33-1.93; I2 = 0%), and upadacitinib (RR = 1.99; 95% CI = 1.81-2.20; I2 = 15%) was associated with notable therapeutic improvement in RA patients as determined by the ACR20. Considering other efficacy outcomes (ACR50, ACR70, DAS28, HAQ-D), all tested interventions demonstrated a superiority to placebo. None of the tested treatment modalities incurred a higher risk of serious adverse events compared to placebo, yet drug discontinuation was more commonly encountered in baricitinib-treated patients. The newly approved JAK and IL-6 inhibitors, namely, baricitinib, upadacitinib, and sarilumab, seem to be effective in alleviating RA-induced clinical implications and thus improving quality of life. Nonetheless, safety issues could be a matter of concern in baricitinib use, while upadacitinib and sarilumab present an acceptable safety profile.

Fetal Growth Associated with Maternal Rheumatoid Arthritis and Juvenile Idiopathic Arthritis

Introduction: Patients with rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) are at a twice-higher risk of developing adverse pregnancy outcomes, such as preterm births and infants with a low birth weight. We aimed to evaluate fetal growth among patients with and without rheumatoid arthritis and juvenile idiopathic arthritis (RA and JIA). Materials and Methods: We conducted a population-based cohort study in Denmark from 2008-2018, which included 503,491 singleton pregnancies. Among them, 2206 were pregnancies of patients with RA and JIA. We linked several nationwide databases and clinical registries in Denmark to achieve our aim. First, we used the International Classification of Diseases-10 codes to identify pregnant patients with RA and JIA from the National Patient Registry. Next, we obtained fetal biometric measurements gathered from second-trimester fetal ultrasound scans and birthweights through the Fetal Medicine Database. Finally, we computed a fetal growth gradient between the second trimester and birth, using the mean difference in the Z-score distances for each fetal growth indicator. We also calculated the risk of small for gestational age (SGA). All outcomes were compared between pregnant individuals with and without RA and JIA, adjusted for confounders. Results: Maternal RA and JIA were not associated with a reduction in the estimated fetal weight (EFW) at 18 to 22 weeks of gestational age [adjusted mean EFW Z-score difference of 0.05 (95% CI 0.01, 0.10)]. We observed reduced mean Z-score differences in the weight gradient from the second trimester to birth among offspring of patients with RA and JIA who used corticosteroids [-0.26 (95% CI -0.11, -0.41)] or sulfasalazine [-0.61 (95% CI -0.45, -0.77)] during pregnancy. Maternal RA and JIA were also associated with SGA [aOR of 1.47 (95% CI 1.16, 1.83)] and the risk estimates were higher among corticosteroid [aOR 3.44 (95% CI 2.14, 5.25)] or sulfasalazine [(aOR 2.28 (95% CI 1.22, 3.88)] users. Conclusions: Among pregnant patients with RA and JIA, fetal growth restriction seemed to occur after 18 to 22 weeks of gestational age. The second half of pregnancy may be a vulnerable period for optimal fetal growth in this population.

Recent advances in nuclear medicine and their role in inflammatory arthritis: focus on the emerging role of FAPI PET/CT

Imaging molecular processes associated with inflammatory disease has been revolutionized by hybrid imaging using positron emission tomography/computed tomography (PET/CT). PET/CT visualizes metabolic activity as well as protein expression and provides a comprehensive whole-body evaluation. It has the potential to reveal inflammation prior to detection of structural changes in inflammatory joint diseases. FAP is a type II transmembrane glycoprotein overexpressed not only in the stroma of tumors but also in the fibrotic processes of certain immune-mediated disorders. The recent introduction of fibroblast activation protein inhibitors (FAPI) labeled by positron emitters and thus suitable for PET/CT allows to investigate FAP expression in vivo. This review will focus on the use of FAPI-PET/CT for the diagnosis and evaluation of treatment response in inflammatory joint diseases.

Efficacy and safety of integrated traditional Chinese and Western medicine for rheumatoid arthritis-interstitial lung disease: A systematic review and meta-analysis

Objective

To systematically evaluate the efficacy and safety of integrated traditional Chinese and Western medicine(TCM-WM) for the treatment of rheumatoid arthritis-associated interstitial lung disease (RA-ILD).

Materials and methods

An independent search of electronic databases (PubMed, Excerpta Medica Database, Cochrane Central Register of Controlled Trials, OVID Medline, China National Knowledge Infrastructure, WanFang Data, VIP Data databases, and China Biology Medicine disc) from inception to June 25, 2024 was performed to identify studies treating RA-ILD that used combined Chinese and Western medicine treatment compared to Western medicine. Two researchers independently audited each article, and the quality was assessed using the Cochrane Risk of Bias Assessment Tool 2 and the modified Jadad. Meta-analyses were performed using Review Manager 5.4 and Stata 16.0 software to analyze data. Sample certainty and conclusiveness of evidence were assessed using the Grading of Recommendations Assessment, Development, and Evaluation Profiler (GRADEPRO) and trial sequential analysis(TSA) 0.9.5.10 beta.

Results

Eighteen randomised controlled trials (RCT), including 1353 patients, were abstracted. Integrated traditional Chinese and Western medicine was significantly more effective than Western medicine in improving lung function in patients with rheumatoid arthritis-associated interstitial lung disease, including forced vital capacity (FVC) (Standardized Mean Difference (SMD) = 1.44, 95 % CI 0.93 to 1.95, P < 0.00001), diffusion capacity for carbon monoxide of the lung (DLCO) (SMD = 1.20, 95 % CI: 0.57 to 1.84, P = 0.0002), and total lung capacity (TLC) (SMD = 1.29, 95 % CI: 0.81 to 1.76, P < 0.00001). There were significant differences between the two groups in the reduced high-resolution Computed Tomography scores (Mean Difference(MD) = -1.92, 95 % CI: 2.73 to -1.10, P < 0.00001). Significantly reduced inflammatory markers, combined Chinese and Western medical treatments for RA-ILD were substantially better than Western treatments, including erythrocyte sedimentation rate(ESR) (MD = -7.89, 95 % CI: 12.40 to -3.39, P < 0.00001), C-reactive protein(CRP) (MD = -4.75, 95 % CI: 8.61 to -1.34, P = 0.006), rheumatoid factor(RF) (MD = -41.76, 95 % CI: 66.95 to -16.56, P = 0.001). Combination therapy improved clinical effectiveness (odds ratio (OR) = 3.69, 95 % CI: 2.68 to 5.07, P < 0.00001). Simultaneously, trial sequential analysis indicated that the results demonstrating the superiority of integrated traditional Chinese and Western medicine over Western medicine alone in the treatment of rheumatoid arthritis-associated interstitial lung disease are robust.

Conclusion

Current evidence shows that combined traditional Chinese medicine is effective and safe for rheumatoid arthritis-associated interstitial lung disease compared with Western medicine alone. The sample size for inclusion concerns may require the inclusion of more randomised trials in the future to validate our results.

Methotrexate inhibits glucocorticoids-induced osteoclastogenesis via activating IFN-γR/STAT1 pathway in the treatment of rheumatoid arthritis

OBJECTIVES

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterised by the synovitis and bone erosion. The combination therapy of glucocorticoids (GCs) and methotrexate (MTX) is recommended in early RA management, although the precise underlying mechanism of action remains unclear. This study is aimed to clarify the mechanism of MTX in combined with GC in treating RA.

METHODS

GC-induced osteoporosis (GIOP) mouse model was used to investigate the bone-protective role of MTX. Lipopolysaccharide-induced arthritis mouse model was used to evaluate the anti-inflammatory effects of GCs and MTX. Functional role of MTX on osteoclastogenesis was assessed by trap staining and micro-computer tomography. Western blot, RT-qPCR and coimmunoprecipitation were used to explore the underlying mechanisms.

