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Botson JK, Tesser JRP, Bennett R, Kenney HM, Peloso PM, Obermeyer K, LaMoreaux B, Weinblatt ME, Peterson J. Pegloticase in Combination With Methotrexate in Patients With Uncontrolled Gout: A Multicenter, Open-label Study (MIRROR). J Rheumatol 2020; 48:767-774. [PMID: 32934137 DOI: 10.3899/jrheum.200460] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine the efficacy and safety of pegloticase in combination with methotrexate (MTX) in patients with uncontrolled gout in an exploratory, open-label clinical trial (ClinicalTrials.gov: NCT03635957) prior to a randomized, controlled trial. METHODS A multicenter, open-label efficacy and safety study of pegloticase with MTX co-treatment was conducted in patients with uncontrolled gout. Patients were administered oral MTX (15 mg/week) and folic acid (1 mg/day) 4 weeks prior to and throughout pegloticase treatment. The primary study outcome was the proportion of responders, defined as serum uric acid (sUA) < 6 mg/dL for ≥ 80% of the time during Month 6 (Weeks 20, 22, and 24). All analyses were performed on a modified intent-to-treat population, defined as patients who received ≥ 1 pegloticase infusion. RESULTS Seventeen patients were screened and 14 patients (all men, average age 49.3 ± 8.7 years) were enrolled. On Day 1, mean sUA was 9.2 ± 2.5 mg/dL, and 12 of the 14 patients had visible tophi. At the 6-month timepoint, 11/14 (78.6%, 95% CI 49.2-95.3%) met the responder definition, with 3 patients discontinuing after meeting protocol-defined treatment discontinuation rules (preinfusion sUA values > 6 mg/dL at 2 consecutive scheduled visits). All patients tolerated MTX. No new safety concerns were identified. CONCLUSION In this study, an increased proportion of patients maintained therapeutic response at 6 months when treated concomitantly with MTX and pegloticase as compared to the previously reported 42% using pegloticase alone. These results support the need for a randomized study of MTX or placebo with pegloticase to validate these open-label findings.
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Affiliation(s)
- John K Botson
- J.K. Botson, MD, RPh, Orthopedic Physicians Alaska, Anchorage, Alaska;
| | - John R P Tesser
- J.R. Tesser, MD, R. Bennett, MD, Arizona Arthritis & Rheumatology Associates, P.C., Phoenix, Arizona
| | - Ralph Bennett
- J.R. Tesser, MD, R. Bennett, MD, Arizona Arthritis & Rheumatology Associates, P.C., Phoenix, Arizona
| | - Howard M Kenney
- H.M. Kenney, MD, Arthritis Northwest, PLLC, Spokane, Washington
| | - Paul M Peloso
- P.M. Peloso, MD, MSc, K. Obermeyer, MS, B. LaMoreaux, MD, MS, Horizon Therapeutics, Lake Forest, Illinois
| | - Katie Obermeyer
- P.M. Peloso, MD, MSc, K. Obermeyer, MS, B. LaMoreaux, MD, MS, Horizon Therapeutics, Lake Forest, Illinois
| | - Brian LaMoreaux
- P.M. Peloso, MD, MSc, K. Obermeyer, MS, B. LaMoreaux, MD, MS, Horizon Therapeutics, Lake Forest, Illinois
| | | | - Jeff Peterson
- J. Peterson, MD, Western Washington Arthritis Clinic, Bothell, Washington, USA
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Cruz BH, Garnica IU, Parera RS, Romero ER, Gutiérrez JC, Sánchez AG, Escalera CR, Sarabia FN. Disease-modifying antirheumatic drug prescription patterns in adult rheumatoid arthritis patients in routine clinical practice in Spain. Eur J Rheumatol 2020; 7:eurjrheum.2020.19053. [PMID: 32910753 PMCID: PMC7574759 DOI: 10.5152/eurjrheum.2020.19053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 04/11/2020] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To describe disease-modifying antirheumatic drug (DMARD) patterns in routine clinical practice in adult rheumatoid arthritis (RA) patients and to ascertain the reasons for methotrexate (MTX) discontinuation. METHODS A cross-sectional observational study was conducted from March to October 2014 at the Rheumatology Units of seven hospitals in Spain. In a single visit, the treating rheumatologist completed an online case report form. This report contained sociodemographic and RA variables. This study was conducted in accordance with Good Clinical Practice and local and national research legislations. RESULTS A total of 301 patients (71% women) with a mean age of 56.7±14.0 years and disease duration of 3.6±1.5 years were examined. The patients had RA with moderate disease activity, at least one poor prognostic factor, and comorbidities. The mean time between RA diagnosis and prescription of the first conventional synthetic DMARD (csDMARD) was 2.4±6.0 months. A total of 295 patients (98%) started the first csDMARD on monotherapy. MTX was the most-prescribed first-line drug (n=233, 79%). The mean treatment time of the first-line csDMARD was 27.0±19.4 months. Of these patients, 98% progressed to a second-line csDMARD; 118 patients were changed to another DMARD, mainly due to inefficacy (51, 37%), adverse events (AEs, 37, 27%), or intolerance (18, 13%). The use of MTX as second-line therapy reduced from 79% to 51%. At the time of the study, 200 patients (66%) received a csDMARD as monotherapy and 45 (15%) a combination of ≥2 csDMARDs. Fifty-five (18%) patients were being treated with a biological drug in monotherapy (16, 29%) or in a combination with a csDMARD (39, 71%), mainly MTX, 147 patients (57%) received steroids. Biological DMARD were prescribed as the second line for 42% of patients and 51% of patients received the third-line therapy or beyond. The rate of AEs that motivated a change in the csDMARD was 34%. CONCLUSION MTX was the most-used csDMARD as first and second-line therapy together with corticosteroids. The combination of two or more csDMARDs as first-line treatment was very infrequent. MTX toxicity and intolerance were higher and more significant than inefficacy but progressively decreased with use.
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Affiliation(s)
| | | | | | - Esteban Rubio Romero
- Department of Rheumatology, Virgen del Rocio University Hospital, Seville, Spain
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Systematic review of recommendations on the use of methotrexate in rheumatoid arthritis. Clin Rheumatol 2020; 40:1259-1271. [PMID: 32876784 DOI: 10.1007/s10067-020-05363-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/21/2020] [Accepted: 08/21/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Most recommendations for the use of methotrexate (MTX) in rheumatoid arthritis (RA) are issued by developed countries. It is unknown whether they are relevant globally. We reviewed existing recommendations on the use of MTX for the treatment of RA and summarized areas of agreement that could be relevant for least developed countries (LDCs). METHODS Electronic databases and registries were searched for recommendations on MTX use in RA, duplicates were eliminated, and the most updated version adopted when there were several versions on the same recommendation. Reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for study quality assessment. Similarities and discrepancies of recommendations are reported. RESULTS After deduplication, 1693 unique citations were found; 25 full texts were screened and 12 included in the narrative synthesis. Average scores for the AGREE II domains ranged from 33.3 to 83.3%. Recommendations targeted rheumatologists and health care providers involved in RA care. Most covered some but not all of the following areas: baseline "pre-MTX" assessment (7/12;58%), prescription of MTX (10/12;83.3%), management of MTX side effects (6/12;50%), and special considerations (e.g., peri-operative management) (8/12; 66.7%). Recommendations agreed on baseline tests prior to starting MTX, monitoring, and need for folic acid supplementation. These aspects can serve as the foundation for the development of MTX recommendations relevant to LDCs. Recommendations disagreed on the MTX starting dose, optimal route, titration, and intervals to monitor toxicity. CONCLUSION Existing recommendations do not uniformly address all aspects related to the use of MTX and disagree in relevant aspects of MTX use. Adaptations to these recommendations are needed to facilitate their implementation in LDCs. Key Points • This paper summarizes current recommendations on the use of methotrexate for the treatment of rheumatoid arthritis. • Areas of agreement between recommendations include the following: pre-methotrexate patient assessment, need for folic acid supplementation, and toxicity monitoring. • Areas of disagreement relate to methotrexate starting and maximal dose, titration, and frequency of assessments.
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Skiba MB, Hopkins LL, Hopkins AL, Billheimer D, Funk JL. Nonvitamin, Nonmineral Dietary Supplement Use in Individuals with Rheumatoid Arthritis. J Nutr 2020; 150:2451-2459. [PMID: 32805045 PMCID: PMC7540062 DOI: 10.1093/jn/nxaa197] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/27/2020] [Accepted: 06/18/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Over-the-counter, natural product-based (nonvitamin, nonmineral) dietary supplement (NVNM DS) use is common in adults with rheumatoid arthritis (RA), a group at risk for drug-DS interactions, due to polypharmacy, but this use is underreported to health care providers. Recent dramatic changes in US sales of specific NVNM DS suggest that the prevalence and types of NVNM DS used in RA populations may also have shifted. OBJECTIVES A study was undertaken to identify current and past use of specific NVNM DS for RA disease treatment and to examine associations between use of NVNM DS, RA pharmaceuticals, and/or vitamin or mineral (VM) DS. METHODS We developed a survey instrument to capture current and ever use of specific NVNM DS, VM DS, and RA pharmaceuticals, with 696 subjects self-reporting an RA diagnosis recruited online or in clinic for survey participation. Analyses were limited to 611 subjects reporting RA diagnosis after age 18 y and treatment with specific RA pharmaceuticals. RESULTS Most participants reported DS use, with current usage prevalence 49.6% (n = 303), 83.5% (n = 510), or 87.6% (n = 535) for NVNM, VM, or any DS, respectively. While not having appeared in previous RA surveys, turmeric and ginger were among the top 3 NVNM DS in current use, along with fish oil/ω-3 (n-3) PUFA. Concurrent NVNM DS use was reported by 48.2% (n = 243) of participants currently using RA pharmaceuticals (n = 504) and was more common in those using disease-modifying antirheumatic drugs only (no biologics). Most methotrexate users (83%) reported concurrent folate supplementation, with one-third also using turmeric, which is notable because methotrexate and turmeric have been associated with hepatotoxicity. CONCLUSION Individuals with RA commonly use NVNM DS in combination with RA pharmaceuticals, including a previously undocumented but popular use of turmeric or ginger supplements with an unclear risk/benefit ratio.
