The burden of disease in rheumatoid arthritis

Use of dipeptidyl peptidase-4 inhibitors is associated with a lower risk of rheumatoid arthritis in patients with type 2 diabetes mellitus: A systematic review and meta-analysis of cohort studies

BACKGROUND AND AIMS

Case reports have described occurrence of rheumatoid arthritis (RA) after initiation of Dipeptidyl Peptidase-4 Inhibitors (DPP4i), suggesting a possible adverse effect of the medications. However, the findings from subsequent cohort studies suggest the opposite as they indicate that T2DM patients who used DPP4i tended to have a lower risk of RA. We aimed to investigate the association between use of DPP4i and incident RA in patients with type 2 diabetes mellitus (T2DM) using systematic review and meta-analysis.

METHODS

Potentially eligible studies were identified from Medline and EMBASE databases from inception to May 2020 using search strategy that comprised of terms for "Dipeptidyl peptidase-4 inhibitor" and "Rheumatoid arthritis". Eligible study must be cohort study consisting of one cohort of patients with T2DM who were DPP4i users and another cohort of comparators with T2DM who did not receive DPP4i. Then, the study must report effect estimates with 95% confidence intervals (95% CIs) comparing incident RA between DPP4i users versus comparators. Point estimates with standard errors retrieved from each study were combined together using the generic inverse variance method.

RESULTS

A total of 709 articles were identified. After systematic review, four retrospective cohort studies met the eligibility criteria and were included into the meta-analysis. DPP4i users had a significantly lower risk of incident RA compared with comparators with the pooled hazard ratio of 0.72 (95% CI, 0.54-0.96; I² 75%).

CONCLUSION

This systematic review and meta-analysis found a significant association between DPP4i use and a lower risk of incident RA.

The global prevalence of rheumatoid arthritis: a meta-analysis based on a systematic review

The objective is to determine the global population prevalence of rheumatoid arthritis (RA) based on population-based studies and assess factors that influence RA prevalence estimates. Four electronic databases were searched (ProQuest Central, MEDLINE, Web of Science, and EMBASE) for peer-reviewed English publications that report prevalence estimates of RA from 1980 and 2019. We included case-control studies, cross-sectional studies, and prospective or retrospective cohort studies in our search strategy. A random-effect meta-analysis model was used to produce the pooled prevalence estimates. The potential between-study heterogeneity was identified using sensitivity analysis, sub-group and meta-regression analyses. A total of 67 studies were included in the meta-analysis, containing 742,246 RA patients and 211,592,925 healthy controls in the study period. The global RA prevalence estimate was 0.46% (95% confidence interval [CI] 0.39-0.54; I² = 99.9%) with a 95% prediction interval (0.06-1.27). The RA point-prevalence was 0.45% (95% CI 0.38-0.53%) between 1986 and 2014, while the pooled period-prevalence was 0.46% (95% CI 0.36% and 0.57%) from 1955 to 2015. The highest RA pooled prevalence (0.69%; 95% CI 0.47-0.95) was derived from linked data source studies. Based on meta-regression, the factors that explain the studies' heterogeneity of RA prevalence, including geographical location, the risk bias assessment of studies and sample size. The global prevalence of RA between 1980 and 2019 was 460 per 100,000 population, with variations due to geographical location and study methodology. Linked data are the preferred method to estimate RA population prevalence as they provide the best case ascertainment.

Effect of Moxibustion on the Serum Levels of MMP-1, MMP-3, and VEGF in Patients with Rheumatoid Arthritis

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease, which will eventually lead to joints deformity and functional damage. The aim of this research is to evaluate the effect of moxibustion on the serum indicators related to bone and cartilage metabolism, matrix metalloproteinase 1 (MMP-1), matrix metalloproteinase 3 (MMP-3), and vascular endothelial growth factor (VEGF) in patients with RA and to explore the mechanism of moxibustion in the treatment of RA.

Methods

We recruited 70 RA patients who met the inclusion criteria, and they were randomly divided into two groups, a treatment group and a control group in equal ratio. The control group took methotrexate, folate, or leflunomide orally, while the treatment group received methotrexate, folate, or leflunomide orally and moxibustion at ST36 (Zusanli), BL23 (Shen shu), and Ashi points. We compared the clinical symptoms, RA serological disease markers and serum contents of interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), MMP-1, MMP-3, and VEGF of RA patients before and after treatment.

Results

(1) The clinical symptoms and RA serological disease markers of the two groups improved after treatment (P < 0.05), while the clinical symptoms of the treatment group were significantly improved in comparison with the control group (P < 0.05). (2) The levels of IL-1β, TNF-α, and VEGF decreased in both groups after treatment (P < 0.05), but the treatment group was significantly decreased compared with the control group (P < 0.05). (3) There were significant differences in MMP-1 and MMP-3 contents after treatment in the treatment group (P < 0.05, P < 0.05), while there were no significant differences in the control group (P > 0.05, P > 0.05). Above all, the contents of IL-1β, TNF-α, MMP-1, MMP-3, and VEGF in the treatment group decreased more significantly than those in the control group (P < 0.05).

Conclusion

The improvement effect of moxibustion on the clinical symptoms of RA patients may be related to influence on the contents of IL-1β, TNF-α, MMP-1, MMP-3, and VEGF, and moxibustion may play a potential role in bone protection.

Berberine Inhibits the Gene Expression and Production of Proinflammatory Cytokines by Mononuclear Cells in Rheumatoid Arthritis and Healthy Individuals

OBJECTIVE

Rheumatoid arthritis (RA) is the most prevalent autoimmune arthritis. Berberine is an alkaloid isolated from Berberis vulgaris, and its anti-inflammatory effect has been identified.

METHODS

Twenty newly diagnosed RA patients and 20 healthy controls participated. Peripheral mononuclear cells were prepared and stimulated with bacterial lipopolysachharide (LPS,1 μg/ml), exposed to different concentrations of berberine (10 and 50μM) and dexamethasone (10-7 M) as a reference. The toxicity of compounds was evaluated by WST-1 assay. The expression of TNF-α and IL-1β was determined by quantitative real-time PCR. Protein level of secreted TNF-α and IL-1β was measured by using ELISA.

RESULTS

Berberine did not have any toxic effect on cells, whereas Lipopolysaccharide (LPS) stimulation caused a noticeable rise in TNF-α and IL-1β production. Berberine markedly downregulated the expression of both TNF-α and IL-1β, and inhibited TNF-α and IL-1β secretion from LPS-stimulated PBMCs.

DISCUSSION

This study provided a molecular basis for anti-inflammatory effect of berberine on human mononuclear cells through the suppression of TNF-a and IL-1secretion. Our findings highlighted the significant inhibitory effect of berberine on proinflammatory responses of mononuclear cells from rheumatoid arthritis individuals, which may be responsible for antiinflammatory property of Barberry. We observed that berberine at high concentration exhibited anti-inflammatory effect in PBMCs of both healthy and patient groups by suppression of TNF-a and IL-1cytokines at both mRNA and protein levels.

CONCLUSION

Berberine may inhibit the gene expression and production of pro-inflammatory cytokines by mononuclear cells in rheumatoid arthritis and healthy individuals without affecting cell viability. Future studies with a larger sample size are needed to prove the idea.