RESULTS

We demonstrate that GCs, but not MTX, rapidly inhibited synovitis in arthritis model. MTX treatment was observed to inhibit osteoclastogenesis induced by GC in vitro and mitigate bone loss attributed by GIOP. GCs were found to augment the interaction between the membrane GC receptor (mGR) and signal transducer and activator of transcription 1 (STAT1), leading to the suppression of IFN-γR/STAT1 signalling pathways. Interestingly, MTX was found to inhibit osteoclastogenesis induced by GCs through the enhancement of the A2AR and IFN-γR interaction, thereby activating the IFN-γR/STAT1 signalling cascade. Consequently, this process results in a reduction in the mGR and STAT1 interaction.

CONCLUSIONS

Our study provides compelling evidence that MTX can make GCs effectively to suppress synovitis and reduce bone loss induced by GCs. This sheds light on the potential mechanistic insights underlying the efficacy of GCs in conjunction with MTX for treating RA.

Remission versus low disease activity as treatment targets in rheumatoid arthritis: how to strike the right balance between too strict and too lenient targets? A meta-epidemiological study of individual patient data

OBJECTIVES

To evaluate the impact of using Simplified Disease Activity Index (SDAI)-LDA (low disease activity) versus different definitions of remission as a treatment target in established rheumatoid arthritis.

METHODS

A meta-epidemiological study of individual patient data from eight randomised controlled trials was performed. Four definitions of the target were considered at 6 months: (1) SDAI-LDA: SDAI≤11; (2) SDAI-Remission: SDAI≤3.3; (3) 4V-Remission: Tender and swollen 28-joint counts and C reactive protein (mg/dL) all ≤1 and patient global assessment (PGA)≤2 and (4) 3-variable (3V)-Remission: as 4V, excluding PGA. The mean radiographic change in the modified total Sharp-van der Heijde score (mTSS) and the Good Radiographic Outcome rates (defined as a change of ≤0.5 units mTSS) over 2 years were compared among target definitions. Radiographic progression and the distribution of the individual criteria of the Boolean definition in the only LDA subgroup (3.3

RESULTS

In total, 4374 patients (mean disease duration of 5.9 years (95% CI 4.6; 7.1)) were included. The pooled rate of SDAI-LDA at 6 months was 49%, with 13% in SDAI-remission. The 4V-Remission and 3V-Remission were achieved by 16% and 23%, respectively. Mean radiographic progression was 0.55 (0.14; 0.96) units for SDAI-LDA and 0.22 (-0.09; 0.54), 0.28 (-0.07; 0.62), 0.28 (-0.10; 0.65) for SDAI-Remission, 4V-Remission and 3V-Remission states, respectively. Patients with SDAI Pure-LDA presented significantly more radiographic progression than patients in SDAI-Remission (mean 0.72 vs 0.22 units, p<0.05). Over 53% of all patients achieving SDAI-LDA were not in 3V-Remission and had more mean radiographic progression over 2 years than those who met both targets (0.70 vs 0.25 units, p=0.014). Among patients with SDAI-LDA but not in SDAI-Remission, 40% scored PGA>2, reflecting relevant disease impact.

CONCLUSION

SDAI-LDA is associated with more structural damage over 2 years than any of the definitions of remission. It also allows substantial disease impact to go unchecked and uncontrolled. Physicians should strive for remission whenever possible and safe while also taking into account the different individual disease activity parameters included in the adopted definition.

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Key Words

• Outcome Assessment, Health Care
• Patient Reported Outcome Measures
• Rheumatoid Arthritis

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MESH Headings

• Humans
• Arthritis, Rheumatoid/drug therapy
• Remission Induction
• Antirheumatic Agents/therapeutic use
• Treatment Outcome
• Severity of Illness Index
• Disease Progression
• Randomized Controlled Trials as Topic
• Female
• Male
• Middle Aged

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Affiliation(s)

Catia Duarte Rheumatology, ULS de Coimbra EPE, Coimbra, Portugal Institute for Clinical and Biomedical Research, University of Coimbra, Coimbra, Portugal
Johannes W G Jacobs Rheumatology & Clinical Immunology, UMC, Utrecht, Netherlands
Ricardo J O Ferreira Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Higher School of Nursing of Lisbon, Lisboa, Portugal Higher School of Nursing of Coimbra Health Sciences Research Unit Nursing, Coimbra, Portugal
Paco M J Welsing Rheumatology & Clinical Immunology, UMC, Utrecht, Netherlands
Laure Gossec INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
Pedro M Machado Department of Neuromuscular Diseases, University College London, London, UK Centre for Rheumatology, University College London, London, UK
Désirée van der Heijde Rheumatology, Leiden University Medical Center, Leiden, Netherlands
Jose Antonio Pereira da Silva Rheumatology, ULS de Coimbra EPE, Coimbra, Portugal Institute for Clinical and Biomedical Research, University of Coimbra, Coimbra, Portugal

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Association between hydroxychloroquine use and risk of diabetes mellitus in systemic lupus erythematosus and rheumatoid arthritis: a UK Biobank-based study

Context/Objectives

Hydroxychoroquine has hypoglycemic effects and may reduce the risk of diabetes mellitus (DM). We determined the association between hydroxychoroquine use and the incidence of DM in a population-based cohort of pations with Rheumatic disease.

Methods

A prospective cohort study among 502392 Potentially eligible participants in the context of UK Biobank, recruitment to the database began between 2006 and 2010. Patients diagnosed with diabetes and fasting glucose greater than or equal to 7 mmol/L at baseline (n=619) were excluded and patients diagnosed with either RA or SLE at baseline (n=6793) were followed up until 2022. Diagnosis was recorded using the International Classification of Diseases, tenth edition (ICD-10) code. The mean follow-up was 13.78 years and the primary outcome was newly recorded type 2 diabetes mellitus (T2DM), with the time of onset of diabetes as the follow-up endpoint date.

Results

During a median follow-up period of 13.78 (12.93, 14.49) years, diabetes developed in 537 participants, with an incidence of 7.9%. New diabetes cases not taking hydroxychloroquine and taking hydroxychloroquine was 504 (8.03%) and 33 (6.36%), respectively. In univariate models, the hazard ratio for diabetes was 0.89 (95% confidence interval, 0.81-0.98, P=0.014) for hydroxychloroquine users compared with those not taking hydroxychloroquine. After adjusting for age, sex, race, education level, and BMI the hazard ratio for incident diabetes among hydroxychloroquine users was 0.88 (95% confidence interval, 0.80-0.97, P=0.008). In complete multivariate model hazard ratio for hydroxychloroquine was 0.87 (95% confidence interval, 0.79- 0.96, P=0.005).

Conclusion

Hydroxychloroquine was associated with decreased risk of DM among rheumatoid arthritis patients, our data taken together with correlational studies, warrant further investigation of the potential preventive effect of hydroxychloroquine against T2DM.

Current practice, trends and attitudes of rheumatologists towards glucocorticoids use for rheumatoid arthritis (GURANTEE): a national cross-sectional survey across China

INTRODUCTION

To investigate current practices, changes, and perceptions of rheumatologists regarding GC use in RA patients.

METHODS

A cross-sectional survey was conducted using a structured questionnaire between April and August 2023. Rheumatologists from 31 province-level regions of Mainland China were invited to participate. Chi-squared tests were adopted to investigate the differences by sociodemographic characteristics.