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Affiliation(s)
- Meghan B Skiba
- Department of Health Promotion Sciences, University of Arizona, Tucson, AZ, USA,Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Laura L Hopkins
- Department of Medicine, University of Arizona, Tucson, AZ, USA,Department of Nutritional Sciences, University of Arizona, Tucson, AZ, USA
| | - Allison L Hopkins
- Department of Anthropology, Texas A&M University, College Station, TX, USA
| | - Dean Billheimer
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ, USA
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García DS, Saturansky EI, Poncino D, Martínez-Artola Y, Rosenberg S, Abritta G, Ascimani-Peña C, Cravero A. "Hepatic toxicity by methotrexate with weekly single doses associated with folic acid in rheumatoid and psoriatic arthritis. What is its real frequency?". Ann Hepatol 2020; 18:765-769. [PMID: 31105018 DOI: 10.1016/j.aohep.2019.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/31/2019] [Accepted: 01/31/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Liver injury caused by methotrexate (MTX) has mostly been investigated without applying criteria for the assessment of causality of drug induced liver injury (DILI). Hence, the existence of DILI by MTX in many cases is debatable. This study aimed to describe the frequency and characteristics of liver injury caused by MTX, applying DILI diagnostic criteria. MATERIAL AND METHODS Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients who were treated with MTX in association with folic acid were included. Serial determinations of alanine amino transferase (ALT) and aspartate amino transferase (AST) were performed. The Roussel Uclaf Causality Assessment Method (RUCAM) was applied in cases of increases of ALT/AST over 1.5 upper limit of normal. Liver biopsy was considered when the total cumulative dosage (TCD) of MTX was ≥3.5g. RESULTS A total of 43 patients were analyzed (median follow up 32 (range: 1-48) months; 3.33 ALT/AST determinations per year). Five subjects presented an increase of ALT/AST. All presented a RUCAM score for MTX≤2 (improbable). Three had a RUCAM score for non-steroidal anti-inflammatory drugs ≥7 (probable) and two patients presented non-alcoholic fatty liver disease. Five patients with no other cause for liver disease consented to liver biopsy (TCD MTX: median 5.1; range: 3.5-7.4g). No significant fibrosis or steatosis was evident on histology. CONCLUSIONS No biochemical or significant histological liver toxicity for MTX was demonstrated when applying causality criteria for DILI. More studies with this methodology are necessary in order to improve the assessment of its frequency.
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Affiliation(s)
- Daniel S García
- Department of Hepatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina.
| | - Etel I Saturansky
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Poncino
- Department of Hepatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Yamila Martínez-Artola
- Department of Hepatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Silvia Rosenberg
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Gloria Abritta
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Carlos Ascimani-Peña
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Amerys Cravero
- Department of Pathology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
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Mori S, Arima N, Ito M, Ueki Y, Abe Y, Aoyagi K, Fujiyama S. Incidence, predictive factors and severity of methotrexate-related liver injury in rheumatoid arthritis: a longitudinal cohort study. Rheumatol Adv Pract 2020; 4:rkaa020. [PMID: 33134809 PMCID: PMC7585403 DOI: 10.1093/rap/rkaa020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/27/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The aims were to determine the incidence rate, predictive factors and severity of liver injury that develops during MTX treatment for RA and to evaluate the role of pretreatment hepatic fat deposition. METHODS We used an ongoing real-life registry containing RA patients who had started MTX between August 2007 and April 2018 at participating institutions. The liver-to-spleen attenuation ratio on CT scans at enrolment was used to evaluate pretreatment fat deposition quantitatively. Patients were followed until persistent transaminitis developed or until the end of the study. Liver biopsy was performed for patients who presented with persistent transaminitis. RESULTS We followed 289 new MTX users without pretreatment elevations of transaminases (mean follow-up time, 58.3 months). Hepatic fat deposition was detected in half of the patients at enrolment. During follow-up, persistent transaminitis occurred at a crude incidence rate of 3.13 per 100 person-years, and the cumulative incidence at 5 years was estimated to be 13%. A multivariate Fine-Gray regression analysis showed that the most important predictive factors were pre-existing moderate to severe fat deposition (adjusted hazard ratio, 7.69; 95% CI: 3.10, 19.10) and obesity (adjusted hazard ratio, 2.68; 95% CI: 1.37, 5.25). Non-alcoholic steatohepatitis (NASH) was the most predominant pattern in liver biopsy samples. Hepatic fibrosis was found in 90% of samples, but most cases were not advanced. CONCLUSION Aggravation of underlying fatty liver to NASH with fibrosis seems to be an important mechanism of liver injury that occurs in MTX-treated RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization Kumamoto Saishun Medical Center, Kohshi, Kumamoto
| | - Nobuyuki Arima
- Department of Pathology, Kumamoto Shinto General Hospital, Kumamoto
| | - Masahiro Ito
- Department of Pathology, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Omura, Nagasaki
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki
| | - Yasuyo Abe
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Kiyoshi Aoyagi
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Shigetoshi Fujiyama
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
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Li CKH, Baker K, Jones T, Coulson E, Roberts A, Birrell F. Safety and Tolerability of Subcutaneous Methotrexate in Routine Clinical Practice. Arthritis Care Res (Hoboken) 2020; 73:1306-1311. [PMID: 32475009 DOI: 10.1002/acr.24334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/19/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To show the safety and efficacy of subcutaneous (SC) methotrexate (MTX) compared to oral MTX, alternative disease-modifying antirheumatic drugs (DMARDs) monotherapy, biologic monotherapy, and combinations (conventional and biologic combination groups) in routine clinical practice. METHODS Clinical and laboratory data were retrospectively analyzed for rheumatology clinic attendances at a large Northeast England hospital trust between January 2014 and January 2018. Rates of adverse events and stop events (transaminitis [serum alanine aminotransferase level of >80 units/liter] or neutropenia [neutrophil count of <2.0 × 109 /liter]) were calculated, with adjustment for duration of DMARD exposure. RESULTS In the present study, 8,394 patients received DMARDs, with 2,093 patients receiving oral MTX and 949 patients receiving SC MTX. The median dose was 15 mg (interquartile range [IQR] 10-20 mg) for oral MTX, and 20 mg (IQR 15-25 mg) for SC MTX (P < 0.0001). Continuation rates were higher for SC MTX therapy when adjusted for follow-up duration, with a rate ratio (RR) of 1.54 (95% confidence interval [95% CI] 1.40-1.70) (P < 0.0001). For the time period assessed, 2,382 patients experienced 4,358 adverse events, with 1,711 incidents of transaminitis and 2,647 incidents of neutropenia recorded. Significantly fewer adverse events were observed in patients who received SC MTX monotherapy versus those who received biologic and combination DMARD therapies (P < 0.01). Compared to oral MTX, SC MTX was associated with a nonsignificant trend toward lower rates of neutropenia, but only a slightly higher rate of transaminitis (RR 1.26 [95% CI 1.07-1.48]) (P = 0.006), despite significantly higher doses of MTX. CONCLUSION Subcutaneous MTX is safe in routine clinical practice. This is the largest study yet reported on SC MTX and provides observational data that SC MTX is continued longer and better tolerated in patients compared to other therapy groups, especially oral MTX.
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Affiliation(s)
- Christien K H Li
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Kenneth Baker
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Tania Jones
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Elizabeth Coulson
- Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Fraser Birrell
- Translational and Clinical Research Institute, Newcastle University and Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
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Fertility and infertility implications in rheumatoid arthritis; state of the art. Inflamm Res 2020; 69:721-729. [PMID: 32458007 DOI: 10.1007/s00011-020-01362-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/28/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND A bulk of investigations imply that women with rheumatoid arthritis (RA) deliver fewer children in comparison to healthy women. PURPOSE This review article attempts to clarify the involvement of infertility-related issues in both RA men and women. Moreover, the effect of RA disease on the fertility quality and quantity will be discussed. RESULTS Declined fertility rate in RA women seems to stem from modified inflammatory settings, advanced maternal age, limited sexual activity, and adverse effects of drugs on ovarian function. Women with RA may have smaller families and seem to be slower to conceive relative to their peer women. The chance of gestation in RA women may drop due to suppressed sexual function through pain and fatigue. In addition, treatment of RA women with non-steroidal anti-inflammatory drugs (NSAIDs) may prevent ovulation and therefore hinder the conception. CONCLUSIONS A complex interaction between RA disease and fertility related issues is present. Despite an increase rate of infertility in RA females or males, the mechanisms involved in this outcome is still unknown. Plausible causes of the decreased fertility rate in RA patients might be due to inflammatory cytokines, suppressed sexual activity, drug treatments, mother age, personal choice, or a combination of these elements.