Systemic bee venom exerts anti-arthritic and anti-inflammatory properties in a rat model of arthritis

Bee venom (BV) is widely used as a traditional China medicine to treat various conditions, including rheumatoid arthritis (RA). The aim of the present study was to evaluate the effects of systemic BV (60 mg/kg) as an anti-arthritic natural product, compare it with Methotrexate and determine the possible underlying mechanisms of BV action using complete Freund's adjuvant-induced arthritic rats. The development of signs of RA signs (knee joint circumference and arthritis scoring index) was evaluated. Erythrocyte sedimentation rate, serum tumor necrosis factor-α (TNF-α) and serum interleukin-1β (IL-1β) levels were measured at the end of the study. Histopathological examination followed by immunostaining of NF-κB (P65) was performed on the affected knee joints. Additionally, in vitro cyclooxygenase (COX) inhibition activity, carrageenan paw edema test and acetic acid writhing tests were performed to evaluate the anti-inflammatory and analgesic effects of the assessed dose and compared with diclofenac. An acute toxicity test was performed to establish the safety of BV at high doses. The results of the present study highlighted the potential of systemic BV on preventing the development of signs of RA. BV also significantly reduced serum levels of TNF-α, IL-1β and NF-κB in the affected joints. In addition to its potent analgesic activity, BV exhibited favorable inhibitory activity of the COX pathway in both in vivo and in vitro models. Therefore, high dose administration of systemic BV displayed safe and promising anti-arthritic, anti-inflammatory and analgesic properties through regulation of different mechanisms associated with the pathogenesis of RA.

Patients with asthma have a higher risk of rheumatoid arthritis: A systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate whether patients with asthma have a higher risk of incident rheumatoid arthritis (RA) using systematic review and meta-analysis technique.

METHODS

Potentially eligible studies were identified from Medline and EMBASE databases from inception to May 2020 using search strategy that comprised of terms for "Asthma" and "Rheumatoid arthritis". Eligible cohort study must consist of one cohort of patients with asthma and another cohort of individuals without asthma. Then, the study must effect estimates with 95% confidence intervals (95% CIs) comparing incident RA between the groups. Eligible case-control studies must include cases with RA and controls without RA. Then, the study must explore their history of asthma. Odds ratio (OR) with 95% CIs of the association between asthma status and RA must be reported. Point estimates with standard errors were retrieved from each study and were combined together using the generic inverse variance method.

RESULTS

A total of 22,442 articles were identified. After two rounds of independent review by three investigators, six cohort studies and fourteen case-control studies met the eligibility criteria and were included into the meta-analysis. Meta-analysis of cohort studies found that patients with asthma had a significantly higher risk of RA compared with individuals without asthma with the pooled hazard ratio of 1.42 (95% CI, 1.18 - 1.70). Meta-analysis of case-control studies revealed that patients with asthma had a higher risk of RA compared with individuals without asthma with the pooled odds ratio of 1.33 (95%CI, 0.97 - 1.83). Funnel plot for the meta-analysis of case-control studies was asymmetric, suggesting the presence of publication bias.

CONCLUSIONS

This systematic review and meta-analysis found a significant association between asthma and higher risk of incident RA.

Presence of anti-citrullinated protein antibodies and costs and disease activity in early rheumatoid arthritis - a 3-year follow-up

Objective: To analyse healthcare utilization, loss of productivity, and disease activity in relation to presence of anti-citrullinated protein antibodies (ACPAs). Method: In total, 447 ACPA-positive and 224 ACPA-negative patients from two early rheumatoid arthritis cohorts, recruited 1996-1998 (cohort 1) and 2006-2009 (cohort 2), were followed during 3 years. Data on disease activity were collected, and patients reported healthcare utilization and days lost from work. Disease activity, healthcare costs, and loss of productivity were compared between ACPA groups. Linear regression was performed, controlling for confounders. Results: Healthcare costs did not differ significantly by ACPA status (EUR 3214 for vs EUR 2174 for ACPA-positive vs ACPA-negative patients in cohort 1, ns; EUR 4150 vs EUR 3820 in cohort 2, ns). Corresponding values for loss of productivity were EUR 9148 vs EUR 7916 (ns) and EUR 5857 vs EUR 5995 (ns). Total prescription of traditional disease-modifying anti-rheumatic drugs was higher in cohort 2 than in cohort 1. Methotrexate prescription was higher in ACPA-positive patients, but biologics did not differ significantly between ACPA groups. Disease activity was significantly more improved in cohort 2, but there was no difference in achieving remission in relation to ACPA status. In cohort 1, 25% of ACPA-positive patients were in remission vs 31% of ACPA-negative (ns) and in cohort 2, 55% vs 60% (ns). Conclusions: With increasing drug treatment for both ACPA-positive and ACPA-negative patients, outcome in ACPA-positive was no more severe than in ACPA-negative patients. Healthcare costs and loss of productivity were similar in the two groups.

The role of advanced MRI in the development of treat-to-target therapeutic strategies, patient stratification and phenotyping in rheumatoid arthritis

In this commentary, we discuss the potential of advanced imaging, particularly Dynamic Contrast Enhanced (DCE) magnetic resonance imaging (MRI) for the objective assessment of the inflammatory process in rheumatoid arthritis (RA). We emphasise the potential of DCE-MRI in advancing the field and exploring new areas of research and development in RA. We hypothesize that different grades of bone marrow edema (BME) and synovitis in RA can be examined and monitored in a more sensitive manner with DCE-MRI. Future treatments for RA may benefit from the application of enhanced imaging of BMEs and synovitis. DCE-MRI may also facilitate enhanced stratification and phenotyping of patients enrolled in clinical trials.

Hospitalization burden and comorbidities of patients with rheumatoid arthritis in Spain during the period 2002-2017

Background

Rheumatoid arthritis (RA) is a chronic autoimmune rheumatic disease that is associated with multiple comorbidities and has a significant economic impact on the Spanish health system. The objective of this study was to estimate the rates of hospitalization of rheumatoid arthritis in Spain, and describing hospitalization rates and their changing by age, region, RA variant, and when RA as a main cause of hospitalization or a comorbidity.

Methods

Observational descriptive study that reviewed hospital records from the CMBD. We included all hospitalizations of patients in Spain whose main diagnosis or comorbidity in the ICD-9-CM was rheumatoid arthritis during the period of 2002–2017.

Results

A total of 315,190 hospitalizations with the RA code were recorded; 67.3% were in women. The mean age of the patients was 68.5 ± 13.9 years. The median length of hospital stay was 7 days (IQR 3–11 days). In 29,809 of the admissions, RA was coded as the main diagnosis (9.4%). When RA was not coded as the main diagnosis, the most frequent main diagnoses were diseases of the circulatory system (18.9%) and diseases of the respiratory system (17.4%). The hospitalization rate during the period of 2002–2017 was 43.8 (95% CI: 43.7–44.0) per 100,000 inhabitants and constantly increased during the period. The total cost for the healthcare system was 1.476 million euros, with a median of 3542 euros per hospitalization (IQR 2646–5222 euros).

Conclusions

In Spain, the hospitalization rate of patients with RA increased during the study period, despite the decrease in the hospitalization rate when RA was the main diagnosis.

Effectiveness of TOcilizumab in comparison to Prednisone In Rheumatoid Arthritis patients with insufficient response to disease-modifying antirheumatic drugs (TOPIRA): study protocol for a pragmatic trial

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease, predominantly affecting joints, which is initially treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). In RA patients with insufficient response to csDMARDs, the addition of prednisone or tocilizumab, a biological DMARD (bDMARD), to the medication has been shown to be effective in reducing RA symptoms. However, which of these two treatment strategies has superior effectiveness and safety is unknown.