RESULTS

1,717 rheumatologists from 598 hospitals completed the survey with a response rate of 92%. Up to 60% of participants expressed currently infrequent initiation of GC co-therapy with csDMARDs (hardly ever 7.0%; occasionally 24.6%; sometimes 29.1%), accompanied by a decline of frequency over time reported in 64.2%. Regarding attitudes towards bridging therapy with GC, 604 (35.2%) participants supported this approach, 468 (27.3%) opposed it, and 645 (37.6%) remained inconclusive. Time to GC discontinuation in context of csDMARDs was commonly reported within 6 months in current practice which has been narrowed over time. Reasons for chronic GC use were mostly reported due to suboptimal disease control, followed by the need of RA complications, and pre-existing comorbidities. After failure of GC cessation, majority of respondents (84.4%) would escalate RA therapy (commonly by addition of JAK inhibitors, TNF inhibitors), which usually or often facilitated the GC cessation. The most frequently reported advantages and weaknesses of GC were rapid and strong efficacy, adverse events, respectively. Regarding long-term low-dose GC use for RA, the percentage of respondents who supported, opposed, or depended on the situation were 15.9%, 17.2%, and 66.9%, respectively.

CONCLUSIONS

The current data demonstrate that GC initiation for RA treatment is not as frequent as before and the awareness of GC discontinuation is growing in current practice. Attitudes towards GC co-therapy with csDMARDs vary considerably and long-term low-dose GC use remain situation dependent.

Clinical effectiveness of baricitinib and abatacept in patients with rheumatoid arthritis

AIM

The objective of this study was to compare the clinical effectiveness of baricitinib and abatacept in patients with rheumatoid arthritis (RA).

METHODS

This study included 274 patients treated with abatacept and 241 treated with baricitinib who were followed for >52 weeks. Potential treatment selection bias was addressed by using inverse probability of treatment weighting. The paired t-test was used to assess differences in Clinical Disease Activity Index (CDAI) score relative to baseline. A generalized estimating equation was used to compare the two treatment groups.

RESULTS

The estimated mean CDAI score was 18.2 at baseline and significantly decreased to 12.6 at 4 weeks, 8.9 at 12 weeks, 7.4 at 24 weeks, and 6.1 at 52 weeks in the abatacept group. The estimated mean CDAI score was 18.6 at baseline and significantly decreased to 9.5 at 4 weeks, 6.5 at 12 weeks, 5.7 at 24 weeks, and 5.5 at 52 weeks in the baricitinib group. The baricitinib group had significantly lower CDAI scores at 4, 12, and 24 weeks compared to the abatacept group. Subgroup analyses revealed that this difference was evident among patients with high disease activity and without concomitant use of methotrexate but was less pronounced among those with remission to moderate disease activity status with methotrexate use.

CONCLUSION

Both baricitinib and abatacept were effective in reducing disease activity in patients with RA. Baricitinib demonstrated potential advantages over abatacept in terms of early disease control, particularly in patients with high disease activity and without methotrexate use.

Trends in the use of biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis and recently diagnosed colorectal, lung, or prostate cancer

INTRODUCTION

Biologic disease-modifying antirheumatic drugs (bDMARD) are often discontinued when a patient with rheumatoid arthritis (RA) is diagnosed with cancer. Our aim was to determine trends in bDMARD utilization in patients with RA and recently diagnosed cancer.

METHOD

We examined two national claims databases to identify adults with RA and recently diagnosed colorectal, lung, or prostate cancer (Optum's de-identified Clinformatics® Data Mart Database 2008-2022, and Surveillance, Epidemiology, and End Results Program (SEER) Medicare-linked 2008-2017). We determined time trends in bDMARD and tumor necrosis factor inhibitor (TNFi) prescriptions during the first 3 years after cancer with Cochram-Armitage tests and multivariable logistic regression. Cancer cohorts were analyzed separately.

RESULTS

We included 3595 patients in all six cohorts (in Clinformatics® 503 with colorectal, 468 with lung, and 440 with prostate cancer; in SEER-Medicare 580 with colorectal, 1010 with lung, and 594 with prostate cancer). No significant increase was observed in bDMARD or TNFi utilization over time. Overall, use of bDMARD within the first 3 years of follow-up ranged from 16.7% (Clinformatics® lung cohort) to 29.7% (SEER-Medicare colorectal cohort). The major predictor of bDMARD utilization was prior use in the 3 months before cancer diagnosis (p < 0.001 for all cancers) and earlier cancer stage (p < 0.001 in colorectal and lung cancer and p = 0.05 in prostate cancer).

CONCLUSIONS

Use of bDMARD in patients with RA and recently diagnosed common cancers has not increased since 2008. Additional evidence on the safety of bDMARD in patients with early cancer is needed to ensure appropriate management of their RA. Key Points • Use of bDMARD and TNFi in patients with RA and early colorectal, lung, or prostate cancer has been stable since 2008, with no significant increases over time. • The major determinant of receiving bDMARD after cancer diagnosis was prior treatment with bDMARD in the prior 3 months before cancer. • Patients with advanced cancer stage and distant metastases were less likely to receive bDMARD and TNFi than those at early stages of disease.

Proactive therapeutic drug monitoring of biologic drugs in adult patients with inflammatory bowel disease, inflammatory arthritis, or psoriasis: a clinical practice guideline

CLINICAL QUESTION

In adult patients with inflammatory bowel disease, inflammatory arthritis (rheumatoid arthritis, spondyloarthritis, psoriatic arthritis), or psoriasis taking biologic drugs, does proactive therapeutic drug monitoring (TDM) improve outcomes as compared with standard care?

CONTEXT AND CURRENT PRACTICE

Standard care for immune mediated inflammatory diseases includes prescribing biologic drugs at pre-determined doses. Dosing may be adjusted reactively, for example with increased disease activity. In proactive TDM, serum drug levels and anti-drug antibodies are measured irrespective of disease activity, and the drug dosing is adjusted to achieve target serum drug levels, usually within pre-specified therapeutic ranges. The role of proactive TDM in clinical practice remains unclear, with conflicting guideline recommendations and emerging evidence from randomised controlled trials.

THE EVIDENCE

Linked systematic review and pairwise meta-analysis which identified 10 trials including 2383 participants. Inflammatory bowel disease, inflammatory arthritis, and psoriasis were grouped together as best current research evidence on proactive TDM did not suggest heterogeneity of effects on outcomes of interest. Proactive TDM of intravenous infliximab during maintenance treatment may increase the proportion of patients who experience sustained disease control or sustained remission without considerable additional harm. For adalimumab, it remains unclear if proactive TDM during maintenance treatment has an effect on sustained disease control or sustained remission. At induction (start) of treatment, proactive TDM of intravenous infliximab may have little or no effect on achieving remission. No eligible trial evidence was available for proactive TDM of adalimumab at induction (start) of treatment. No eligible trial evidence was available for proactive TDM of other biologic drugs in maintenance or at induction (start) of treatment.

RECOMMENDATIONS

The guideline panel issued the following recommendations for patients with inflammatory bowel disease, inflammatory arthritis, or psoriasis:1. A weak recommendation in favour of proactive TDM for intravenous infliximab during maintenance treatment2. A weak recommendation against proactive TDM for adalimumab and other biologic drugs during maintenance treatment3. A weak recommendation against proactive TDM for intravenous infliximab, adalimumab, and other biologic drugs during induction (start) of treatment.

UNDERSTANDING THE RECOMMENDATIONS

When considering proactive TDM, clinicians and patients should engage in shared decision making to ensure patients make choices that reflect their values and preferences. The availability of laboratory assays to implement proactive TDM should also be considered. Further research is warranted and may alter recommendations in the future.

HOW THIS GUIDELINE WAS CREATED

An international panel including patient partners, clinicians, and methodologists produced these recommendations based on a linked systematic review and pairwise meta-analysis which identified 10 trials including 2383 participants. The panel followed standards for trustworthy guidelines and used the GRADE approach, explicitly considering the balance of benefits and harms and burdens of treatment from an individual patient perspective.