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Bermas BL. Paternal safety of anti-rheumatic medications. Best Pract Res Clin Obstet Gynaecol 2020; 64:77-84. [DOI: 10.1016/j.bpobgyn.2019.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
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A Pilot Randomized Controlled Double-Blind Trial of High- Versus Low-Dose Weekly Folic Acid in People With Rheumatoid Arthritis Receiving Methotrexate. J Clin Rheumatol 2020; 25:284-287. [PMID: 30001258 DOI: 10.1097/rhu.0000000000000848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE The aim of this study was to determine whether reducing the dose of supplemental folic acid used in conjunction with methotrexate (MTX) therapy in people with active rheumatoid arthritis (RA) improved disease control and/or increased MTX-related adverse effects. METHODS A randomized double-blind randomized controlled trial comparing 5 mg/wk and 0.8 mg/wk folic acid was undertaken. Rheumatoid arthritis patients on MTX for 3 months or more at a stable dose for 1 month or more were recruited. All participants had DAS28 of 3.2 or greater or required a change in therapy determined by the treating clinician. Disease activity, full blood count, liver function tests, red blood cell (RBC) folate, and RBC MTX polyglutamates were assessed at weeks 0, 4, 8, 16, and 24 along with reports of adverse events. RESULTS Forty participants were recruited. The mean (SD) change in RBC folate between week 0 and 24 was +87.9 (57.4) nmol/L in the high-dose group and -113.3 (65.7) nmol/L in the low-dose group (p < 0.05). There was no significant difference in the change in DAS28 between the high- and low-dose groups at 24 weeks (-0.13 [95% confidence interval, -0.69 to 0.43] vs -0.25 [-0.87 to 0.37], respectively [p = 0.78]). There was no significant difference in MTX-related adverse effects between the 2 groups. CONCLUSIONS A reduction in RBC folate secondary to reduction in folic acid dose was not associated with a change in RA disease activity or MTX-related adverse effects. The prevention of MTX-related adverse effects remains the primary reason for coprescribing folic acid with MTX. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR12610000739011).
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Mulder MLM, Vriezekolk JE, den Broeder N, Mahler EAM, Helliwell PS, van den Hoogen FHJ, den Broeder AA, Wenink MH. Comparing methotrexate monotherapy with methotrexate plus leflunomide combination therapy in psoriatic arthritis: protocol of a randomized, placebo-controlled, double-blind clinical trial (COMPLETE-PsA). Trials 2020; 21:155. [PMID: 32041657 PMCID: PMC7011519 DOI: 10.1186/s13063-020-4097-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Both methotrexate (MTX) and leflunomide (LEF) are registered and regularly prescribed as first-line treatments for the use in patients with psoriatic arthritis (PsA) and they are occasionally used in combination. However, evidence about their individual, and especially combined efficacy, in PsA is lacking. The aim of this study is to compare the effectiveness and safety of MTX and LEF combination therapy to MTX monotherapy in patients with PsA. Methods COMPLETE-PsA is a randomized, placebo-controlled, double-blind clinical trial. Disease-modifying antirheumatic drug (DMARD)-untreated patients (n = 78) with clinical diagnosis of active (i.e. ≥2 swollen joints) PsA will be randomized 1:1 (stratified for high disease activity, Psoriatic Arthritis Disease Activity Score [PASDAS] ≥ 5.4) to the combination or monotherapy. The intervention group receives MTX 25 mg (oral or subcutaneous) once weekly plus LEF 20 mg daily, and the control group receives the same but with placebo instead of LEF daily. Primary endpoint is between-group difference in PASDAS at 16 weeks, adjusted for baseline PASDAS. Key secondary parameters include between-group comparisons in change in Disease Activity in Psoriatic Arthritis (DAPSA) score, skin score, enthesitis score, dactylitis score, and swollen/tender joint count, as well as the proportion of patients fulfilling minimal disease activity (MDA), American College of Rheumatology (ACR) 20/50/70 response criteria at week 16. Furthermore, safety, function and quality of life (Health Assessment Questionnaire [HAQ], Psoriatic Arthritic Impact of Disease [PSAID], Short Form 12 [SF-12]) will be assessed. Discussion This is, to our knowledge, the first randomized, placebo-controlled, double-blind clinical trial assessing the effectiveness of MTX and LEF combination therapy in patients with PsA. The study will provide important information for treatment strategies and treatment recommendations. Trial registration Dutch Trial Register NTR7632 (3 December 2018). CMO NL66544.091.18 (19 November 2018).
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Affiliation(s)
- Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands. .,Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Johanna E Vriezekolk
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
| | - Elien A M Mahler
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
| | - Philip S Helliwell
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands.,Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands.,Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark H Wenink
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
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Sonawane K, Zhu Y, Chan W, Aguilar D, Deshmukh AA, Suarez-Almazor ME. Association of Serum Folate Levels With Cardiovascular Mortality Among Adults With Rheumatoid Arthritis. JAMA Netw Open 2020; 3:e200100. [PMID: 32101310 PMCID: PMC7137687 DOI: 10.1001/jamanetworkopen.2020.0100] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Patients with rheumatoid arthritis (RA) are at high risk for cardiovascular (CV) mortality, attributed to chronic inflammation coupled with elevated circulatory homocysteine levels. Increasing the serum folate level reduces homocysteine, but the association of serum folate concentration with CV mortality in patients with RA has not been previously examined. OBJECTIVE To examine the association of serum folate concentration and CV mortality risk among patients with RA. DESIGN, SETTING, AND PARTICIPANTS A cohort study of the third National Health and Nutrition Examination Survey (1988-1994) and 2011 Linked Mortality File was performed. Adults aged 18 years or older with self-reported physician-diagnosed RA were included. Data analysis was performed between April 2019 and June 2019. EXPOSURE Serum folate level. MAIN OUTCOMES AND MEASURES All-cause and CV mortality risk estimated using Cox proportional hazards models, adjusted for the complex survey design and patient characteristics, including demographic characteristics, body mass index, C-reactive protein level, smoking, RA medication use, and comorbid conditions. RESULTS A total of 683 patients with RA (mean [SE] age, 55.9 [1.0] years; 225 [30.2%] men; 478 [87.0%] white) were classified into tertiles based on serum folate levels, as follows: tertile 1, folate levels less than 4.3 ng/mL (n = 239); tertile 2, folate levels 4.3 ng/mL to 8.2 ng/mL (n = 234); and tertile 3, folate levels greater than 8.2 ng/mL (n = 210). During a median (interquartile range) follow-up of 17.4 (10.0-19.4) years, a total of 392 all-cause deaths and 258 CV deaths occurred. Compared with tertile 1, patients in tertile 2 had lower all-cause mortality risk (hazard ratio [HR], 0.63; 95% CI, 0.47-0.85). The risk of CV mortality was lower among patients in tertile 2 (HR, 0.52; 95% CI, 0.30-0.92) and tertile 3 (HR, 0.44; 95% CI, 0.26-0.75) compared with those in tertile 1 (P for trend = .01). Findings for CV mortality were consistent in a sensitivity analysis that estimated 10-year risk; patients in tertile 2 (HR, 0.31; 95% CI, 0.17-0.57) and tertile 3 (HR, 0.39; 95% CI, 0.22-0.69) had lower CV mortality risk compared with those in tertile 1 (P for trend = .04). CONCLUSIONS AND RELEVANCE Among patients with RA, a serum folate level of at least 4.3 ng/mL was associated with lower CV mortality risk. Further research is needed to examine whether a causal relationship exists between serum folate and CV risk among patients with RA.
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Affiliation(s)
- Kalyani Sonawane
- Center for Healthcare Data, Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston
- Center for Health Services Research, Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston
| | - Yenan Zhu
- Department of Management, Policy, and Community Health, University of Texas Health Science Center at Houston
| | - Wenyaw Chan
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston
| | - David Aguilar
- Department of Medicine, Division of Cardiology, University of Texas Health Medical School at Houston
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston
| | - Ashish A. Deshmukh
- Center for Health Services Research, Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston
| | - Maria E. Suarez-Almazor
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
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Olsen IC, Lie E, Vasilescu R, Wallenstein G, Strengholt S, Kvien TK. Assessments of the unmet need in the management of patients with rheumatoid arthritis: analyses from the NOR-DMARD registry. Rheumatology (Oxford) 2020; 58:481-491. [PMID: 30508189 PMCID: PMC6381770 DOI: 10.1093/rheumatology/key338] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 10/15/2018] [Indexed: 01/19/2023] Open
Abstract
Objective To describe the outcomes of MTX and biologic DMARD (bDMARD) treatment in patients with RA and assess unmet needs in patients who fail treatment, using real-world data from the Norwegian DMARD (NOR-DMARD) registry. Methods Data included RA treatment courses from January 2007 until July 2016. Patients received MTX monotherapy (in MTX-naïve patients), bDMARD monotherapy, bDMARDs + MTX, or bDMARDs + other conventional synthetic DMARDs (csDMARDs). DAS28-4(ESR) was used to measure remission (<2.6) and inadequate response (>3.2) across all groups at Months 6 and 12. Estimated ACR20/50/70 and EULAR good and good/moderate response rates (based on DAS28-4[ESR] score) for bDMARDs were modelled at Months 6 and 12 using logistic mixed regression. DAS28-4(ESR) scores and changes from baseline, and rates and reasons for discontinuation, were evaluated for all groups over 24 months. Results The 2778 treatment courses in this analysis included 714 MTX monotherapy, 396 bDMARD monotherapy, 1460 bDMARDs + MTX and 208 bDMARDs + other csDMARDs. Of patients with DAS28-4(ESR) data at Months 6 and 12 (25.0–34.1%), 33.9–47.2% did not switch treatment and were inadequate-responders at Month 12. There were no significant differences in efficacy between bDMARD groups (bDMARD monotherapy, or bDMARDs + MTX or other csDMARDs). Lack of efficacy was the most common reason for stopping treatment across all groups (13.7–22.1% over 24 months). Conclusion An unmet treatment need exists for patients still experiencing inadequate response to MTX monotherapy and bDMARDs as monotherapy or in combination with MTX/other csDMARDs after 12 months. Trial registration ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT01581294.