Methods

In this multicenter, investigator-initiated, open-label, randomized, pragmatic trial, we aim to recruit 120 RA patients meeting the 2010 ACR/EULAR classification criteria for RA, with active disease defined as a Clinical Disease Activity Index (CDAI) > 10 and at least one swollen joint of the 28 assessed. Patients must be on stable treatment with csDMARDs for ≥ 8 weeks prior to screening and must have been treated with ≥ 2 DMARDs, of which a maximum of one tumor necrosis factor inhibitor (a class of bDMARDs) is allowed. Previous use of other bDMARDs or targeted synthetic DMARDs is not allowed. Patients will be randomized in a 1:1 ratio to receive either tocilizumab (subcutaneously at 162 mg/week) or prednisone (orally at 10 mg/day) as an addition to their current csDMARD therapy. Study visits will be performed at screening; baseline; and months 1, 2, 3, 6, 9, and 12. Study medication will be tapered in case of clinical remission (CDAI ≤ 2.8 and ≤ 1 swollen joint at two consecutive 3-monthly visits) with careful monitoring of disease activity. In case of persistent high disease activity at or after month 3 (CDAI > 22 at any visit or > 10 at two consecutive visits), patients will switch to the other strategy arm. Primary outcome is a change in CDAI from baseline to 12 months. Secondary outcomes are additional clinical response and quality of life measures, drug retention rate, radiographically detectable progression of joint damage, functional ability, and cost utility. Safety outcomes include tocilizumab-associated adverse events (AEs), glucocorticoid-associated AEs, and serious AEs.

Discussion

This will be the first randomized clinical trial comparing addition of oral prednisone or of tocilizumab head to head in RA patients with insufficient response to csDMARD therapy. It will yield important information for clinical rheumatology practice.

Trial registration

This trial was prospectively registered in the Netherlands Trial Register on October 7, 2019 (NL8070). The Netherlands Trial Register contains all items from the World Health Organization Trial Registration Data Set.

Comparison of methods to construct a genetic risk score for prediction of rheumatoid arthritis in the population-based Nord-Trøndelag Health Study, Norway

Objectives

To evaluate selection methods among published single-nucleotide polymorphisms (SNPs) associated with RA to construct predictive genetic risk scores (GRSs) in a population-based setting.

Methods

The Nord-Trøndelag Health (HUNT) Study is a prospective cohort study among the whole adult population of northern Trøndelag, Norway. Participants in HUNT2 (1995–1997) and HUNT3 (2006–2008) were included (489 RA cases, 61 584 controls). The initial SNP selection from relevant genome-wide studies included 269 SNPs from 30 studies. Following different selection criteria, SNPs were weighted by published odds ratios. The sum of each person’s carriage of all weighted susceptibility variants was calculated for each GRS.

Results

The best-fitting risk score included 27 SNPs [weighted genetic risk score 27 (wGRS27)] and was identified using P-value selection criterion ≤5 × 10−8, the largest possible SNP selection without high linkage disequilibrium (r2 &lt; 0.8), and lasso regression to select for positive coefficients. In a logistic regression model adjusted for gender, age and ever smoking, wGRS27 was associated with RA [odds ratio 1.86 (95% CI 1.71, 2.04) for each s.d. increase, P &lt; 0.001]. The AUC was 0.76 (95% CI 0.74, 0.78). The positive and negative predictive values were 1.6% and 99.7%, respectively, and the positive predictive value was not improved in sensitivity analyses subselecting participants to illustrate settings with increased RA prevalences. Other schemes selected more SNPs but resulted in GRSs with lower predictive ability.

Conclusion

Constructing a wGRS based on a smaller selection of informative SNPs improved predictive ability. Even with a relatively high AUC, the low PPV illustrates that there was a large overlap in risk variants among RA patients and controls, precluding clinical usefulness.

Efficacy and Safety of Etanercept in Elderly Patients with Rheumatoid Arthritis: A Post-Hoc Analysis of Randomized Controlled Trials

BACKGROUND

Elderly individuals are disproportionately affected by rheumatoid arthritis (RA), but few studies have addressed the efficacy and safety of treatments in this population.

OBJECTIVE

Our objective was to assess the efficacy and safety of etanercept in elderly patients (aged ≥ 65 years) with RA.

METHODS

The efficacy analysis was a post hoc analysis of data from the open-label period of three phase IV clinical trials of etanercept for RA. Least squares (LS) change from baseline (cfb) in 28-joint Disease Activity Score (DAS28), Health Assessment Questionnaire Disability Index (HAQ-DI), and modified Total Sharp Scores (mTSS) were analyzed by age (< 65 vs. ≥ 65 years) for each study. The safety analyses were of data pooled from the double-blind, placebo-controlled periods of 19 phase I-IV randomized studies of etanercept in patients with RA. The percentage occurrence of adverse events (AEs) in placebo- and etanercept-treated patients was analyzed by age (< 65 vs. ≥ 65 years).

RESULTS

There were no significant differences in LS mean cfb in DAS28 or mTSS between the two age groups. LS mean cfb in HAQ-DI scores was consistently lower in elderly than in non-elderly patients, although significant differences were not observed in all trials. Overall, AE occurrence was higher in elderly than non-elderly patients, regardless of treatment. In etanercept-treated patients, there were small yet statistically significant increases in the occurrence of congestive heart failure, serious infections, and non-melanoma skin cancers in elderly versus non-elderly patients. For most AEs, occurrence did not significantly differ between elderly and non-elderly patients.

CONCLUSION

Overall, there were no substantial differences in the efficacy or safety of etanercept between elderly and non-elderly patients with RA.

Patients with rheumatoid arthritis have an increased risk of incident chronic kidney disease: a systematic review and meta-analysis of cohort studies

OBJECTIVES

Patients with rheumatoid arthritis (RA) may have a higher risk of developing chronic kidney (CKD) compared with general population, but the data on this risk are still not well characterized. This systematic review and meta-analysis aimed to comprehensively investigate this association by reviewing all available studies.

METHODS

A systematic review was performed using MEDLINE and EMBASE database from inception to July 2019 to identify all cohort studies that compared the risk of developing CKD after index date among patients with RA versus individuals without RA. Pooled risk ratio and 95% confidence interval (CI) were calculated using random-effect, generic inverse-variance method of DerSimonian and Laird.

RESULTS

A total of four cohort studies (three retrospective cohort studies and four prospective cohort study) comprising of 1,627,833 participants met the inclusion criteria and were included in the meta-analysis. The overall quality of the included studies was good. The risk of incident CKD was significantly increased among patients with RA with the pooled risk ratio of 1.52 (95% CI 1.28-1.80). The statistical heterogeneity was high with an I² of 82%.

CONCLUSIONS

A significantly increased risk of incident CKD among patients with RA compared with individuals without RA was demonstrated in this study.

Patients with rheumatoid arthritis have a higher risk of bipolar disorder: A systematic review and meta-analysis

The current study was conducted with the aim to investigate the relationship between rheumatoid arthritis (RA) and bipolar disorder (BD). Potentially eligible studies were identified from Medline and EMBASE databases from inception to May 2019. Eligible cohort studies must include patients with RA and comparators without RA, follow them for incident BD and report the relative risk, hazard risk ratio or standardized incidence ratio and associated 95% confidence intervals (CI) comparing the incidence of BD between the two groups. Eligible case-control studies must include cases with BD and controls without BD, explore prior history of RA and report the odds ratio and associated 95% CI for this association. Point estimates with standard errors were extracted from individual study and were combined together using random-effect model, generic inverse variance method. A total of six studies fulfilled the inclusion criteria and were included into the meta-analysis. The risk of developing BD was significantly higher among patients with RA than individuals without RA with the pooled relative risk of 2.06 (95% CI, 1.34-3.17; I² 86%). Chronic inflammation is a potential mechanism and could be a modifiable risk factor of BD. However, further studies are still required to confirm this.