Understanding Ultrasound Power Doppler Synovitis at Clinically Quiescent Joints and Thermographic Joint Inflammation Assessment in Patients with Rheumatoid Arthritis

Background/Objectives: Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory arthritis. We aim to study subclinical PD synovitis and thermographic joint inflammation assessment in patients with RA. Methods: We compared (1) PD synovitis at clinically quiescent (non-swollen; non-tender) joints based on patients' disease activity and (2) thermography (hands/wrists) outcomes based on PD joint inflammation findings and patient's disease activity. Results: Among eighty RA patients (mean (SD) age 57.0 (12.6) years; 61 of whom (76.3%) were female), the wrists (62.7%), second metacarpophalangeal joints (MCPJs) (37.0%), third MCPJs (33.8%), fourth MCPJs (24.8%), and fifth MCPJs (20.9%) were the five joint sites most frequently displaying subclinical PD synovitis; with no statistically significance differences (p > 0.05) between patients with 28-joint disease activity score (DAS28) < 3.2 versus those with DAS28 ≥ 3.2. At these five joint sites bilaterally, (1) the total maximum (Total Tmax), total average (Total Tavg), and total minimum (Total Tmin) temperatures were significantly greater (p < 0.05) for Total PD (TPD) score >1 versus TPD score ≤ 1, while their area under the ROC curve (AUC) values in identifying TPD score >1 ranged from 0.789 to 0.810, and (2) Total Tmax, Total Tavg, Total Tmin, and TPD score were significantly greater (p < 0.05) for patients with DAS28 ≥ 3.2 versus those with DAS28 < 3.2. Conclusions: Our results would serve as useful background data in studies on RA monitoring strategies detecting subclinical PD synovitis. Thermographic temperatures were greater in patients with greater disease activity and can help discriminate ultrasound PD joint inflammation severity.

Therapeutic Potential of Bee and Wasp Venom in Anti-Arthritic Treatment: A Review

Arthritis has a high global prevalence. During the early ancient human era, bee (Apis) venom therapy was employed in Egypt, Greece, and China to alleviate ailments such as arthritis and neuralgia. In addition, bee venom has long been used as a traditional medicine for immune-related diseases in Korea. Wasp (Vespa) venom is a folk medicine of the Jingpo people in Yunnan, China, and has been widely used to treat rheumatoid arthritis. In spite of this, the underlying mechanisms of bee and wasp venoms for the treatment of arthritis are yet to be fully understood. In recent years, researchers have investigated the potential anti-arthritic properties of bee and wasp venoms. Studies have shown that both bee and wasp venom can improve swelling, pain, and inflammation caused by arthritis. The difference is that bee venom reduces arthritis damage to bone and cartilage by inhibiting the IRAK2/TAK1/NF-κB signaling pathway, NF-κB signaling pathway, and JAK/STAT signaling pathway, as well as decreasing osteoclastogenesis by inhibiting the RANKL/RANK signaling pathway. Wasp venom, on the other hand, regulates synovial cell apoptosis via the Bax/Bcl-2 signaling pathway, inhibits the JAK/STAT signaling pathway to reduce inflammation production, and also ameliorates joint inflammation by regulating redox balance and iron death in synovial cells. This review provides a detailed overview of the various types of arthritis and their current therapeutic approaches; additionally, it comprehensively analyzes the therapeutic properties of bee venom, wasp venom, or venom components used as anti-arthritic drugs and explores their mechanisms of action in anti-arthritic therapy.

Consensus statement on the management of late-onset rheumatoid arthritis

OBJECTIVES

Late-onset rheumatoid arthritis (LORA), which has been increasing in recent years, lacks evidence for initial treatment. Japanese rheumatology experts recognized this gap and addressed it by developing consensus statements on the first clinical application of LORA.

METHODS

These statements were created following an introductory discussion about treatment fundamentals, which included a review of existing literature and cohort data. The steering committee created a draft, which was refined using a modified Delphi method that involved panel members reaching a consensus. The panel made decisions based on input from geriatric experts, clinical epidemiologists, guideline developers, patient groups, and the LORA Research Subcommittee of the Japan College of Rheumatology.

RESULTS

The consensus identified four established facts, three basic approaches, and six expert opinions for managing LORA. Methotrexate was recommended as the primary treatment, with molecular-targeted agents being considered if treatment goals cannot be achieved. An emphasis was placed on assessing the lives of older patients due to challenges in risk management and methotrexate accessibility caused by comorbidities or cognitive decline.

CONCLUSIONS

The experts substantiated and refined 13 statements for the initial treatment of LORA. To validate these claims, the next is to conduct a registry study focusing on new LORA cases.

What do we know about dietary perceptions and beliefs of patients with rheumatoid arthritis? A scoping review

Rheumatoid arthritis is a debilitating inflammatory condition which has a high disease burden. While there is emerging evidence that certain foods and diets could have anti-inflammatory properties and there are published 'anti-inflammatory' diets, there is very little understanding of patient beliefs and perceptions about the impact of diet on symptom management or attitudes to particular dietary interventions. This scoping review aims to summarize the existing literature around the beliefs that patients with rheumatoid arthritis hold regarding the impact of diet on disease activity and joint pain. It also examines the current state of evidence regarding the impact of specific dietary interventions on patient reported and objective parameters of RA disease activity. A search was conducted across seven databases for studies which included reporting on dietary beliefs related to disease management or investigations on the effect of particular diets on disease activity or joint pain. Articles were excluded if they examined extracted compounds or individual dietary supplements. Included studies were synthesized narratively. We retrieved 25,585 papers from which 68 were included in this review: 7 assessed dietary beliefs, 61 explored dietary interventions. The available literature on patient beliefs has been largely limited to quantitative studies with limited qualitative exploration. The Mediterranean, fasting and vegan diets appear to have the most benefit with regards to rheumatoid arthritis outcomes for patients. Research which examines RA patient's beliefs and attitudes about the impact of diet on their RA symptoms and disease is currently lacking.

Safety and Efficacy of Upadacitinib in Patients with Rheumatoid Arthritis Refractory to Biologic DMARDs: Results Through Week 216 from the SELECT-CHOICE Study

INTRODUCTION

The safety and efficacy of upadacitinib 15 mg (UPA15) through week 216 was evaluated in patients with rheumatoid arthritis (RA) from the long-term extension (LTE) of the phase 3 SELECT-CHOICE study.

METHODS

Patients with RA refractory to biologic disease-modifying antirheumatic drugs (bDMARDs) were randomized to UPA15 or abatacept (ABA) for 24 weeks. During the open-label LTE, patients on ABA switched to UPA15 at week 24, and those on UPA15 continued treatment. The safety and efficacy of continuous UPA15, and ABA to UPA15, are summarized through week 216.

RESULTS

The LTE was comprised of 91.4% (n = 277/303) of patients that initially received UPA15, and 89.6% (n = 277/309) that initially received ABA. Of patients on UPA15 in the LTE (n = 547), 28.3% (n = 155/547) discontinued the study drug by week 216. Relative to other adverse events of special interest, and largely consistent with previous findings at week 24, higher rates of serious infection, COVID-19, herpes zoster, and elevated creatine phosphokinase were reported, while rates of malignancy excluding nonmelanoma skin cancer (NMSC), NMSC, major adverse cardiovascular event (MACE), and venous thromboembolism (VTE) were low. Long-term safety data with UPA through week 216 aligned with previous observations and no new safety risks were identified, including in patients who switched from ABA to UPA15. Proportions of patients achieving 28-joint disease activity score based on C-reactive protein (DAS28[CRP]) < 2.6/ ≤ 3.2, clinical disease activity index (CDAI) and simple disease activity index (SDAI) low disease activity/remission, ≥ 20%/50%/70% improvement in the American College of Rheumatology (ACR20/50/70) response criteria, and Boolean remission were maintained or improved with UPA15 through week 216. Improvements in the Health Assessment Questionnaire-Disability Index (HAQ-DI), patient's assessment of pain, and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) were also maintained or improved with UPA15 through week 216. Across all efficacy endpoints, similar results were observed in patients who switched from ABA to UPA15 versus continuous UPA15. Patients with an inadequate response to ≥ 1 prior tumor necrosis factor (TNF) inhibitor (UPA15: n = 263/303, 86.8%; ABA to UPA15: n = 273/309, 88.3%) showed similar responses to the total population.