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Affiliation(s)
- Inge C Olsen
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Elisabeth Lie
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | | | | | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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Suzuki Y, Sugiyama N, Fukuma Y, Sugiyama N, Kokubo T. RETRACTED ARTICLE: Safety and effectiveness of high-dose methotrexate (over 8 mg/week) in 2838 Japanese patients with rheumatoid arthritis: A postmarketing surveillance report. Mod Rheumatol 2020; 30:vii-xviii. [DOI: 10.1080/14397595.2017.1304857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Yasuo Suzuki
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | | | - Yuri Fukuma
- Medical Affairs, Pfizer Japan Inc., Tokyo, Japan
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65
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Jekic B, Maksimovic N, Damnjanovic T. Methotrexate pharmacogenetics in the treatment of rheumatoid arthritis. Pharmacogenomics 2019; 20:1235-1245. [DOI: 10.2217/pgs-2019-0121] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
For many decades, methotrexate (MXT) has remained the drug of choice in the treatment of rheumatoid arthritis (RA). Unfortunately, a considerable number of patients do not achieve an appropriate therapeutic response. Pharmacogenetics studies do not give usable results regarding differences in MTX response among RA patients. The mechanism of MTX action in RA is not completely understood. We present and discuss data regarding the molecular basis of folate and adenosine pathways, the most obvious MTX targets, to explain possible causes of therapy failure. The molecular basis of the disease could also have an impact on therapy outcomes and in this review we explore this. Finally, we make a short review of available pharmacogenetics study results.
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Affiliation(s)
- Biljana Jekic
- Institute of Human Genetics, Faculty of Medicine, University of Belgrade,11000 Belgrade, Serbia
| | - Nela Maksimovic
- Institute of Human Genetics, Faculty of Medicine, University of Belgrade,11000 Belgrade, Serbia
| | - Tatjana Damnjanovic
- Institute of Human Genetics, Faculty of Medicine, University of Belgrade,11000 Belgrade, Serbia
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66
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Leung JL, Owen CE, Buchanan RRC, Liew DFL. Management of polymyalgia rheumatica in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jessica L. Leung
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - Claire E. Owen
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - Russell R. C. Buchanan
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - David F. L. Liew
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
- Department of Clinical Pharmacology and Therapeutics Austin Health Melbourne Australia
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67
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O'Shaughnessy MA, Kannas S, Ernste F, Rizzo M. Team Approach: Role of Medical and Surgical Management in Rheumatoid Arthritis of the Hand and Wrist. JBJS Rev 2019; 7:e10. [PMID: 31460989 DOI: 10.2106/jbjs.rvw.18.00196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Maureen A O'Shaughnessy
- Departments of Orthopedic Surgery (M.A.O. and M.R.), Physical Medicine and Rehabilitation (S.K.), and Rheumatology (F.E.), Mayo Clinic, Rochester, Minnesota
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68
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Lucas CJ, Dimmitt SB, Martin JH. Optimising low-dose methotrexate for rheumatoid arthritis-A review. Br J Clin Pharmacol 2019; 85:2228-2234. [PMID: 31276602 DOI: 10.1111/bcp.14057] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
Methotrexate at low doses (5-25 mg/week) is first-line therapy for rheumatoid arthritis. However, there is inter- and intrapatient variability in response, with contribution of variability in concentrations of active polyglutamate metabolites, associated with clinical efficacy and toxicity. Prescribing remains heterogeneous across population groups, disease states and regimens. This review examines current knowledge of dose-response of oral methotrexate in the setting of rheumatoid arthritis, and how this could help inform dosage regimens.
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Affiliation(s)
- Catherine J Lucas
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Simon B Dimmitt
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Internal Medicine, Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Western Australia, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
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69
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Asai S, Hayashi M, Hanabayashi M, Kanayama Y, Takemoto T, Yabe Y, Shioura T, Ishikawa H, Yoshioka Y, Kato T, Hirano Y, Fujibayashi T, Hattori Y, Kobayakawa T, Ando M, Kuwatsuka Y, Takahashi N, Matsumoto T, Asai N, Sobue Y, Nishiume T, Suzuki M, Ishiguro N, Kojima T. Discontinuation of concomitant methotrexate in Japanese patients with rheumatoid arthritis treated with tocilizumab: An interventional study. Mod Rheumatol 2019; 30:434-441. [PMID: 31390271 DOI: 10.1080/14397595.2019.1641934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objectives: To evaluate the efficacy and safety of methotrexate (MTX) discontinuation in Japanese rheumatoid arthritis (RA) patients with sustained low disease activity undergoing combination therapy with tocilizumab (TCZ) plus MTX.Methods: This multicenter, open-label, uncontrolled, prospective study included RA patients maintaining low disease activity (Clinical Disease Activity Index (CDAI) ≤10) for ≥12 weeks with TCZ plus MTX. Methotrexate was discontinued following 12 weeks of biweekly administration while continuing TCZ therapy. The primary endpoint was the proportion of patients maintaining low disease activity with no flare at week 36.Results: A total of 49 patients completed 36 weeks of therapy. The proportion of patients maintaining low disease activity at week 36 was 75.5%. The lower limit of the 95% confidence interval exceeded the assumed threshold response rate of 60%, demonstrating the clinical feasibility of MTX discontinuation. The prevalence of gastroesophageal reflux disease, defined as a Frequency Scale for Symptoms of Gastroesophageal reflux disease score ≥8, significantly decreased from week 0 to 12 (27.1-18.4%; p= .025).Conclusion: Discontinuation of concomitant MTX is clinically feasible for maintaining low disease activity, and may be beneficial from the perspective of reducing gastrointestinal symptoms in Japanese RA patients treated with TCZ. Trial registration number: UMIN000021247.
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Affiliation(s)
- Shuji Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masatoshi Hayashi
- Department of Rheumatology, Nagano Red Cross Hospital, Nagano, Japan
| | | | | | - Toki Takemoto
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Yuichiro Yabe
- Department of Rheumatology, Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Tomone Shioura
- Department of Rheumatology, Shizuoka Kosei Hospital, Shizuoka, Japan
| | - Hisato Ishikawa
- Department of Rheumatology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Yutaka Yoshioka
- Department of Rheumatology, Handa Municipal Hospital, Handa, Japan
| | | | - Yuji Hirano
- Department of Rheumatology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | | | - Yosuke Hattori
- Department of Orthopedic Surgery and Rheumatology, Nagoya Medical Center, Nagoya, Japan
| | | | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Nobunori Takahashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Matsumoto
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Nishiume
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mochihito Suzuki
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Lee YK, Chao SC, Lee CN, Hung JH. Scleritis and anterior uveitis may herald the development of an epibulbar tumor in patients with extranodal Rosai-Dorfman disease: a case report. BMC Ophthalmol 2019; 19:144. [PMID: 31291929 PMCID: PMC6617840 DOI: 10.1186/s12886-019-1158-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 07/05/2019] [Indexed: 12/17/2022] Open
Abstract
Background Rosai-Dorfman disease is a rare non–Langerhans cell histiocytosis. Ocular involvement is even rarer, mostly involving the orbit and eyelids, although marginal corneal ulcers, uveitis, and epibulbar masses have also been reported, and is characterized by multiple recurrences. However, the disease course and optimal treatment strategies remain undetermined, in light of the rarity of this disease. Case presentation We reported a 36-year-old male patient with the extranodal form of Rosai-Dorfman disease, presenting with scleritis and anterior uveitis in the left eye, who experienced subsequent development of an epibulbar tumor in the same eye. The patient was also complicated by a relapsing facial nodule on the right cheek. After the pathological diagnosis of Rosai-Dorfman disease was obtained, the patient underwent surgical excision of the epibulbar tumor and the facial nodule, accompanied by systemic immunosuppression therapy. At the last follow-up, the patient was asymptomatic without signs of recurrence. Conclusions This report highlights the progression of ocular manifestations of Rosai-Dorfman disease and emphasizes the importance of systemic therapy.
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Affiliation(s)
- Yu-Kuei Lee
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheau-Chiou Chao
- Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chaw-Ning Lee
- Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jia-Horung Hung
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Tanaka Y, Mimori T, Yamanaka H, Sunaga N, Morita K, Kimura J, Takeuchi T. Effectiveness, safety, and methotrexate dose-tapering pattern over two years of treatment with adalimumab and ≥12 mg/week methotrexate for early rheumatoid arthritis: Results of the HAWK postmarketing surveillance study in Japan. Mod Rheumatol 2019; 30:424-433. [PMID: 31267801 DOI: 10.1080/14397595.2019.1639931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: To investigate the long-term effectiveness, safety, and methotrexate (MTX) dose-tapering patterns in patients with rheumatoid arthritis (RA) receiving adalimumab plus high-dose MTX.Methods: In this prospective, postmarketing study (2012-2017), conducted at 128 sites in Japan, biologic-naïve patients with RA (duration ≤2 years) previously treated with MTX for ≥3 months, initiated treatment with adalimumab and MTX (≥12 mg/week). Effectiveness by Disease Activity Score in 28 joints using C-reactive protein (DAS28-CRP), safety, and MTX dose-tapering were assessed from baseline to 104 weeks.Results: In the effectiveness analysis set (n = 292), DAS28-CRP remission (<2.6) was achieved in 92.3% (n = 120/130) of patients at week 104. The proportions of patients receiving MTX dose <10 mg/week increased to 32.3% (n = 50/155) and ≥12 mg/week reduced to 52.9% (n = 82/155) by week 104. Per univariate regression analysis, MTX dose tapering was associated with longer adalimumab drug survival. Of 70 patients with joint X-rays available, 59 (84.3%) achieved Δ modified total Sharp score ≤1.0 at 104 weeks. In the safety analysis set (n = 300), 143 adverse drug reactions were reported in 92 patients (30.7%, non-serious; 24.7%, serious 8.7%).Conclusion: The long-term effectiveness and safety of adalimumab with high-dose MTX was confirmed in biologic-naïve patients with early RA in a real-world setting in Japan.Clinical Trial Registration: This study is registered at ClinicalTrials.gov (identifier: NCT01736189; retrospectively registered 29 November 2012, due to administrative reasons).