Methyl Jasmonate Reduces Inflammation and Oxidative Stress in the Brain of Arthritic Rats

Methyl jasmonate (MeJA), common in the plant kingdom, is capable of reducing articular and hepatic inflammation and oxidative stress in adjuvant-induced arthritic rats. This study investigated the actions of orally administered MeJA (75–300 mg/kg) on inflammation, oxidative stress and selected enzyme activities in the brain of Holtzman rats with adjuvant-induced arthritis. MeJA prevented the arthritis-induced increased levels of nitrites, nitrates, lipid peroxides, protein carbonyls and reactive oxygen species (ROS). It also prevented the enhanced activities of myeloperoxidase and xanthine oxidase. Conversely, the diminished catalase and superoxide dismutase activities and glutathione (GSH) levels caused by arthritis were totally or partially prevented. Furthermore, MeJA increased the activity of the mitochondrial isocitrate dehydrogenase, which helps to supply NADPH for the mitochondrial glutathione cycle, possibly contributing to the partial recovery of the GSH/oxidized glutathione (GSSG) ratio. These positive actions on the antioxidant defenses may counterbalance the effects of MeJA as enhancer of ROS production in the mitochondrial respiratory chain. A negative effect of MeJA is the detachment of hexokinase from the mitochondria, which can potentially impair glucose phosphorylation and metabolism. In overall terms, however, it can be concluded that MeJA attenuates to a considerable extent the negative effects caused by arthritis in terms of inflammation and oxidative stress.

Discussions of lifestyle habits as an integral part of care management: a cross-sectional cohort study in patients with established rheumatoid arthritis in Sweden

Objectives

The primary aim was to determine whether patients with RA recalled having discussions concerning lifestyle habits during their health-care visits. The secondary aim was to study the association between patients' reported lifestyle and their wish to discuss it.

Methods

A postal questionnaire sent to 1542 eligible patients from the Better Anti-Rheumatic Pharmacotherapy (BARFOT) study included questions on lifestyle habits (physical activity, diet, smoking and alcohol), on whether these were discussed during health-care visits and on whether there was an interest in such discussions.

Results

A total of 1061 patients (68%) responded [mean age 67 (s.d. 13) years, 73% women]. Half of the patients (49%) recalled discussions on physical activity, and 23% recalled discussions about diet. Those who reported health-enhancing levels of physical activity were more likely to discuss physical activity with their health professionals. Likewise, patients who reported having a non-traditional mixed diet were more likely to discuss diet. Smoking was discussed with 25% of the patients, more often with current smokers than with non-smokers (32 vs 17%; P < 0.001). Alcohol was discussed with 17% of the patients. Of those patients who reported having hazardous drinking habits, 77% had not discussed alcohol use with any health professional.

Conclusion

Discussions about lifestyle were recalled by half of the patients with established RA. There is a need for improvement, because lifestyle habits may affect the long-term outcome in a chronic disease, such as RA. Patient education concerning lifestyle habits should be an integral part of care management and an interactive process.

"Not Thinking that This Means the End When You Are Seriously Ill but Doing Something Positive about It"-A Qualitative Study of Living with a Life-Changing Disease

Background: Chronic diseases have an impact on and can change the lives of the persons affected by them. This study examines how a disease can influence patients’ daily lives, the strategies they adopt to cope, and their experiences of support. The study focuses on four chronic diseases: asthma-allergy, cancer, diabetes mellitus, and inflammatory rheumatic arthritis. Methods: The study has a qualitative design and includes 41 transcribed in-depth interviews and a content analysis. Results: The participants’ new life situation was changed for a very long time or forever, and this was not a voluntary choice. The new life situation comprised the following themes: life-changing—the disease could be a turning point in a negative or positive way, strategies—designed to create ways of coping with daily tasks to find a good quality of life, and support—that could be obtained from the participants’ private network or the healthcare professionals. Conclusions: The patients had to make changes in their daily life, and these could bring about different feelings and restrict activity. Healthcare professionals need more knowledge of the process of coping with such life-changing matters and what could strengthen patients and give a sense of empowerment in their lives.

Anti-inflammatory Ellagitannins from Cleidion brevipetiolatum for the Treatment of Rheumatoid Arthritis

Six new ellagitannins, brevipetins B-G (5 and 7-11), and a new phenolic glucoside, brevipetin A (4), along with six known compounds were isolated from the traditional Chinese medicinal plant Cleidion brevipetiolatum. Their structures and absolute configurations were determined by spectroscopic analyses, chemical methods, and TD-DFT-ECD calculations. Compounds 5-11 exhibited NO inhibitory effects with IC₅₀ values of 1.9-8.2 μM, and 9 showed the most potent inhibitory effect (IC₅₀: 1.9 μM). An in vivo anti-inflammatory assessment of 9 showed that it exerts therapeutic effects in both the carrageenan-induced rat paw edema and collagen-induced arthritis (CIA) models at 50 mg/kg oral administration. The enhanced protein and mRNA expression levels of iNOS (inducible nitric oxide synthase) and COX-2 (cyclooxygenase-2) in LPS-stimulated RAW 264.7 cells were dose-dependently suppressed by 9. An anti-inflammatory mechanistic study revealed that 9 suppressed NF-κB activity by inhibiting IκBα phosphorylation and blocking translocation of p65 from the cytosol to the nucleus. Therefore, 9 might have the potential to be developed as a lead compound for relieving rheumatoid arthritis.

Absence of Pharmacokinetic Interactions between the Bruton's Tyrosine Kinase Inhibitor Fenebrutinib and Methotrexate

Fenebrutinib (GDC-0853) is an orally administered small molecule inhibitor of Bruton's tyrosine kinase being investigated for treatment of rheumatoid arthritis in patients with inadequate responses to methotrexate (MTX). This study interrogated the potential for pharmacokinetic drug interactions between fenebrutinib and MTX. Eighteen healthy male subjects were enrolled in the study. They received a single oral dose of MTX (7.5 mg) on day 1 followed by a 13-day washout period. Subsequently, on days 15-20 the participants received 200 mg of fenebrutinib twice daily. On day 21, they received a 7.5 mg dose of MTX and a 200 mg dose of fenebrutinib under fasting conditions. The geometric mean ratios of MTX area under the plasma concentration-time curve (AUC) and C _max on day 21 relative to day 1 (90% confidence interval [CI]) were 0.96 (0.88-1.04) and 1.05 (0.94-1.18), respectively. The geometric mean ratios of fenebrutinib AUC and C _max for day 21 relative to day 20 (90% CI) were 1.03 (0.95-1.11) and 1.02 (0.90-1.15), respectively. The combination treatment was well tolerated, with an adverse event profile similar to that reported in other MTX trials. These results indicate that there is no clinically significant pharmacokinetic interaction between fenebrutinib and MTX.

Identification of Characteristic Autoantibodies Associated With Deficiency Pattern in Traditional Chinese Medicine of Rheumatoid Arthritis Using Protein Chips

Background: Rheumatoid arthritis (RA) is an autoimmune disease. Based on traditional Chinese medicine (TCM) theory, deficiency pattern (DP) which leads to specific treatment principles in clinical management is a crucial pattern diagnosis among RA patients, and autoantibodies have potential implications in TCM pattern classification. The purpose of this study was to identify specific RA DP-associated autoantibodies.