CONCLUSIONS

The long-term safety profile of UPA was consistent with previous findings and the broader RA clinical program. Compared to the primary analyses at week 24, efficacy responses were maintained or further improved with UPA15 through week 216 in patients with RA. Trial registration, ClinicalTrials.gov identifier: NCT03086343.

Can a simple 0-10 RheuMetric physician estimate of inflammatory activity (DOCINF) depict a detailed swollen joint count (SJC) as accurately as a DAS28 or CDAI in patients with rheumatoid arthritis?

OBJECTIVE

To compare a 0-10 physician subglobal estimate of inflammatory activity (DOCINF) on a RheuMetric checklist to a formal swollen joint count (SJC) and other rheumatoid arthritis (RA) Core data set measures in a disease activity score 28 (DAS28), clinical disease activity index (CDAI), and simplified disease activity index (SDAI) in patients with RA, recognizing that RA measures, index scores and physician global assessment (DOCGL) may be elevated by joint damage and patient distress, independent of inflamamtory activity, and that formal joint counts are not recorded at most routine care visits.

METHODS

A cross-sectional study at a routine care visit included a RheuMetric checklist completed by a rheumatologist, with four 0-10 visual numeric scales (VNS) for DOCGL, and three sub-global estimates for inflammatory activity (DOCINF), joint damage (DOCDAM), and patient distress (DOCDIS), e.g., anxiety, depression, and/or fibromyalgia, etc. Variation in SJC according to other individual measures in the DAS28, CDAI, and SDAI, and in the indices was analyzed using Spearman correlation coefficients and regressions with and without DOCINF as an independent variable.

RESULTS

In 173 patients with long disease duration, regressions which included individual DAS28, CDAI or SDAI measures and added DOCINF as an independent variable explained 46 % of variation in SJC, compared to 23 % if DOCINF was not included. DOCINF was more explanatory of SJC than even the DAS28 or CDAI indices themselves, although SJC is a component of these indices.

CONCLUSION

In routine care RA patients with long disease duration, DOCINF depicts SJC as effectively as RA indices which require 90-100 seconds to record, and may provide a feasible, informative quantitative clinical measure without recording formal joint counts.

Efficacy and Safety of Biologics in Polymyalgia Rheumatica: A Retrospective Study

INTRODUCTION

The study aimed to determine the efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) in the treatment of polymyalgia rheumatica (PMR) complicated by rheumatoid arthritis (RA).

METHODS

Patients with PMR which could be classified as RA and who were treated with bDMARDs were included in the analysis. The primary endpoint was the clinical Polymyalgia Rheumatica Activity Score (Clin-PMR-AS) after 26 weeks of treatment, and the secondary endpoint was adverse events during the observation period.

RESULTS

A total of 203 patients with PMR which was resistant or intolerant to glucocorticoids and could be classified as RA were receiving bDMARDs and were enrolled in the study. There were 83, 82, and 38 patients in the tumor necrosis factor inhibitor (TNFi), interleukin-6 receptor inhibitor (IL-6Ri), and cytotoxic T lymphocyte-associated antigen-4-immunoglobulin (CTLA4-Ig) groups, respectively. Twenty-six weeks after bDMARD initiation, Clin-PMR-AS levels were significantly lower in the IL-6Ri group as compared to other groups. Multiple regression analysis was performed with Clin-PMR-AS as the objective variable. Body mass index (BMI), history of bDMARDs, and IL-6Ri use were identified as factors involved in Clin-PMR-AS. After adjustment for group characteristics using inverse probability of treatment weighting with propensity scores, the Clin-PMR-AS score at 26 weeks was significantly lower in the IL-6Ri group (9.0) than in both the TNFi (12.4, p = 0.004) and CTLA4-Ig (15.9, p = 0.003) group.

CONCLUSION

IL-6Ri may potentially improve the disease activity of PMR compared to other bDMARDs.

Diospyros kaki fruit extract produces antiarthritic and antinociceptive effects in rats with complete Freund's adjuvant-induced arthritis

Current treatments for rheumatoid arthritis produce untoward effects; thus, considerable effort has been made to recognize effective herbal medicines against the condition. In the present study, the therapeutic effect of Diospyros kaki fruit hydroalcoholic extract (DFHE) on complete Freund's adjuvant (CFA)-induced arthritis in rats was investigated. The extract was characterized using liquid chromatography-electrospray mass spectrometry (LC-ESIMS). Male Wistar rats were grouped as follows (eight rats in each): control, CFA, CFA + indomethacin (5 mg/kg), CFA + DFHE (50 mg/kg), and CFA + DFHE (100 mg/kg). Paw volume, mechanical allodynia, thermal hyperalgesia, and arthritis score were evaluated. Serum levels of malondialdehyde (MDA), thiol groups, tumor necrosis factor-alpha (TNF-α), as well as glutathione peroxidase (GPx) and superoxide dismutase (SOD) activities were evaluated. Carotenoids were found to be the major components of DFHE. Administration of DFHE (100 mg/kg) significantly decreased arthritis score, paw volume, and thermal hyperalgesia, and improved mechanical allodynia. MDA and TNF-α levels were decreased while thiol levels and SOD and GPx activities were increased in DFHE-treated groups compared to the CFA group. These results suggest that D. kaki extract caused an improvement in clinical signs of rheumatoid arthritis symptoms possibly through suppression of oxidative stress and inflammation.

Geographical Differences in the Safety and Efficacy of Tofacitinib Versus TNFi: A Post Hoc Analysis of ORAL Surveillance

INTRODUCTION

In ORAL Surveillance, incidence rates (IRs) of major adverse cardiovascular events (MACE) and malignancies (excluding non-melanoma skin cancer [NMSC]) in cardiovascular (CV)-risk-enriched patients with rheumatoid arthritis (RA) were numerically greater with tofacitinib in North America versus the rest of the world, due to underlying risk factors. Here, we evaluated the safety and efficacy of tofacitinib versus tumor necrosis factor inhibitors (TNFi) among patients with RA across geographical regions.

METHODS

Patients with RA in ORAL Surveillance (NCT02092467), who were aged ≥ 50 years with ≥ 1 additional CV risk factor, received tofacitinib 5 or 10 mg twice daily or TNFi; 45.9% were from either Poland or North America. This post hoc analysis stratified patients by region (Poland, North America, Other countries). Efficacy endpoints included Clinical Disease Activity Index, Disease Activity Score in 28 joints, with C-reactive protein (DAS28-4[CRP]), and Health Assessment Questionnaire-Disability Index (HAQ-DI). IRs and hazard ratios for adverse events were reported.