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tsuneyo Mimori
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | | | | | | | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University, Tokyo, Japan
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Fang C, Zhang Q, Wang N, Jing X, Xu Z. Effectiveness and tolerability of methotrexate in pulmonary sarcoidosis: A single center real-world study. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2019; 36:217-227. [PMID: 32476957 PMCID: PMC7247084 DOI: 10.36141/svdld.v36i3.8449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/14/2019] [Indexed: 12/16/2022]
Abstract
Background Pulmonary sarcoidosis patients who get disease progression despite corticosteroid treatment or can't tolerate corticosteroid required second-line drug. Methotrexate (MTX) is the most widely used in our clinical practice. Data on its safety and efficacy at different doses are still limited, especially for those without folic acid supplements. Objective To report effectiveness of different MTX dosages and tolerability of MTX in pulmonary sarcoidosis without folic acid supplements. Methods A retrospective study on pulmonary sarcoidosis patients receiving MTX therapy with various dose ≥3 months was conducted. The primary outcome was change in high-resolution computed tomography (HRCT) before and after MTX therapy. Other efficacy parameters included SGRQ score, prednisone dose change, discontinuation and relapse-free survival. Response-linked factors and safety outcomes were also analyzed. Results Overall, 49 patients (81.7%) were assessed as MTX responders by HRCT and there was no significant difference in clinical response rate among three groups with different doses. The health-related quality of life (HRQL) of the responders improved obviously, which was evidenced by SGRQ score declining from 16.7(IQR: 7.9-26.4) to 10.7(IQR: 4.8-19.3) (P=0.029). The corticosteroids sparing effect was confirmed in "responders" group (P<0.001). When MTX was discontinued in 11 responders with complete improvement, 2 patients experienced relapses within 15.5 (range: 1-30) months (mean follow-up time of these 11 responders: 13.5±13.0 months). No clinical characteristics were found related to MTX effectiveness. Adverse events occurred in 31.7% of the patients, with gastrointestinal-related being the commonest. Drug discontinuation owing to adverse events occupied 6.7% of the subjects. Conclusions Nearly 80% of the sarcoidosis subjects had well response to MTX. Its effectiveness was irrelevant to the treatment dosages and baseline characteristics. A quite low relapse rate was witnessed in those complete responders discontinuing MTX therapies. The steroid-sparing effect, well drug tolerability and low drug withdrawal rate were observed in these patients even without folic acid supplements in clinical practice.
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Affiliation(s)
| | | | | | | | - Zuojun Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Abstract
A variety of rheumatologic disorders may affect the liver. There is a significant epidemiologic, genetic, and immunologic overlap between immune-mediated rheumatologic disorders and autoimmune liver diseases. There is an increased frequency of autoimmune liver diseases, such as primary biliary cholangitis, autoimmune hepatitis, primary sclerosing cholangitis, or overlap syndrome, in patients with systemic lupus erythematosus, rheumatoid arthritis, Sjögren syndrome, systemic sclerosis, vasculitis, and other immune-related diseases. Non-immune-mediated rheumatologic diseases such as gouty arthritis may also have hepatic manifestations. Furthermore, medications used to treat rheumatologic diseases occasionally cause liver dysfunction. Conversely, primary immune-mediated and non-immune-mediated liver disorders may present with rheumatologic manifestations.
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Affiliation(s)
- Agazi Gebreselassie
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Howard University Hospital, 2041 Georgia Avenue Northwest, Suite 4J19, Washington, DC 20060, USA
| | - Farshad Aduli
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Howard University Hospital and College of Medicine, 2041 Georgia Avenue Northwest, Suite 5C22, Washington, DC 20060, USA
| | - Charles D Howell
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Howard University Hospital and College of Medicine, 2041 Georgia Avenue Northwest, Suite 5C02, Washington, DC 20060, USA.
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How to Get the Most from Methotrexate (MTX) Treatment for Your Rheumatoid Arthritis Patient?-MTX in the Treat-to-Target Strategy. J Clin Med 2019; 8:jcm8040515. [PMID: 30991730 PMCID: PMC6518419 DOI: 10.3390/jcm8040515] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 02/07/2023] Open
Abstract
Methotrexate (MTX) is a remarkable drug with a key role in the management of rheumatoid arthritis (RA) at every stage of its evolution. Its attributes include good overall efficacy for signs and symptoms, inhibition of structural damage and preservation of function with acceptable and manageable safety, a large dose-titratable range, options for either an oral or parenteral route of administration, and currently unrivalled cost-effectiveness. It has a place as a monotherapy and also as an anchor drug that can be safely used in combination with other conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or used concomitantly with biological DMARDs or targeted synthetic DMARDs. MTX is not without potential issues regarding toxicity, notably hepatotoxicity and bone marrow toxicity, as well as tolerability problems for some, but not all, patients. But many of these issues can be mitigated or managed. In the face of a welcome expansion in available targeted therapies for the treatment of RA, MTX looks set to remain at the foundation of pharmacotherapy for the majority of people living with RA and other inflammatory rheumatic diseases. In this article, we provide an evidence-based discussion as to how to achieve the best outcomes with this versatile drug in the context of a treat-to-target strategy for the management of RA.
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Daien C, Hua C, Gaujoux-Viala C, Cantagrel A, Dubremetz M, Dougados M, Fautrel B, Mariette X, Nayral N, Richez C, Saraux A, Thibaud G, Wendling D, Gossec L, Combe B. Update of French society for rheumatology recommendations for managing rheumatoid arthritis. Joint Bone Spine 2019; 86:135-150. [DOI: 10.1016/j.jbspin.2018.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
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Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. Arch Rheumatol 2019; 33:251-271. [PMID: 30632540 DOI: 10.5606/archrheumatol.2018.6911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/08/2018] [Indexed: 01/15/2023] Open
Abstract
Objectives This study aims to report the assessment of the Turkish League Against Rheumatism (TLAR) expert panel on the compliance and adaptation of the European League Against Rheumatism (EULAR) 2016 recommendations for the management of rheumatoid arthritis (RA) in Turkey. Patients and methods The EULAR 2016 recommendations for the treatment of RA were voted by 27 specialists experienced in this field with regard to participation rate for each recommendation and significance of items. Afterwards, each recommendation was brought forward for discussion and any alteration gaining ≥70% approval was accepted. Also, Turkish version of each item was rearranged. Last version of the recommendations was then revoted to determine the level of agreement. Levels of agreement of the two voting rounds were compared with Wilcoxon signed-rank test. In case of significant difference, the item with higher level of agreement was accepted. In case of no difference, the changed item was selected. Results Four overarching principles and 12 recommendations were assessed among which three overarching principles and one recommendation were changed. The changed overarching principles emphasized the importance of physical medicine and rehabilitation specialists as well as rheumatologists for the care of RA patients in Turkey. An alteration was made in the eighth recommendation on treatment of active RA patients with unfavorable prognostic indicators after failure of three conventional disease modifying anti-rheumatic drugs. Remaining principles were accepted as the same although some alterations were suggested but could not find adequate support to reach significance. Conclusion Expert opinion of the TLAR for the treatment of RA was composed for practices in Turkish rheumatology and/or physical medicine and rehabilitation clinics.
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Suzuki Y, Sugiyama N, Fukuma Y, Sugiyama N, Kokubo T. Safety and effectiveness of high-dose methotrexate (over 8 mg/week) in 2838 Japanese patients with rheumatoid arthritis: a postmarketing surveillance report. Mod Rheumatol 2019; 30:24-35. [DOI: 10.1080/14397595.2018.1532483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Yasuo Suzuki
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | | | - Yuri Fukuma
- Medical Affairs, Pfizer Japan Inc., Tokyo, Japan
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78
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Chen X, Zhu X, Xu T, Xu M, Wen Y, Liu Y, Liu J, Qin X. Targeted hexagonal Pd nanosheet combination therapy for rheumatoid arthritis via the photothermal controlled release of MTX. J Mater Chem B 2019; 7:112-122. [DOI: 10.1039/c8tb02302f] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Methotrexate (MTX) is a drug that is used for the clinical treatment of rheumatoid arthritis (RA), a stubborn disease caused by over-immunization.
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Affiliation(s)
- Xu Chen
- Department of Chemistry
- College of Chemistry and Materials Science
- Jinan University
- Guangzhou 510632
- China
| | - Xufeng Zhu
- Department of Chemistry
- College of Chemistry and Materials Science
- Jinan University
- Guangzhou 510632
- China
| | - Taoyuan Xu
- Department of Chemistry
- College of Chemistry and Materials Science
- Jinan University
- Guangzhou 510632
- China
| | - Mengmeng Xu
- Department of Chemistry
- College of Chemistry and Materials Science
- Jinan University
- Guangzhou 510632
- China
| | - Yayu Wen
- Department of Chemistry
- College of Chemistry and Materials Science
- Jinan University
- Guangzhou 510632
- China
| | - Yanan Liu
- Department of Chemistry
- College of Chemistry and Materials Science
- Jinan University
- Guangzhou 510632
- China
| | - Jie Liu
- Department of Chemistry
- College of Chemistry and Materials Science
- Jinan University
- Guangzhou 510632
- China
| | - Xiuying Qin
- College of Pharmacy
- Guilin Medical University
- Guangxi Guilin
- China
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79
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Abstract
Rheumatoid arthritis (RA) is a common systemic inflammatory autoimmune disease characterized by painful, swollen joints that can severely impair physical function and quality of life. The presenting symptoms of musculoskeletal pain, swelling, and stiffness are common in clinical practice, so familiarity with diagnosing and managing RA is crucial. Patients with RA are at greater risk for serious infection, respiratory disease, osteoporosis, cardiovascular disease, cancer, and mortality than the general population. In recent years, early diagnosis, aggressive treatment, and expanded therapeutic options of disease-modifying antirheumatic drugs have markedly improved both the management and long-term prognosis of RA.