Methods: RA DP patients, RA nondeficiency pattern (NDP) patients and healthy controls (HCs) were recruited for this study. Then, clinical data and sera from all subjects were collected. After that, the sera were probed with protein chips, which were constructed by known RA related autoantigens, to screen for DP-associated candidate autoantibodies. Lastly, candidate autoantibodies were validated via enzyme-linked immunosorbent assay (ELISA) and function was evaluated by network analysis.

Results: Protein chips results showed that RA patients have higher levels of anti-vascular endothelial growth factor (VEGF) A165 antibodies than HC (P < 0.005); anti-VEGFA165 antibodies levels of patients with RA DP were lower than patients with RA NDP (P < 0.05). The results of the ELISA also showed statistically significant differences in anti-VEGFA165 antibodies between the RA and HC group (P < 0.0001); and there were statistically significant differences in anti-VEGFA165 antibodies between the RA DP and RA NDP group (P < 0.05). Network analysis results suggested IL-6 signaling pathway has a significant effect on VEGFA165 in RA patients.

Conclusion: Autoantibodies identification in RA using protein chips help in understanding DP in TCM. Discovery of anti-VEGFA165 antibodies may provide the possibility for clinical precision treatment.

Dose-response associations between metabolic indexes and the risk of comorbid type 2 diabetes mellitus among rheumatoid arthritis patients from Northern China: a case-control study

OBJECTIVE

To investigate whether there were any differences in the patterns of metabolic abnormalities between patients with rheumatoid arthritis (RA) with comorbid type 2 diabetes mellitus (T2DM) and other populations, and to plot the dose-response relationships between metabolic indexes and the risk of comorbid T2DM among patients with RA.

DESIGN AND SETTING

This is a retrospective case-control study using electronic medical records (EMRs). Patients with RA and/or T2DM or controls who were admitted to the First Affiliated Hospital of China Medical University between April 2008 and December 2016 were retrospectively recruited through the EMR system. After age-matching and sex-matching, 261 controls, 274 patients with T2DM, 276 patients with RA and 151 patients with RA+T2DM were eventually recruited.

RESULTS

Patients with RA+T2DM exhibited higher levels of systolic blood pressure (SBP), fasting plasma glucose (FPG) and triglyceride (TG) than the RA only patients. Moreover, the proportions of impaired fasting glucose (IFG), and total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) dyslipidaemia in the RA+T2DM group were higher than those in the RA alone group (for IFG: 28.48% vs 18.84%, p=0.02; for TC: 25.17% vs 15.22%, p=0.01; for LDL-C: 25.83% vs 17.03%; p=0.03). Rheumatoid factor (RF) positivity and IFG were independent risk indicators for comorbid T2DM among patients with RA (for RF positivity: OR=0.45; 95% CI: 0.29 to 0.69; p<0.001; for IFG: OR=1.70; 95% CI: 1.04 to 2.76; p=0.03).

CONCLUSION

Linear dose-response associations between SBP, TC, TG and the risk of comorbid T2DM among patients with RA were observed, whereas a non-linear dose-response association between FPG and the risk of comorbid T2DM was found. Patients with RA+T2DM were more likely to exhibit metabolic abnormalities than RA only patients. Patients with RA+T2DM with metabolic abnormalities deserve more attention from rheumatologists and endocrinologists.

Meta-analysis of IL-17 inhibitors in two populations of rheumatoid arthritis patients: biologic-naïve or tumor necrosis factor inhibitor inadequate responders

OBJECTIVES

To evaluate the efficacy and safety of interleukin 17 (IL-17) inhibitors in two rheumatoid arthritis (RA) populations: biologic-naïve or tumor necrosis factor inhibitor inadequate responders (TNF-IR).

METHOD

A systematic search was performed in major electronic databases to identify relevant randomized controlled trials (RCTs) reporting the American College of Rheumatology 20% (ACR20), ACR50, ACR70 responses and adverse events (AEs) of IL-17 inhibitors versus placebo in patients with RA. We divided these patients into two subgroups: biologic-naïve or TNF-IR. The meta-analysis was performed using Review Manager 5.3 software. Results were expressed as risk ratio (RR) with pertinent 95% confidence interval (95% CI).

RESULTS

Ten studies with a total of 2499 patients were included. For biologic-naïve patients, ACR50 and ACR70 responses were significantly better with IL-17 inhibitors than placebo (RR = 1.71, 95% CI 1.23-2.38, P = 0.001 and RR = 2.63, 95% CI 1.10-6.25, P = 0.03, respectively), but ACR20 responses for IL-17 inhibitors were not statistically superior to placebo (RR = 1.34, 95% CI 0.94-1.91, P = 0.11). For TNF-IR, IL-17 inhibitors were effective in achieving ACR20 (RR = 1.67, 95% CI 1.40-2.00, P < 0.00001), ACR50 (RR = 1.94, 95% CI 1.43-2.63, P < 0.0001), and ACR70 (RR = 2.11, 95% CI 1.26-3.55, P = 0.005) compared to placebo. In the safety analysis, IL-17 inhibitors did not show increased risk of any AEs by comparing to placebo in both biologic-naïve patients and TNF-IR.

CONCLUSION

IL-17 inhibitors were effective in the treatment of RA without increased risk of AEs, whether for biologic-naïve patients or TNF-IR. Key Points • In this meta-analysis comparing IL-17 inhibitors with placebo in 2499 rheumatoid arthritis patients, IL-17 inhibitors improved ACR50 and ACR70, but not ACR20, responses in biologic-naïve patients. • IL-17 inhibitors improved ACR20, ACR50, and ACR70 responses in tumor necrosis factor inhibitor inadequate responders.

Tocilizumab Patterns of Use, Effectiveness, and Safety in Patients with Rheumatoid Arthritis: Final Results from a Set of Multi-National Non-Interventional Studies

INTRODUCTION

The objective of this study was to observe the patterns of usage, efficacy, and safety of tocilizumab (TCZ) in clinical practice in patients with rheumatoid arthritis.

METHODS

Data on the real-world usage, efficacy, and safety of TCZ were collected from patients during routine follow-up visits conducted over a 6-month period. Patients were grouped by previous exposure to biologic therapies (biologic exposed vs. biologic naive).

RESULTS

Of 1912 patients enrolled from 16 countries, 639 (33.4%) received TCZ monotherapy and 1273 (66.6%) received TCZ combination therapy. At baseline, 1073 patients (56.1%) were biologic naive and 839 (43.9%) were biologic exposed. At 6 months, 1504 patients (78.7%) continued to receive TCZ treatment, with no descriptive differences in retention rates between biologic-exposed and biologic-naive patients and between patients receiving TCZ monotherapy or combination therapy. Dose and use of methotrexate and prednisone were reduced at 6 months. Efficacy at 6 months, including patient-reported outcomes, was demonstrated in both biologic-naive and biologic-exposed groups. Adverse events (AEs) occurred in 817 patients [42.7%; incidence rate: 179 events per 100 patient-years (PY)], and serious AEs (SAEs) occurred in 118 patients (6.2%; 17 events per 100 PY), with comparable rates of AEs and SAEs between subgroups.

CONCLUSION

In routine clinical practice, TCZ discontinuation rates were low and unaffected by prior use of biologics. Effectiveness was similar between groups, and no new safety signals were identified.

FUNDING

F. Hoffmann-La Roche.

'Preclinical' rheumatoid arthritis in patients with celiac disease: A cross-sectional study

Objective: Preclinical or latent RA is characterized by the presence of autoantibodies in the absence of clinical symptoms. The objective of this study was to identify the prevalence of preclinical RA in patients with Celiac disease in order to determine whether or not such individuals should be screened for RA based on the high-risk.