RESULTS

Of 4362 patients (Poland, N = 759; North America, N = 1243; Other countries, N = 2360), more patients from North America versus Poland/Other countries had CV risk factors such as body mass index ≥ 30 kg/m2 and history of diabetes/hypertension; however, more patients from Poland versus other regions were ever smokers and more patients from Poland/North America versus Other countries had history of coronary artery disease. MACE IRs were similar in North America and Poland, and numerically higher versus Other countries. IRs for malignancies (excluding NMSC) were numerically higher in North America versus Poland/Other countries with tofacitinib. Serious infections IRs were numerically higher in North America versus Poland across treatments. Venous thromboembolism/all-cause mortality IRs were generally comparable across regions. DAS28-4(CRP)/HAQ-DI improvements were generally lowest in North America.

CONCLUSIONS

Differences in safety outcomes were driven by the presence of baseline risk factors; North America and Poland demonstrated a higher proportion of patients with some baseline CV risk factors/comorbidities versus Other countries.

TRIAL REGISTRATION

NCT02092467 (ClinicalTrials.gov).

Incidence of Malignancies and the Association with Biological Disease-Modifying Antirheumatic Drugs in Japanese Patients with Rheumatoid Arthritis: A Time-Dependent Analysis from the IORRA Patient Registry

INTRODUCTION

Patients with rheumatoid arthritis (RA) may have an increased malignancy risk versus the general population, potentially elevated by biological disease-modifying antirheumatic drug (bDMARD) use. Using patient registry data, we determined malignancy risk, stratified by bDMARD use, among Japanese patients with RA versus the Japanese general population and investigated whether bDMARD use is a time-dependent risk factor for the development of malignancy.

METHODS

Patients aged ≥ 18 years with ≥ 2 data entries of RA in the IORRA (Institute of Rheumatology, Rheumatoid Arthritis) patient registry, enrolled from January 2013-December 2018, were identified ('All RA' cohort). Patients were stratified into bDMARD (≥ 1 bDMARD received) or non-bDMARD (no history of bDMARDs) sub-cohorts. Malignancy incidence rates and standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) versus the Japanese general population were calculated. Risk of RA medication use was analyzed using a time-dependent Cox proportional hazards model, after adjusting for covariates.

RESULTS

A total of 8020 patients were identified for the All RA cohort; 2187 and 5833 for the bDMARD and non-bDMARD sub-cohorts, respectively. For all three cohorts, incidence of overall malignancies was similar versus the Japanese general population. Incidence of specific malignancies was also similar, but incidence of lymphoma was higher for all three cohorts (SIRs [95% CIs] 3.72 [2.71-4.93], 5.97 [3.34-9.59], and 2.79 [1.82-4.02], respectively). In the bDMARD sub-cohort, no increase in SIRs was observed for other site-specific malignancies. In the All RA cohort, use of methotrexate, tacrolimus, glucocorticoids, non-steroidal anti-inflammatory drugs, and bDMARDs were not associated with the risk of overall malignancy; the hazard ratio (95% CI) was 1.36 (0.96-1.93) for bDMARD use. Increased disease activity was a time-dependent risk factor of overall malignancy with a hazard ratio (95% CI) of 1.35 (1.15-1.59).

CONCLUSIONS

The use of bDMARDs was not a time-dependent risk factor for malignancy.

Femoral bone mineral density as a tool of personalized medicine for rheumatoid arthritis: Interleukin-6 inhibitors for patients with low density whereas tumor necrosis factor inhibitor for patients with preserved density?

Objectives

There is a lack of indicators to distinguish between interleukin-6 inhibitors responders and tumor necrosis factor inhibitors responders in the treatment of rheumatoid arthritis. Osteoporosis is a complication of rheumatoid arthritis and is closely related to inflammatory pathology. The purpose of this study was to evaluate whether bone mineral density can distinguish interleukin-6 inhibitors responders from tumor necrosis factor inhibitors responders in rheumatoid arthritis.

Methods

Either interleukin-6 inhibitors or tumor necrosis factor inhibitors was introduced as the first biologics to patients naïve to both corticosteroid and osteoporosis treatment. Correlations between baseline bone mineral density and Clinical Disease Activity Index after 3 months were analyzed.

Results

The subjects were 26 rheumatoid arthritis patients with a median age of 60 years old, disease duration of 1.4 years, Clinical Disease Activity Index of 13.7, and C-reactive protein of 1.69 mg/dL. The subjects were divided into two groups (high (H) and low (L)) according to their femoral bone mineral density with a cutoff of young adult mean of 80%. Six in group H and 11 in group L received interleukin-6 inhibitors, and nine in group H received tumor necrosis factor inhibitors. Clinical Disease Activity Index remission rate by interleukin-6 inhibitors was significantly greater in group L (8/11 (72.7%)) than in group H (1/6 (16.7%); p < 0.05). In the whole group H, significantly more patients obtained Clinical Disease Activity Index remission by tumor necrosis factor inhibitors (7/9, 77.8%) than by interleukin-6 inhibitors (1/6 (16.7%); p = 0.04).

Conclusions

In patients with rheumatoid arthritis, interleukin-6 inhibitors may be more beneficial for patients with low femoral bone mineral density, whereas tumor necrosis factor inhibitors may be advantageous for those with preserved bone mineral density.

Is Total Joint Arthroplasty an Effective and Safe Option for Psoriatic Arthritis Patients? A Scoping Review

Recent advancements in the treatment of psoriatic arthritis (PsA) have improved patient outcomes, but many still experience disease progression, potentially leading to joint replacement surgery. In this scoping review, we examine the relationship between PsA and orthopedic surgery, focusing on the risks and temporal trends of total hip arthroplasty (THA) and total knee arthroplasty (TKA), the prevalence of postoperative complications, and the effectiveness of these procedures in PsA. The included studies suggest that PsA patients have an overall higher risk of undergoing THA and TKA compared to the general population, but with temporal trends showing a decreased risk for patients diagnosed in recent years. Acute complications, such as renal failure, stroke, and postoperative infections, may be more common in PsA patients than in those with osteoarthritis after THA and TKA. No significant differences were found in pain, function, or satisfaction between PsA, skin psoriasis, and osteoarthritis patients after THA. A key conclusion from our review is the need to strengthen the collaboration between rheumatologists and orthopedic surgeons, as interdisciplinary evaluation is crucial for improving the outcomes of PsA patients undergoing orthopedic surgery.

Omics-based pharmacological evaluation reveals Yuanhu Zhitong oral liquid ameliorates arthritis by regulating PKC/ERK/NF-κB signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Successful use of herbal medicine in the treatment of rheumatoid arthritis (RA) creates opportunities for alternative therapies. Yuanhu Zhitong oral liquid (YZOL) is an herbal preparation known for its potent analgesic and anti-inflammatory properties in traditional use. However, the pharmacological mechanism of YZOL for treating RA remains unclear.

AIM OF THE STUDY

The aim of this study was to evaluate the efficacy of YZOL in the treatment of RA and to explore its potential mechanisms through omics analysis.

MATERIALS AND METHODS

Type II collagen was used to induce an arthritis rat model. The effects of YZOL on paw swelling, inflammatory cytokines, oxidative stress, and histopathological changes were systematically investigated. A pathway-driven transcriptomic analysis was performed to identify key signaling pathways associated with YZOL therapy. The key alterations were validated by qRT-PCR, Western blot, and immunohistochemistry assays.

RESULTS

YZOL significantly attenuated arthritis progression, reduced paw swelling rate, and lowered arthritis score in CIA rats. YZOL also inhibited systemic inflammation and associated oxidative stress during RA. Transcriptomic analysis identified 341 genes with significantly altered expression following YZOL treatment. These genes were enriched in inflammation-related pathways, particularly in the NF-κB and MAPK signaling pathways. In addition, we discovered that YZOL can alleviate inflammation in the local synovial tissue. The effect of YZOL was confirmed by the suppression of PKC/ERK/NF-κB p65 signaling at systemic and local levels.