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Affiliation(s)
- Jeffrey A Sparks
- From Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. (J.A.S.)
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80
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Dalkilic E, Coskun BN, Yağız B, Tufan AN, Ermurat S, Pehlivan Y. Methotrexate intoxication: Beyond the adverse events. Int J Rheum Dis 2018; 21:1557-1562. [PMID: 30146743 DOI: 10.1111/1756-185x.13339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Methotrexate (MTX) is the first-line disease-modifying antirheumatic drug in rheumatoid arthritis (RA). However, this anchor may cause some side effects that may range from nausea to mortality. The clinical features of MTX toxicity are under-researched. In this study, we aimed to find out the potential predisposing factors and outcomes of the MTX toxicity (n = 31). METHODS The data were collected from 31 patients whose ages ranged from 25 to 81 years, who were suffering from immune-mediated inflammatory diseases and major MTX-related toxicity. RESULTS Out of 31 patients, six (19.4%) used MTX every day, and 13 (41.9%) patients had renal insufficiency who were admitted to the hospital because of mucositis (90.3%) and fever (71%). While using MTX, 27 patients (87.1%) were discharged after the treatment and four patients (12.9%) died. CONCLUSIONS Although MTX has high efficacy for the toxicity ratio, wrong use and dosage of MTX may be harmful to patients. Thus, patients should be informed about the proper use of MTX.
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Affiliation(s)
- Ediz Dalkilic
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Belkıs Nihan Coskun
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Burcu Yağız
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Ayşe Nur Tufan
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Selime Ermurat
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Yavuz Pehlivan
- Division of Rheumatology, Faculty of Medicine, Uludağ University, Bursa, Turkey
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81
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Bitencourt N, Bermas BL. Pharmacological Approach to Managing Childhood-Onset Systemic Lupus Erythematosus During Conception, Pregnancy and Breastfeeding. Paediatr Drugs 2018; 20:511-521. [PMID: 30175398 DOI: 10.1007/s40272-018-0312-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.
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Affiliation(s)
- Nicole Bitencourt
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA.
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82
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Lertnawapan R, Chonprasertsuk S, Siramolpiwat S. Association between cumulative methotrexate dose, non-invasive scoring system and hepatic fibrosis detected by Fibroscan in rheumatoid arthritis patients receiving methotrexate. Int J Rheum Dis 2018; 22:214-221. [DOI: 10.1111/1756-185x.13442] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/12/2018] [Accepted: 10/18/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Ratchaya Lertnawapan
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine; Thammasat University; Patumthani Thailand
| | - Soonthorn Chonprasertsuk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine; Thammasat University; Patumthani Thailand
| | - Sith Siramolpiwat
- Division of Gastroenterology and Hepatology, Department of Internal Medicine; Thammasat University; Patumthani Thailand
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83
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[Perioperative management of immunosuppressive treatment in patients undergoing joint surgery]. Z Rheumatol 2018; 76:767-775. [PMID: 28913596 DOI: 10.1007/s00393-017-0379-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The perioperative management of patients on immunosuppressive drugs is uncertain due to a lack of controlled studies. Continuation of medication without a pause may increase the risk of postoperative infections and wound healing disorders and when the pause is too long this can induce a flare of the underlying rheumatic disease. Additional factors, such as rheumatic disease activity, comorbidities, previous infections and the type of surgical procedure also modulate the risk. The highest risk of infection is associated with corticosteroids depending on the dose, so that a dosage as low as possible but stable in the perioperative period is recommended. Among the conventional disease-modifying antirheumatic drugs (DMARDs) only methotrexate has been sufficiently investigated and in this case a pause in treatment induces higher risks than continuation. Antimalarial agents and sulphasalazine should be continued due to the low risks, whereas leflunomide should be washed out before major surgical interventions. The perioperative risk of treatment with biologics is still far from clear; therefore, as a rule of thumb, withholding treatment for two serum half-lives before an intervention and restarting after completed wound healing are recommended.
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84
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Wieringa WG, Armbrust W, Legger GE, Los LI. Efficacy of High-Dose Methotrexate in Pediatric Non-Infectious Uveitis. Ocul Immunol Inflamm 2018; 27:1305-1313. [PMID: 30346845 DOI: 10.1080/09273948.2018.1529800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose: To analyze the efficacy of high dose (≥ 15mg/m2/week) methotrexate (MTX) versus low dose (<15mg/m2/week) MTX in relation to time to remission on medication.Methods: Retrospective observational cohort study of pediatric patients with auto-immune uveitis with or without underlying systemic disease treated with MTX at the University Medical Center Groningen (the Netherlands) between 1990 and 2014. Primary outcome was time to remission on medication, which was defined as an observable inactive disease in the affected eye for longer than 3 months without the use of systemic corticosteroids.Results: A total of 42 patients were included. Mean age at uveitis diagnosis was 6.5 years (range 1.7 - 14.4), and 22 (52.4%) patients were male. Bilateral disease was found in 33 patients. Most patients (n=25) had anterior uveitis. JIA was the underlying systemic disease in 21 patients. Overall, 28 (66.7%) patients reached remission on medication in (median) 22.5 months (IQR 10.4- 45). Time to remission on medication in the low dose group (median 35.2, IQR 20.5 - 72.1 months) was significantly longer than in the high dose group (median 16.6, IQR 7.8 - 22.5 months) (p= 0.01). No statistically significant differences in ocular complications, steroid-sparing effect, cumulative dosage and side effects of MTX were found between the high and low dose groups.Conclusion: In this retrospective study on pediatric auto-immune uveitis, high dose MTX was associated with a shorter time to remission on medication as compared to low dose MTX, while side effects were comparable in both groups.
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Affiliation(s)
- Wietse G Wieringa
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wineke Armbrust
- Department of Children's Rheumatology and Immunology, Beatrix Children's Hospital, Groningen, the Netherlands
| | - G Elizabeth Legger
- Department of Children's Rheumatology and Immunology, Beatrix Children's Hospital, Groningen, the Netherlands
| | - Leonoor I Los
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,W.J. Kolff Institute, Graduate School of Medical Sciences, University of Groningen, Groningen, the Netherlands
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85
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Paternal exposure to antirheumatic drugs—What physicians should know: Review of the literature. Semin Arthritis Rheum 2018; 48:343-355. [DOI: 10.1016/j.semarthrit.2018.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/19/2017] [Accepted: 01/09/2018] [Indexed: 12/11/2022]
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86
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Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review. Eur J Med Chem 2018; 158:502-516. [PMID: 30243154 DOI: 10.1016/j.ejmech.2018.09.027] [Citation(s) in RCA: 304] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022]
Abstract
Methotrexate (MTX) is used as an anchor disease-modifying anti-rheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA) because of its potent efficacy and tolerability. MTX benefits a large number of RA patients but partially suffered from side effects. A variety of side effects can be associated with MTX when treating RA patients, from mild to severe or discontinuation of the treatment. In this report, we reviewed the possible side effects that MTX might cause from the most common gastrointestinal toxicity effects to less frequent malignant diseases. In order to achieve regimen with less side effects, the administration of MTX with appropriate dose and a careful pretreatment inspection is necessary. Further investigations are required when combining MTX with other drugs so as to enhance the efficacy and reduce side effects at the same time. The management of MTX treatment is also discussed to provide strategies for occurred side effects. Thus, this review will provide scholars with a comprehensive understanding the side effects of MTX administration by RA patients.
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87
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Tanaka Y, Mimori T, Yamanaka H, Nakajima R, Morita K, Kimura J, Takeuchi T. Effectiveness and safety of initiating adalimumab plus ≥12 mg/week methotrexate with adjustable dosing in biologic-naïve patients with early rheumatoid arthritis: HAWK study postmarketing surveillance in Japan. Mod Rheumatol 2018; 29:572-580. [DOI: 10.1080/14397595.2018.1500979] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Tsuneyo Mimori
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | | | | | | | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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88
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Asai S, Nagai K, Takahashi N, Watanabe T, Matsumoto T, Asai N, Sobue Y, Ishiguro N, Kojima T. Influence of methotrexate on gastrointestinal symptoms in patients with rheumatoid arthritis. Int J Rheum Dis 2018; 22:207-213. [PMID: 30168274 DOI: 10.1111/1756-185x.13380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/18/2018] [Accepted: 08/07/2018] [Indexed: 01/03/2023]
Abstract
AIM This study aimed to determine the influence of methotrexate (MTX) on gastrointestinal (GI) symptoms in patients with rheumatoid arthritis (RA). METHODS This cross-sectional study examined 529 consecutive patients with RA receiving oral MTX in our department between April 1 and September 30, 2017. GI symptoms were evaluated by the Gastrointestinal Symptom Rating Scale (GSRS); a score of ≥2 was considered "symptomatic." Prevalence of GI symptoms was compared between patients receiving ≤8 mg/wk (low-dose) vs >8 mg/wk (high-dose) of MTX. RESULTS Of our study population, 313 (59%) received low-dose MTX at a median (interquartile range) dose of 6 (6-8) mg/wk, whereas 216 (41%) received high-dose MTX at a median dose of 12 (10-12) mg/wk. Relative to the low-dose MTX group, the high-dose MTX group exhibited a higher prevalence of reflux (32% vs 24%, P = 0.043) and abdominal pain (28% vs 18%, P = 0.007). There was no significant group-dependent difference in the prevalence of indigestion, diarrhea or constipation. Multivariate logistic regression analysis revealed that high-dose MTX (>8 mg/wk) was independently associated with reflux (odds ratio [OR]: 1.62, 95% confidence interval [CI]: 1.07-2.43) and abdominal pain (OR: 1.60, 95% CI: 1.04-2.43), and that the ORs for reflux and abdominal pain among those receiving high-dose MTX (>8 mg/wk) were similar to those using nonsteroidal anti-inflammatory drugs. CONCLUSION High-dose MTX is independently associated with the prevalence of upper GI symptoms in Japanese patients with RA.