Method: A cross-sectional study was carried out on patients with celiac disease in a tertiary care center in Rawalpindi, Pakistan. After initial assessment, RA-autoantibody levels (Rheumatoid factor and anti-CCP) were checked. Descriptive analysis was performed on the data gathered.

Results: Sixteen patients with known celiac disease were identified to have positive rheumatoid factor and/or anti-CCP levels with an overall prevalence rate of 35%. This trend was significant for celiac patients having history of inflammatory arthritis and active celiac disease. No statistical significance was seen in baseline characteristics for categories of patients with positive rheumatoid factor versus with positive anti-CCP antibodies.

Conclusion: Patients with CD can be considered as a high-risk group based on the high prevalence rate of rheumatoid factor/anti-CCP positivity observed in this study and should be considered for further RA screening/preventive studies.

Abbreviations: RA = Rheumatoid arthritis; CD = Celiac disease; anti-CCP = anti-citrullinated cyclic peptide) antibodies; RF = Rheumatoid factor; GFD = Gluten-free diet

Serum levels of adiponectin and vitamin D correlate with activity of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease in which numerous cells and mediators affect inflammatory conditions and disease severity. To compare the serum levels of adiponectin, vitamin D, copper, and zinc in patients with RA and to investigate the relationship between these parameters and RA severity. Ninety patients with RA and 30 healthy controls participated in this cross-sectional case-control study between November 2016 and April 2017; according to the ACR/EULAR criteria for RA. Serum levels of adiponectin were determined by ELISA; copper and zinc by colorimetric spectrophotometry; and vitamin D by HPLC. Kruskal-Wallis and Spearman tests were performed using SPSS software and data were depicted by GraphPad Prism software. Compared with healthy controls, the serum level of adiponectin was significantly increased, whereas vitamin D was significantly decreased in patients with RA. Adiponectin and vitamin D levels were inversely correlated in RA subgroups (P < 0.001, r = - 0.410). Adiponectin and vitamin D correlated with RA severity. Furthermore, no significant difference was found in copper and zinc levels between RA groups and controls. The definitive roles of adiponectin, vitamin D, copper, and zinc are not completely determined in RA development. Based on disease activity, these parameters can modulate inflammatory conditions, thus they have the potential to be used as promising therapeutic biomarkers to follow up the severity of disease, as well as the progression and treatment success in patients with RA.

An Anti-hTNF-α Variable New Antigen Receptor Format Demonstrates Superior in vivo Preclinical Efficacy to Humira® in a Transgenic Mouse Autoimmune Polyarthritis Disease Model

Tumor necrosis factor-alpha (TNF-α), an established pro-inflammatory cytokine plays a central role in the induction and progression of several chronic inflammatory and autoimmune diseases. Targeting TNF-α as a treatment modality has shown tremendous success, however there are several limitations associated with the current anti-TNF-α biologic drugs including: immunogenicity, life-threatening infections, resistance to treatment, complexity of manufacture and cost of treatment. Here, we report the in vivo efficacy of novel anti-TNF-α formats generated from molecular engineering of variable new antigen receptors (VNARs), originally derived from the immune system of an immunized nurse shark. Two anti-TNF-α VNAR formats, a tandem multivalent trimer, D1-BA11-C4 and an Fc-fused quadrivalent D1-Fc-C4 (Quad-X™) construct were tested in a clinically relevant, preclinical mouse efficacy model of polyarthritis (Tg197) and compared to the commercial anti-TNF-α "best in class" therapy, Adalimumab (Humira®). Both VNAR formats bind and neutralize TNF-α through an epitope that appears to be different from those recognized by other anti-TNF biologics used clinically. All doses of Quad-X™, from 0.5 to 30 mg/kg, significantly blocked the development of polyarthritis. At 0.5 mg/kg Quad-X™, the arthritis score was improved by 76% and the histopathology score by 63%. At 3 mg/kg Quad-X™, control of disease was almost complete at 90% (arthritis) and 88% (histopathology). In marked contrast, 1 mg/kg Humira® saw profound disease breakthrough with scores of 39 and 16% respectively, increasing to a respectable 82 and 86% inhibition at 10 mg/kg Humira®. We have previously reported the superior potency of anti-TNF-α VNARs in vitro and in these studies translate this superiority into an in vivo setting and demonstrate the potential of VNAR formats to meet the requirements of next-generation anti-TNF-α therapies.

Effects of Sarilumab on Rheumatoid Arthritis as Reported by Patients Using the Rheumatoid Arthritis Impact of Disease Scale

OBJECTIVE

We evaluated the effect of sarilumab on patient-perceived impact of rheumatoid arthritis (RA) using the 7-domain RA Impact of Disease (RAID) scale.

METHODS

Two phase III, randomized, controlled trials of sarilumab in patients with active, longstanding RA were analyzed: (1) sarilumab 150 mg and 200 mg every 2 weeks plus conventional synthetic disease-modifying antirheumatic drugs (+csDMARD) versus placebo + csDMARD [TARGET (NCT01709578)]; and (2) sarilumab 200 mg versus adalimumab (ADA) 40 mg monotherapy [MONARCH (NCT02332590)]. Least-squares mean (LSM) differences in RAID total score (range 0-10) and 7 key RA symptoms, including pain and fatigue (baseline to Weeks 12 and 24), were compared. "Responders" by RAID total score were defined by improvements from baseline ≥ minimal clinically important difference (MCID), and ≥ patient-acceptable symptom-state (PASS) at endpoint.

RESULTS

Sarilumab 150 mg and 200 mg + csDMARD were nominally superior (p < 0.05) versus placebo + csDMARD and 200 mg sarilumab versus ADA 40 mg in LSM differences for RAID total score at weeks 12 (-0.93 and -1.13; -0.49, respectively) and 24 (-0.75 and -1.01; -0.78), and all effects of RA (except functional impairment in MONARCH Week 12). Effects were greater in physical domains (e.g., pain) than mental domains (e.g., emotional well-being). More patients receiving sarilumab versus placebo or ADA reported improvements ≥ MCID and PASS in total RAID scores at both assessments.

CONCLUSION

Based on the RAID, sarilumab + csDMARD or as monotherapy reduced the effect of RA on patients' lives to a greater extent than placebo + csDMARD or ADA monotherapy. (ClinicalTrials.gov: NCT01709578 and NCT02332590).

Reasons to stop drinking alcohol among patients with rheumatoid arthritis in Sweden: a mixed-methods study

OBJECTIVES

The aims were to identify patients with rheumatoid arthritis (RA) who had stopped drinking alcohol and compare them with patients drinking alcohol, and to explore reasons for stopping drinking alcohol.

DESIGN

A sequential explanatory mixed methods design was used.

SETTING

Six rheumatology clinics in Southern Sweden Better Anti-Rheumatic FarmacOTherapy cohort.

PARTICIPANTS

A total of 1509 patients completed the questions about alcohol and were included in the study. 86 of these had stopped drinking alcohol and 72 responded to the open question and their answers were analysed with qualitative content analysis.

OUTCOME MEASURES

The quantitative data were from a cross-sectional survey assessing disease severity, physical function (Health Assessment Questionnaire, HAQ) and health-related quality of life (EuroQol five dimensions, EQ5D), pain, fatigue, patient global assessment (PatGA) and lifestyle factors, for example, alcohol. The questions assessing alcohol included an open question 'Why have you stopped drinking alcohol?'