CONCLUSIONS

This study provides novel evidence that YZOL treatment ameliorates RA by suppressing the PKC/ERK/NF-κB pathway, suggesting its potential as an alternative therapy for RA.

Adherence to the antirheumatic drugs: a systematic review and meta-analysis

Introduction

This systematic review and meta-analysis aimed to analyze the adherence rate for conventional and biological disease-modifying antirheumatic drugs (DMARDs) utilizing different assessment measures.

Method

A systematic literature search was performed in four electronic databases, including PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL), covering the time frame from April 1970 to April 2023. Studies that present data on medication adherence among adult patients with rheumatoid arthritis (RA), specifically focusing on DMARDs (conventional or biological), were included in the analysis. The adherence rate for different assessment measures was documented and compared, as well as for conventional and biological DMARDs. A random-effects meta-analysis was performed to assess adherence rates across different adherence assessment measures and drug groups.

Results

The search identified 8,480 studies, out of which 66 were finally included in the analysis. The studies included in this meta-analysis had adherence rates ranging from 12 to 98.6%. Adherence rates varied across several adherent measures and calculation methods. Using the subjective assessment measures yielded the outcomes in terms of adherence rate: 64.0% [0.524, 95% CI 0.374-0.675] for interviews and 60.0% [0.611, 95% CI 0.465-0.758] for self-reported measures (e.g., compliance questionnaires on rheumatology CQR-5), p > 0.05. In contrast, the objective measurements indicated a lower adherence rate of 54.4% when using the medication event monitoring system (p > 0.05). The recorded rate of adherence to biological DMARDs was 45.3% [0.573, 95% CI 0.516-0.631], whereas the adherence rate for conventional DMARDs was 51.5% [0.632, 95% CI 0.537-0.727], p > 0.05. In the meta-regression analysis, the covariate "Country of origin" shows a statistically significant (p = 0.003) negative effect with a point estimate of -0.36, SE (0.12), 95% CI, -0.61 to -0.12.

Discussion

Despite its seemingly insignificant factors that affect the adherence rate, this meta-analysis reveals variation in adherence rate within the types of studies conducted, the methodology used to measure adherence, and for different antirheumatic drugs. Further research is needed to validate the findings of this meta-analysis before applying them to clinical practice and scientific research. In order to secure high reliability of adherence studies, compliance with available reporting guidelines for medication adherence research is more than advisable.

A Real-World Comparison of Clinical Effectiveness in Patients with Rheumatoid Arthritis Treated with Upadacitinib, Tumor Necrosis Factor Inhibitors, and Other Advanced Therapies After Switching from an Initial Tumor Necrosis Factor Inhibitor

INTRODUCTION

This study compared the clinical effectiveness of switching from tumor necrosis factor inhibitor (TNFi) to upadacitinib (TNFi-UPA), another TNFi (TNFi-TNFi), or an advanced therapy with another mechanism of action (TNFi-other MOA) in patients with rheumatoid arthritis (RA).

METHODS

Data were drawn from the Adelphi RA Disease Specific Programme™, a cross-sectional survey administered to rheumatologists and their consulting patients in Germany, France, Italy, Spain, the UK, Japan, Canada, and the USA from May 2021 to January 2022. Patients who switched treatment from an initial TNFi were stratified by subsequent therapy of interest: TNFi-UPA, TNFi-TNFi, or TNFi-other MOA. Physician-reported clinical outcomes including disease activity (with formal DAS28 scoring available for 29% of patients) categorized as remission, low/moderate/high disease activity, as well as pain were recorded at initiation of current treatment and ≥ 6 months from treatment switch. Fatigue and treatment adherence were measured ≥ 6 months from treatment switch. Inverse-probability-weighted regression adjustment compared outcomes by subsequent class of therapy: TNFi-UPA versus TNFi-TNFi, or TNFi-UPA versus TNFi-other MOA.

RESULTS

Of 503 patients who switched from their first TNFi, 261 were in TNFi-UPA, 128 in TNFi-TNFi, and 114 in TNFi-other MOA groups. At the time of switch, most patients had moderate/high disease activity (TNFi-UPA: 73%; TNFi-TNFi: 52%; TNFi-other MOA: 60%). After adjustment for differences in characteristics at point of switch, patients in TNFi-UPA group (n = 261) were significantly more likely to achieve physician-reported remission (67.7% vs. 40.3%; p = 0.0015), no pain (55.7% vs. 25.4%; p = 0.0007), and complete adherence (60.0% vs. 34.2%; p = 0.0049) compared with patients in TNFi-TNFi group (n = 121). Similar findings were observed for TNFi-UPA versus TNFi-other MOA groups (n = 111).

CONCLUSION

Patients who switched from TNFi to UPA had significantly better clinical outcomes of remission, no pain, and complete adherence than those who cycled TNFi or switched to another MOA.

Tumour necrosis factor inhibitors and serious infections in reproductive-age women and their offspring: a narrative review

Tumour necrosis factor inhibitors (TNFi) are commonly used to treat patients with chronic inflammatory diseases, and function by inhibiting the pro-inflammatory cytokine tumour necrosis factor-α (TNF-α). Although beneficial in reducing disease activity, they are associated with an increased risk of serious infections. Data on the risk of serious infections associated with TNFi use during the reproductive years, particularly in pregnancy, are limited. For pregnant women, there is an additional risk of immunosuppression in the offspring as TNFi can be actively transported across the placenta, which increases in the second and third trimesters. Several studies have explored the risk of serious infections with TNFi exposure in non-pregnant and pregnant patients and offspring exposed in utero, indicating an increased risk in non-pregnant patients and a potentially increased risk in pregnant patients. The studies on TNFi-exposed offspring showed conflicting results between in utero TNFi exposure and serious infections during the offspring's first year. Further research is needed to understand differential risks based on TNFi subtypes. Guidelines conditionally recommend the rotavirus vaccine before 6 months of age for offspring exposed to TNFi in utero, but more data are needed to support these recommendations because of limited evidence. This narrative review provides an overview of the risk in non-pregnant patients and summarizes evidence on how pregnancy can increase vulnerability to certain infections and how TNFi may influence this susceptibility. This review focuses on the evidence regarding the risk of serious infections in pregnant patients exposed to TNFi and the risk of infections in their offspring.

Managing rheumatoid arthritis and cardiovascular disease: the role of physical medicine and rehabilitation

INTRODUCTION

Cardiovascular disease (CVD) presents a significant challenge in rheumatoid arthritis (RA), a systemic chronic ailment affecting the joints and causing systemic inflammation. Effective RA management, including pharmacological and non-pharmacological interventions, is crucial for mitigating cardiac risk. Pharmacotherapy, though effective, can have adverse effects, leading many patients to seek complementary therapies. This study investigates the impact of physical medicine and rehabilitation on RA management in patients with cardiovascular disease, analyzing clinical data to assess the efficacy of integrated therapeutic approaches.

METHODS

This retrospective monocentric study draws upon data from patient records at the Rheumatology Department of the Regional Clinical Hospital of Shymkent, Kazakhstan, spanning 2019 to 2022. Data collected included demographic information, diagnoses, comorbidities, medical anamneses, lab results, and treatment regimens, including physical medicine and rehabilitation interventions. Data were summarized in Microsoft Excel. Statistical analysis was performed using IBM SPSS Statistics (version 26.0).