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Affiliation(s)
- Shuji Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Nagai
- Department of Nursing, Nagoya University Hospital, Nagoya, Japan
| | - Nobunori Takahashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tatsuo Watanabe
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Matsumoto
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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89
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Keely Boyle K, Rachala S, Nodzo SR. Centers for Disease Control and Prevention 2017 Guidelines for Prevention of Surgical Site Infections: Review and Relevant Recommendations. Curr Rev Musculoskelet Med 2018; 11:357-369. [PMID: 29909445 PMCID: PMC6105476 DOI: 10.1007/s12178-018-9498-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The associated patient morbidity and resource-intensive nature of managing surgical site infections (SSI) has focused attention toward not only improving treatment protocols but also enhancing preventative measures. The purpose of this review was to summarize the relevant updated CDC guidelines for the prevention of SSI that were released in 2017. The CDC recommends the integration of the guidelines for improvement in quality metrics, reportable outcomes, and patient safety. RECENT FINDINGS The updated guidelines include generalized recommendations for parenteral antimicrobial prophylaxis, non-parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, and antiseptic prophylaxis. The arthroplasty section includes recommendations for blood transfusion, systemic immunosuppressive therapy, and antibiotics during drain use. There was low-quality evidence precluding recommendations for preoperative intra-articular corticosteroid injections, orthopedic surgical space suits, and biofilm management. The recommendations provided throughout this review, including more recent guidelines from other organizations such as the AAOS and ACR, should assist clinicians in developing and/or refining surgical site prevention protocols for their patients undergoing total joint arthroplasty procedures.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY, 14215, USA.
| | - Sridhar Rachala
- Department of Orthopaedics, Buffalo General Medical Center, 100 High Street, Buffalo, NY, 14203, USA
| | - Scott R Nodzo
- Department of Orthopaedics, Mike O'Callaghan Medical Center, 4700 N. Las Vegas Blvd, Las Vegas, NV, 89191, USA
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90
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Mori S, Arima N, Ito M, Fujiyama S, Kamo Y, Ueki Y. Non-alcoholic steatohepatitis-like pattern in liver biopsy of rheumatoid arthritis patients with persistent transaminitis during low-dose methotrexate treatment. PLoS One 2018; 13:e0203084. [PMID: 30142184 PMCID: PMC6108522 DOI: 10.1371/journal.pone.0203084] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/14/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The mechanism of liver injury with low-dose methotrexate (MTX) is incompletely understood. This study was designed to evaluate the association between non-alcoholic fatty liver disease (NAFLD) and liver injury during MTX treatment for rheumatoid arthritis (RA). METHODS Between October 2014 and May 2015, we enrolled all MTX users for RA and monitored participant serum hepatic transaminase levels for 1 year. All patients had normal transaminase levels before the first MTX prescription. Using diagnostic criteria for non-alcoholic steatohepatitis (NASH), we performed histological analyses for patients presenting persistent transaminitis, defined as elevations of hepatic transaminases in four of six determinations during the follow-up period. Possible risk factors for persistent transaminitis were also examined. RESULTS We followed 846 RA patients with a mean cumulative MTX dose of 2.48 g and identified 51 patients presenting persistent transaminitis. According to multivariate logistic regression analysis, obesity (odds ratio [OR] 3.23, p < 0.001), type 2 diabetes (OR 3.52, p = 0.001), hypercholesterolemia (OR 2.56, p = 0.004), and hyperuricemia (OR 3.52, p = 0.019), which are recognized as risk factors for NAFLD, were independently associated with a risk of persistent transaminitis. Among patients with persistent transaminitis, 42 showed fatty liver at ultrasonography. These patients had no evidence of alcoholic fatty liver, chronic viral hepatitis, autoimmune liver diseases, or hereditary liver diseases. Biopsy specimens were obtained from 32 patients, and we found that a NASH-like pattern was the most prevalent histological abnormality. There was no significant impact of MTX dose and duration on the histological severity. CONCLUSION Risk factors and histological findings are similar between NAFLD/NASH and liver injury during low-dose MTX treatment for RA, which suggests a strong association between both entities. NAFLD/NASH may be an underlying condition causing persistent transaminitis in MTX-treated RA patients. The results of this study illustrate the need for monitoring liver injury in RA patients with NAFLD risk factors during MTX treatment.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kohshi, Kumamoto, Japan
| | - Nobuyuki Arima
- Department of Pathology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Masahiro Ito
- Department of Pathology, Clinical Research Center, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Shigetoshi Fujiyama
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Yasuhiro Kamo
- Gastrointestinal Endoscopy Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
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91
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Sergeant JC, Hyrich KL, Anderson J, Kopec-Harding K, Hope HF, Symmons DPM, Barton A, Verstappen SMM. Prediction of primary non-response to methotrexate therapy using demographic, clinical and psychosocial variables: results from the UK Rheumatoid Arthritis Medication Study (RAMS). Arthritis Res Ther 2018; 20:147. [PMID: 30005689 PMCID: PMC6044018 DOI: 10.1186/s13075-018-1645-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/13/2018] [Indexed: 12/04/2022] Open
Abstract
Background Methotrexate (MTX) remains the disease-modifying anti-rheumatic drug of first choice in rheumatoid arthritis (RA) but response varies. Predicting non-response to MTX could enable earlier access to alternative or additional medications and control of disease progression. We aimed to identify baseline predictors of non-response to MTX and combine these into a prediction algorithm. Methods This study included patients recruited to the Rheumatoid Arthritis Medication Study (RAMS), a UK multi-centre prospective observational study of patients with RA or undifferentiated polyarthritis, commencing MTX for the first time. Non-response to MTX at 6 months was defined as “no response” using the European League Against Rheumatism (EULAR) response criteria, discontinuation of MTX due to inefficacy or starting biologic therapy. The association of baseline demographic, clinical and psychosocial predictors with non-response was assessed using logistic regression. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots. Results Of 1050 patients, 449 (43%) were classified as non-responders. Independent multivariable predictors of MTX non-response (OR (95% CI)) were rheumatoid factor (RF) negativity (0.62 (0.45, 0.86) for RF positivity versus negativity), higher Health Assessment Questionnaire score (1.64 (1.25, 2.15)), higher tender joint count (1.06 (1.02, 1.10)), lower Disease Activity score in 28 joints (0.29 (0.23, 0.39)) and higher Hospital Anxiety and Depression Scale anxiety score (1.07 (1.03, 1.12)). The optimism-corrected AUC was 0.74. Conclusions This is the first model for MTX non-response to be developed in a large contemporary study of patients commencing MTX in which demographic, clinical and psychosocial predictors were considered. Patient anxiety was a predictor of non-response and could be addressed at treatment commencement. Electronic supplementary material The online version of this article (10.1186/s13075-018-1645-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jamie C Sergeant
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - James Anderson
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Kamilla Kopec-Harding
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Holly F Hope
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Deborah P M Symmons
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Anne Barton
- NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Arthritis Research UK Centre for Genetics and Genomics, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK. .,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
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92
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Folate Supplementation for Methotrexate Therapy in Patients With Rheumatoid Arthritis. ACTA ACUST UNITED AC 2018; 25:197-202. [DOI: 10.1097/rhu.0000000000000810] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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93
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Favalli EG, Becciolini A, Biggioggero M, Bertoldi I, Crotti C, Raimondo MG, Marchesoni A. The role of concomitant methotrexate dosage and maintenance over time in the therapy of rheumatoid arthritis patients treated with adalimumab or etanercept: retrospective analysis of a local registry. Drug Des Devel Ther 2018; 12:1421-1429. [PMID: 29872265 PMCID: PMC5973379 DOI: 10.2147/dddt.s162286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the pattern of prescription and maintenance over time of concomitant methotrexate (MTX), and its impact on a 2-year clinical response in a cohort of rheumatoid arthritis (RA) patients treated with a first-line tumor necrosis factor alpha inhibitor (TNFi). PATIENTS AND METHODS The study population included all RA patients receiving adalimumab or etanercept a as first-line biologic drug, extracted from a local registry. Enrolled patients were stratified into 3 subgroups according to baseline concomitant MTX: no MTX, low-dose MTX (≤10 mg/wk), and high-dose MTX (≥12.5 mg/wk). The 2-year persistence of the initial MTX regimen was computed by the Kaplan-Meier method, and a Cox proportional hazard model was developed to examine potential predictors of MTX withdrawal/change of dosage. European League Against Rheumatism remission and good-to-moderate response were evaluated according to baseline MTX regimen and MTX maintenance over time. RESULTS A total of 330 patients (163 treated with adalimumab and 167 with etanercept) were included; 141 were prescribed TNFi without MTX and 112 received low-dose and 77 high-dose concomitant MTX. Male sex, younger age, and shorter mean disease duration were predictors of high-dose MTX use. Among MTX users (76.2% parenteral and 23.8% oral), initial MTX dose persisted over time in 79.9% at 1 year and 70.2% at 2 years. Fifty-one patients (27%) underwent MTX dose de-escalation/discontinuation because of intolerance/adverse events. The 2-year EULAR remission rate was higher in the patients receiving and maintaining high-dose MTX than in those receiving low-dose or no MTX (46.2% vs 29.5% and 23.4%, respectively; p=0.009). The same was true for good-to-moderate response rate (71.2% vs 52.6% and 50.4%, respectively; p=0.031). CONCLUSION In a real-life setting, about one-third of RA patients treated with TNFis experienced dose reduction/discontinuation of concomitant MTX because of intolerance/adverse events over a 2-year follow-up period. Initial high-dose MTX and its maintenance over time are associated with better 2-year clinical response.