RESULTS

The patients who stopped drinking alcohol were older (median (min-max) 69 (36-90) vs 66 (23-95), p=0.011), had worse HAQ (1.00 (0-2.75) vs 0.50 (0-3.00), p<0.001), worse EQ5D (0.69 (-0.02-1.00) vs 0.76 (-0.58-1.00), p<0.001) worse PatGA (5 (0-10) vs 3 (0-10), p<0.001), more pain (5 (0-10) vs 3 (0-10), p<0.001) and more fatigue (6 (0-10) vs 4 (0-10), p<0.001 compared with patients drinking alcohol. The qualitative content analysis revealed five categories describing reasons for patients with RA to stop drinking alcohol: illness and treatment; health and well-being; work and family; faith and belief; and dependences and abuse.

CONCLUSIONS

The patients who had stopped drinking had worse physical functioning and higher levels in pain-related variables. Most stopped drinking due to their illness or a desire to improve health.

Pharmacologic Effect of Miao Medicine Illicium simonsii Maxim. on Collagen-Induced Arthritis in Rats

Objectives

To study the pharmacologic effect and mechanism of action of Miao medicine Illicium simonsii Maxim. (ISM) in treating rheumatoid arthritis.

Methods

Sixty rats were randomly divided to six groups: normal control (normal), collagen-induced arthritis (CIA) model (model), CIA + tripterygium glycosides (TG), CIA + ISM high dose oral (ISM-H), CIA + ISM low-dose oral (ISM-L), and CIA + ISM topical application (ISM-T). The treatment doses were selected based on published reports and folk medicine practice. The outcome measurements included paw swelling, joint pathology, organ index, blood count, T helper 17 (Th17) cell count, and interleukin-6 (IL-6) level.

Results

Compared to the CIA model group, all treatment groups showed a significant reduction in paw swelling, blood vessel pathology, Th17 cell count, and IL-6 levels (p < 0.05 or p < 0.01). All treatment groups showed alleviated foot swelling and lower total number of white blood cells, and these effects were observed earlier with oral ISM than topical ISM. The effect of ISM was weaker than that of TG. In addition, less organ damage was observed with topical ISM than oral ISM but better than TG.

Conclusions

These results suggest that, by downregulating Th17 cells, ISM inhibits the production of Il-6, thereby alleviating the proliferation of endothelial and rheumatoid-like cells and leukocytosis in CIA rats, ultimately eliminating foot swelling.

Anti-Inflammatory and Antioxidant Actions of Methyl Jasmonate Are Associated with Metabolic Modifications in the Liver of Arthritic Rats

Methyl jasmonate (MeJA) is a fatty acid-derived cyclopentanone which shares structural similarities with prostaglandins and has been under study as a promising anti-inflammatory agent. This study investigated the actions of MeJA on systemic inflammation and oxidative status in rats with adjuvant-induced arthritis, a model for rheumatoid arthritis. MeJA (75 to 300 mg·kg⁻¹) was administrated orally during 18 days after arthritis induction with Freund's adjuvant. Articular and systemic inflammation was greatly increased in arthritic rats, likewise the oxidative stress in plasma and liver. The hepatic glucokinase activity and glycolysis were increased in arthritic rats. MeJA decreased most inflammatory parameters and abolished the increased protein carbonylation in plasma and liver, diminished the increased hepatic ROS content, and restored the hepatic GSH/GSSG ratio in arthritic rats. However, the MeJA treatment decreased the hepatic glucokinase activity and glycolysis and stimulated mitochondrial ROS production in healthy and arthritic rats. Oxygen uptake was increased by MeJA only in livers from treated arthritic rats. This action may bear relation to the increased activity of mitochondrial NADP⁺-dependent enzymes to provide reducing equivalents for the glutathione cycle. These beneficial effects, however, are associated with a decreased glucose flux through the glycolysis in the liver of arthritic and healthy rats.

The association of fatigue, pain, depression and anxiety with work and activity impairment in immune mediated inflammatory diseases

Impairment in work function is a frequent outcome in patients with chronic conditions such as immune-mediated inflammatory diseases (IMID), depression and anxiety disorders. The personal and economic costs of work impairment in these disorders are immense. Symptoms of pain, fatigue, depression and anxiety are potentially remediable forms of distress that may contribute to work impairment in chronic health conditions such as IMID. The present study evaluated the association between pain [Medical Outcomes Study Pain Effects Scale], fatigue [Daily Fatigue Impact Scale], depression and anxiety [Hospital Anxiety and Depression Scale] and work impairment [Work Productivity and Activity Impairment Scale] in four patient populations: multiple sclerosis (n = 255), inflammatory bowel disease (n = 248, rheumatoid arthritis (n = 154) and a depression and anxiety group (n = 307), using quantile regression, controlling for the effects of sociodemographic factors, physical disability, and cognitive deficits. Each of pain, depression symptoms, anxiety symptoms, and fatigue individually showed significant associations with work absenteeism, presenteeism, and general activity impairment (quantile regression standardized estimates ranging from 0.3 to 1.0). When the distress variables were entered concurrently into the regression models, fatigue was a significant predictor of work and activity impairment in all models (quantile regression standardized estimates ranging from 0.2 to 0.5). These findings have important clinical implications for understanding the determinants of work impairment and for improving work-related outcomes in chronic disease.

Disease activity and biologic use in patients with psoriatic arthritis or rheumatoid arthritis

To compare disease burden and biologic use among psoriatic arthritis (PsA) or rheumatoid arthritis (RA) patients recruited to the Corrona registry. Retrospective study of patients with PsA or RA enrolled in Corrona between January 2002 and March 2013 and grouped in 2-year intervals. Clinical outcomes and biologic use were assessed. Biologic use increased over time in both cohorts, with 62 and 52% of patients with PsA and RA, respectively, receiving biologics by 2012–2013. However, 25 and 35% of patients with PsA and RA, respectively, continued to experience moderate/high disease activity. Overall, the progressive increase in biologic use accompanied progressive decreases in Clinical Disease Activity Index (from 14.2 to 10.4 for RA, and 12.4 to 8.1 for PsA) and mean Health Assessment Questionnaire score (from 0.36 to 0.34, and 0.3 to 0.24). Mean patient pain, the proportion of patients reporting morning stiffness, and the mean duration of morning stiffness remained similar for both cohorts. PsA and RA treated in the rheumatology setting had a comparable impact on patient quality of life and functional ability. Disease burden improved with increased biologic utilization in both groups; however, moderate/severe disease remains in a significant proportion of PsA and RA patients.

Costs and disease activity in early rheumatoid arthritis in 1996-2000 and 2006-2011, improved outcome and shift in distribution of costs: a two-year follow-up

OBJECTIVE

To evaluate changes in healthcare utilization, costs, and disease activity from 1996 to 2011 for patients with early rheumatoid arthritis (RA).

METHOD

Two cohorts of patients with early RA, included in 1996-1998 (T1) and 2006-2009 (T2), were followed regularly. Healthcare utilization, costs, and disease activity were compared between cohorts during 2 years after diagnosis.

RESULTS

Disease activity was significantly improved in T2 vs T1. Drug costs increased in T2 vs T1 (EUR 911 vs EUR 535, respectively; p = 0.017), and costs for RA-related hospitalization decreased. More than 90% in T2 were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion compared to 50% in T1. At 2 year follow-up, levels were still > 90% in T2, while corresponding values in T1 were just above 70%. Comparing T2 to T1, total direct costs were slightly higher in T2 (EUR 3941 vs EUR 3364, respectively; ns), sick leave decreased (EUR 3511 vs EUR 5672; p = 0.025), while disability pension increased slightly (EUR 4889 vs EUR 4244; ns), but total indirect costs remained unchanged (EUR 8400 vs EUR 9916; ns). Total direct and indirect costs did not differ between the cohorts (EUR 12 342 in T2 vs EUR 13 280 in T1; ns), and loss of productivity still represented the largest component of total costs.