RESULTS

An analysis of 350 patients with RA identified 143 cases of concomitant CVD, with arterial hypertension being the most common cardiovascular disease. The prevalence of CVD among patients with RA was 40%, with a mean age of 58 years, peaking between 50 and 65 years. The majority of patients were women. A strong association was found between increased RA activity and elevated cardiovascular risk. Despite the widespread use of glucocorticosteroid therapy, rehabilitation coverage remained limited. A significant proportion of patients had elevated cholesterol and C-reactive protein levels, while those who engaged in physical therapy and rehabilitation had lower cholesterol levels. Comparative analysis of yoga integration into rehabilitation programs for patients with RA, alongside other modalities (kinesiotherapy, balneotherapy, and pilates), showed that yoga participants exhibited lower pain levels, reduced morning stiffness duration, and lower mean DAS-28 scores compared to those using alternative rehabilitation methods.

CONCLUSION

Integrating physical medicine and rehabilitation, particularly yoga, with pharmacological treatments appears promising for improving patient outcomes. Yoga has demonstrated benefits in reducing pain, morning stiffness, and disease activity. Continued research is essential to refine these approaches and enhance RA and CVD management in patients.

Efficacy and safety of methotrexate plus hydroxychloroquine combination therapy vs. methotrexate monotherapy in the treatment of rheumatoid arthritis: A randomized controlled clinical trial

OBJECTIVE

To explore the efficacy and safety of combination therapy with methotrexate (MTX) plus hydroxychloroquine (HCQ) vs. MTX monotherapy in patients with rheumatoid arthritis (RA).

METHODS

Sixty patients without prior RA treatments were randomly allocated in a 1:1 ratio to two groups: one receiving MTX plus HCQ, and the other receiving MTX monotherapy. We conducted a comparative analysis before and after the 12-week trial, evaluating the visual analogue scale (VAS), the disease activity score in 28 joints (DAS), serum inflammatory factor (including serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), as well as the outcome of the World Health Organization Quality of Life Brief Version questionnaire (WHOQOL-BREF) and the treatment-emergent adverse events (TEAEs) for all the participants in the study.

RESULTS

At the 12th week of the trial, a more remarkable decrease in pain score (VAS), disease activity score (DAS), and serum inflammatory factor levels could be noticed in individuals on the combination therapy. The quality of life score was as well found to be higher in the MTX + HCQ group than the MTX monotherapy group. The incidence of adverse reactions in the MTX + HCQ and the MTX monotherapy groups were 10.00% and 6.67%, respectively. However, no statistical significance could be observed (p > .05).

CONCLUSION

In our study, both the MTX + HCQ combination therapy and MTX monotherapy demonstrated improvements in symptoms, conditions and quality of life for patients with RA. Notably, the combination therapy could achieve better outcomes across all indices compared to MTX monotherapy, highlighting its potential as the optimal first-line treatment for RA. © 2024 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.

Automated multi-scale computational pathotyping (AMSCP) of inflamed synovial tissue

Rheumatoid arthritis (RA) is a complex immune-mediated inflammatory disorder in which patients suffer from inflammatory-erosive arthritis. Recent advances on histopathology heterogeneity of RA synovial tissue revealed three distinct phenotypes based on cellular composition (pauci-immune, diffuse and lymphoid), suggesting that distinct etiologies warrant specific targeted therapy which motivates a need for cost effective phenotyping tools in preclinical and clinical settings. To this end, we developed an automated multi-scale computational pathotyping (AMSCP) pipeline for both human and mouse synovial tissue with two distinct components that can be leveraged together or independently: (1) segmentation of different tissue types to characterize tissue-level changes, and (2) cell type classification within each tissue compartment that assesses change across disease states. Here, we demonstrate the efficacy, efficiency, and robustness of the AMSCP pipeline as well as the ability to discover novel phenotypes. Taken together, we find AMSCP to be a valuable cost-effective method for both pre-clinical and clinical research.

Comparison of effectiveness of methotrexate in patients with late-onset versus younger-onset rheumatoid arthritis: Real-world data from an inception cohort in Japan (NICER-J)

OBJECTIVE

To compare the effectiveness of methotrexate (MTX) as initial therapy in patients with late-onset and younger-onset rheumatoid arthritis (LORA and YORA).

METHODS

Of 114 patients with YORA and 96 patients with LORA, defined as RA occurring at ≥65 years of age, enrolled in a multicentre RA inception cohort study, 71 and 66 patients who had been followed up to 6 months after starting MTX treatment were included in this study.

RESULTS

Proportions of patients on MTX treatment at 6 months were 96% and 92% in the YORA and LORA groups, respectively. Despite lower doses of MTX in the LORA group compared with the YORA group, no significant difference was observed in clinical disease activity index scores between the two groups throughout the follow-up period. The proportion of patients in clinical disease activity index remission at 6 months was 35% in both groups. Logistic regression analysis revealed that knee joint involvement and high Health Assessment Questionnaire-Disability Index were significant negative predictors of achieving clinical disease activity index remission at 6 months in the LORA group.

CONCLUSION

Observations up to 6 months revealed that the effectiveness of MTX administered based on rheumatologist discretion in patients with LORA is comparable to that in patients with YORA in clinical settings.

Trends in treatment for patients with late-onset rheumatoid arthritis in Japan: Data from the NinJa study

OBJECTIVES

Our objective was to investigate trends in the treatment of patients with late-onset rheumatoid arthritis (LORA) using data from the National Database of Rheumatic Diseases in Japan (NinJa).

METHODS

Patients registered in the National Database of Rheumatic Diseases in Japan were classified according to the disease onset: at <65 years (young-onset rheumatoid arthritis); at 65-74 years (early LORA); and at ≥75 years (late LORA). Chronological changes in the treatment and disease activity were compared.

RESULTS

A total of 7178, 13,171, 15,295, and 15,943 patients were evaluated in 2010, 2013, 2016, and 2019, respectively. In all groups, the use of methotrexate gradually decreased, whereas that of biological/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) increased; the use of tumor necrosis factor inhibitors decreased, whereas that of non-tumor necrosis factor inhibitors increased. LORA was characterized by more single DMARD use and less methotrexate and biological/targeted synthetic DMARD use. Tumor necrosis factor inhibitors and interleukin-6 inhibitors were used less frequently, whereas abatacept was utilized more frequently in late versus early LORA. Conventional synthetic DMARD (excluding methotrexate) and glucocorticoid use was higher in late versus early LORA.

CONCLUSIONS

This analysis revealed chronological changes in the treatment of LORA in Japan. Differences between early and late LORA suggest that patients are not a homogeneous population.

Safety and effectiveness of peficitinib 100 mg/day in patients achieving clinical remission from a long-term open-label extension study in Japan, Korea, and Taiwan (RAJ2)

OBJECTIVES

This post hoc analysis of the RAJ2 study assessed long-term safety and effectiveness of peficitinib 100 mg/day for treatment of rheumatoid arthritis.

METHODS

Eligible patients previously completed two Phase 3 (RAJ3 and RAJ4) studies of peficitinib in Asia. All patients received peficitinib 100 mg/day at RAJ2 Week (W)0; dose change to 50 mg/day or 150 mg/day was permitted. Safety endpoints included treatment-emergent adverse events and laboratory test results. Effectiveness endpoints included peficitinib exposure pattern, achievement of Clinical Disease Activity Index (CDAI) remission by peficitinib exposure pattern at W0 and W48, and association of demographics/characteristics with CDAI remission at W0 and W48.

RESULTS

Overall, no new safety findings were reported at W48, and renal function was unaffected. Of patients included in effectiveness analyses at W48, 70.9% (451/636) had maintained peficitinib 100 mg/day since W0. Of patients who achieved CDAI remission at W0 and maintained peficitinib 100 mg/day to W48, 50.3% (79/157) maintained CDAI remission to W48. Low disease activity and a lower number of prior disease-modifying antirheumatic drugs were significantly associated with CDAI remission at W48.

CONCLUSIONS

Long-term peficitinib treatment at a dose of 100 mg/day was generally well tolerated and, following induction therapy, maintained effectiveness through to W48.