CONCLUSION

T2 patients were prescribed DMARDs earlier and more aggressively than T1 patients. Stable and better improvements in disease activity, function, and quality of life were achieved in T2 compared to T1. There was a shift within the components in direct costs and indirect costs, but total costs remained essentially unchanged.

Temporal trends and regional disparity in rheumatoid arthritis and gout hospitalizations in Sweden, 1998-2015

Hospitalization is an important component of rheumatoid arthritis (RA) and gout economic burden. This study aimed to assess temporal trends and regional disparities in RA and gout hospitalizations among people aged ≥ 20 years in Sweden during 1998–2015. Data on hospital admissions with a principal diagnosis of RA or gout were collected from the National Patient Register. Age-standardized hospitalization rates (ASHRs) were calculated by means of direct standardization. The absolute and relative regional disparities were assessed. The temporal trends in ASHR and proportion of RA and gout hospitalizations from all and musculoskeletal disorders hospitalizations were analyzed using joinpoint regression. Between 1998–2000 and 2013–2015, the ASHR for RA declined by 78.9% from 109.9 to 23.2 per 100,000 Swedish adults, while it almost doubled for gout (from 10.5 to 20.8 per 100,000 Swedish adults). While in 1998–2000, RA hospitalizations were 10.3 times more frequent than gout (0.54 vs 0.05% of all hospitalizations), this ratio declined to 1.1 in 2013–2015 (0.13 vs 0.11% of all hospitalizations). The joinpoint regression revealed that, on average, the ASHR for RA declined by 10.2% (95% CI: 9.3–11.1) per year whereas for gout, it rose by 4.3% (3.2–5.4) per year during 1998–2015. While the relative regional disparities were stable, the absolute regional disparity declined for RA and increased for gout over the study period. While substantial decline in RA hospitalization is encouraging, the substantial rise in gout hospitalization is of concern, reflecting potential increase in prevalence of gout and suboptimal management of the disease.

The effect of an intensive smoking cessation intervention on disease activity in patients with rheumatoid arthritis: study protocol for a randomised controlled trial

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, inflammatory rheumatic disease with the potential to induce significant disability. Patients with RA are at increased risk of cardiovascular diseases (CVD). Smokers with RA tend to experience more pain and fatigue, higher disease activity, more erosive joint destruction and a lower health-related quality of life (HR-QoL) than non-smokers. It remains to be determined whether these effects can be reduced by smoking cessation. This randomised controlled trial (RCT) in patients with RA aims to examine the effect of intensive smoking cessation intervention (motivational counselling combined with tailored nicotine replacement therapy) versus standard care on smoking cessation, and consequently on disease activity. Secondary objectives are to explore the effect on flare, risk factors for CVD, lung function, physical function, HR-QoL, pain and fatigue in patients with RA.

METHODS

This will be a multicentre, open label, two arm, parallel group, RCT, including 150 daily smokers with RA, being in remission or having low-moderate disease activity (DAS28 ≤ 5.1). The intervention group (n = 75) will receive five counselling sessions with a trained smoking cessation counsellor based on the principles of motivational counselling. Furthermore, intervention patients will be offered nicotine replacement therapy tailored to individual needs. Participants randomised to the control group will receive standard care. The co-primary outcome is a hierarchical endpoint, which will be evaluated at 3 months follow-up and will include (1) self-reported smoking cessation biochemically validated by exhaled carbon monoxide and (2) achievement of EULAR clinical response (an improvement in DAS28 of > 0.6). Follow-up visits will be performed at 3, 6 and 12 months post-intervention.

DISCUSSION

This trial will reveal whether intensive smoking cessation counselling helps smokers with RA to achieve continuous smoking cessation and whether, as a concomitant benefit, it will reduce their RA disease activity. The trial aims to generate high quality evidence for the feasibility of a health promotion intervention for smokers with RA.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02901886 . Registered on 10 September 2016. Recruitment status updated on 10th October 2016.

EULAR recommendations for the management of rheumatoid arthritis: what is new in 2017 and its applicability in our local setting

Rheumatoid arthritis (RA) is the most common rheumatic disease being managed by the rheumatologists. With the emergence of the biologic and targeted synthetic disease modifying anti-rheumatic drugs (b/tsDMARDs), the prognosis of RA has improved substantially. However, these novel agents are associated with high cost and untoward effects. International consensus statements for the drug management of RA have been published to guide the practice of rheumatologists. In this article, updates from the 2016 EULAR management recommendations for RA are reviewed and discussed within the context of our local situation in Hong Kong.

Managing Rheumatoid Arthritis with Dietary Interventions

Self-help by means of dietary interventions can help in management of various disorders including rheumatoid arthritis (RA), a debilitating autoimmune disease. Dietary interventions necessitate a widespread appeal for both patients as well as clinicians due to factors including affordability, accessibility, and presence of scientific evidences that demonstrate substantial benefits in reducing disease symptoms such as pain, joint stiffness, swelling, tenderness and associated disability with disease progression. However, there is still an uncertainty among the community about the therapeutic benefits of dietary manipulations for RA. In the present review, we provide an account of different diets and their possible molecular mechanism of actions inducing observed therapeutic benefits for remission and management of RA. We further indicate food that can be a potential aggravating factor for the disease or may help in symptomatic relief. We thereafter summarize and thereby discuss various diets and food which help in reducing levels of inflammatory cytokines in RA patients that may play an effective role in management of RA following proper patient awareness. We thus would like to promote diet management as a tool that can both supplement and complement present treatment strategies for a better patient health and recovery.

Modeled Health Economic Impact of a Hypothetical Certolizumab Pegol Risk-Sharing Scheme for Patients with Moderate-to-Severe Rheumatoid Arthritis in Finland

PURPOSE

To model the American College of Rheumatology (ACR) outcomes, cost-effectiveness, and budget impact of certolizumab pegol (CZP) (with and without a hypothetical risk-sharing scheme at treatment initiation for biologic-naïve patients) versus the current mix of reimbursed biologics for treatment of moderate-to-severe rheumatoid arthritis (RA) in Finland.

METHODS

A probabilistic model with 12-week cycles and a societal approach was developed for the years 2015-2019, accounting for differences in ACR responses (meta-analysis), mortality, and persistence. The risk-sharing scheme included a treatment switch and refund of the costs associated with CZP acquisition if patients failed to achieve ACR20 response at week 12. For the current treatment mix, ACR20 at week 24 determined treatment continuation. Quality-adjusted life years were derived on the basis of the Health Utilities Index.

RESULTS

In the Finnish target population, CZP treatment with a risk-sharing scheme led to a estimated annual net expenditure decrease ranging from 1.7% in 2015 to 5.6% in 2019 compared with the current treatment mix. Per patient over the 5 years, CZP risk sharing was estimated to decrease the time without ACR response by 5%-units, decrease work absenteeism by 24 days, and increase the time with ACR20, ACR50, and ACR70 responses by 5%-, 6%-, and 1%-units, respectively, with a gain of 0.03 quality-adjusted life years. The modeled risk-sharing scheme showed reduced costs of €7866 per patient, with a more than 95% probability of cost-effectiveness when compared with the current treatment mix.

CONCLUSION

The present analysis estimated that CZP, with or without the risk-sharing scheme, is a cost-effective alternative treatment for RA patients in Finland. The surplus provided by the CZP risk-sharing scheme could fund treatment for 6% more Finnish RA patients.

FUNDING

UCB Pharma.