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Affiliation(s)
| | | | - Martina Biggioggero
- Department of Clinical Sciences and Health Community, University of Milan, Division of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | | | - Chiara Crotti
- Department of Clinical Sciences and Health Community, University of Milan, Division of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - Maria Gabriella Raimondo
- Department of Clinical Sciences and Health Community, University of Milan, Division of Rheumatology, Gaetano Pini Institute, Milan, Italy
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94
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Kameda H, Fujii T, Nakajima A, Koike R, Sagawa A, Kanbe K, Tomita T, Harigai M, Suzuki Y. Japan College of Rheumatology guideline for the use of methotrexate in patients with rheumatoid arthritis. Mod Rheumatol 2018; 29:31-40. [DOI: 10.1080/14397595.2018.1472358] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Hideto Kameda
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Japan
| | - Ayako Nakajima
- Department of Rheumatology, Center for Rheumatic Diseases, Mie University Graduate School of Medicine, Mie, Japan
| | - Ryuji Koike
- Medical Innovation Promotion Center, Clinical Research Center of Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akira Sagawa
- Sagawa Akira Rheumatology Clinic, Hokkaido, Japan
| | - Katsuaki Kanbe
- Department of Kuranomachi Community Medicine, Regional Clinical Education Center, Jichi Medical University, Tochigi, Japan
| | - Tetsuya Tomita
- Department of Orthopaedic Biomaterial Science, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masayoshi Harigai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases, Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Division of Rheumatology, Tokai University School of Medicine, Kanagawa, Japan
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95
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Dorreen A, Heisler C, Jones J. Treatment of Inflammatory Bowel Disease in the Older Patient. Inflamm Bowel Dis 2018; 24:1155-1166. [PMID: 29788361 DOI: 10.1093/ibd/izy023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Indexed: 12/11/2022]
Abstract
The incidence of inflammatory bowel disease (IBD) is increasing, and as our population ages, there is a growing number of IBD patients who are transitioning into advanced age; 15% to 20% of IBD patients are classified as late-onset (between 60-65 years of age). This has led clinicians to treat a large number of older patients with IBD. The principles of management of IBD in older patients are the same as those who are younger. There are, however, phenotypic differences that are unique to late-onset IBD and age-related concerns that clinicians must consider when initiating therapy for their older patients with IBD. Given the increasing number of older IBD patients, the aim of this article is to present an updated, evidence-based review of the therapeutic options and issues that arise in this unique patient population.
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Affiliation(s)
- Alastair Dorreen
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Courtney Heisler
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Epidemiology and Biostatistics, Dalhousie University, Halifax, Nova Scotia, Canada
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96
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Teitsma XM, Jacobs JWG, Welsing PMJ, de Jong PHP, Hazes JMW, Weel AEAM, Pethö-Schramm A, Borm MEA, van Laar JM, Lafeber FPJG, Bijlsma JWJ. Inadequate response to treat-to-target methotrexate therapy in patients with new-onset rheumatoid arthritis: development and validation of clinical predictors. Ann Rheum Dis 2018; 77:1261-1267. [PMID: 29760159 DOI: 10.1136/annrheumdis-2018-213035] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/30/2018] [Accepted: 04/23/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify and validate clinical baseline predictors associated with inadequate response (IR) to methotrexate (MTX) therapy in newly diagnosed patients with rheumatoid arthritis (RA). METHODS In U-Act-Early, 108 disease-modifying antirheumatic drug (DMARD)-naive patients with RA were randomised to initiate MTX therapy and treated to target until sustained remission (disease activity score assessing 28 joints (DAS28) <2.6 with four or less swollen joints for ≥24 weeks) was achieved. If no remission, hydroxychloroquine was added to the treatment regimen (ie, 'MTX+') and replaced by tocilizumab if the target still was not reached thereafter. Regression analyses were performed to identify clinical predictors for IR, defined as needing addition of a biological DMARD, to 'MTX+'. Data from the treatment in the Rotterdam Early Arthritis Cohort were used for external validation of the prediction model. RESULTS Within 1 year, 56/108 (52%) patients in U-Act-Early showed IR to 'MTX+'. DAS28 (adjusted OR (ORadj) 2.1, 95% CI 1.4 to 3.2), current smoking (ORadj 3.02, 95% CI 1.1 to 8.0) and alcohol consumption (ORadj 0.4, 95% CI 0.1 to 0.9) were identified as baseline predictors. The area under the receiver operator characteristic curve (AUROC) of the prediction model was 0.75 (95% CI 0.66 to 0.84); the positive (PPV) and negative predictive value (NPV) were 65% and 80%, respectively. When applying the model to the validation cohort, the AUROC slightly decreased to 0.67 (95% CI 0.55 to 0.79) and the PPV and NPV to 54% and 80%, respectively. CONCLUSION Higher DAS28, current smoking and no alcohol consumption are predictive factors for IR to step-up 'MTX+' in DMARD-naive patients with new-onset RA. TRIAL REGISTRATION NCT01034137; Post-results, ISRCTN26791028; Post-results.
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Affiliation(s)
- Xavier M Teitsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pascal H P de Jong
- Department of Rheumatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Angelique E A M Weel
- Department of Rheumatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | | | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Zhou YZ, Zhao LD, Chen H, Zhang Y, Wang DF, Huang LF, Lv QW, Liu B, Li Z, Wei W, Li H, Liao X, Liu H, Liu X, Jin H, Wang J, Fei YY, Wu QJ, Zhang W, Shi Q, Zheng WJ, Zhang FC, Tang FL, Lipsky PE, Zhang X. Comparison of the impact of Tripterygium wilfordii Hook F and Methotrexate treatment on radiological progression in active rheumatoid arthritis: 2-year follow up of a randomized, non-blinded, controlled study. Arthritis Res Ther 2018; 20:70. [PMID: 29636089 PMCID: PMC5894170 DOI: 10.1186/s13075-018-1563-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 03/12/2018] [Indexed: 01/19/2023] Open
Abstract
Background Tripterygium wilfordii Hook F (TwHF) alone or in combination with methotrexate (MTX) has been shown to be more effective than MTX monotherapy in controlling the manifestations in subjects with disease-modifying antirheumatic drug (DMARD)-naïve active rheumatoid arthritis (RA) over a 6-month period. The long-term impact of these therapies on disease activity and radiographic progression in RA has not been examined. Methods Patients with DMARD-naïve RA enrolled in the “Comparison of Tripterygium wilfordii Hook F with methotrexate in the Treatment of Active Rheumatoid Arthritis” (TRIFRA) study were randomly allocated into three arms with TwHF or MTX or the two in combination. Clinical indexes and radiographic data at baseline and year 2 was collected and compared using an intent-to-treat (ITT) and a per-protocol (PP) analysis. Two radiologists blinded to the treatment scored the images independently. Results Of 207 subjects 109 completed the 2-year follow up. The number of subjects withdrawing from the study and the number adhering to the initial regimens were similar among the three groups (p > = 0.05). In the ITT analysis, proportions of patients reaching American College of Rheumatology 50% (ACR50) response criteria were 46.4%, 58.0% and 50.7% in the MTX, TwHF and MTX + TwHF groups (TwHF vs MTX monotherapy, p = 0.004). Similar patterns were found in ACR20, ACR70, Clinical Disease Activity Index good responses, European League Against Rheumatism good response, remission rate and low disease activity rate at year 2. The results of the PP analysis agreed with those in the ITT analysis. The changes in total Sharp scores and joint erosion and joint space narrowing during the 2 years were associated with changes in disease activity measured by the 28-joint count Disease Activity Score and were comparable among the three groups (p > 0.05). Adverse events were similar in the three treatment groups. Conclusions During the 2-year therapy period, TwHF monotherapy was not inferior to MTX monotherapy in controlling disease activity and retarding radiological progression in patients with active RA. Trial registration This is a follow-up study. Original trial registration: ClinicalTrials.gov, NCT01613079. Registered on 4 June 2012.
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Affiliation(s)
- Yang-Zhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Li-Dan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Yan Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dan-Feng Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin-Fang Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China.,Department of Nephrology and Rheumatology, The First People's Hospital of ChenZhou, ChenZhou, Hunan, China
| | - Qian-Wen Lv
- The Body Sculpture and Liposuction Center of Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100144, China
| | - Bin Liu
- Department of Rheumatology, The Affiliated Hospital of QingDao University Medical College, Qingdao, Shandong, China
| | - Zhenbin Li
- Department of Rheumatology, The Bethune International Heping Hospital of Hebei, Shijiazhuang, Hebei, China
| | - Wei Wei
- Department of Rheumatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Hongbin Li
- Department of Rheumatology, Affiliated Hospital of Inner Mongolia Medical College, Hohhot, Inner Mongolia, China
| | - Xiangping Liao
- Department of Nephrology and Rheumatology, The First People's Hospital of ChenZhou, ChenZhou, Hunan, China
| | - Hui Liu
- Department of Rheumatology, Beijing Dongfang Hospital, Beijing, China
| | - Xiumei Liu
- Department of Rheumatology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hongtao Jin
- Department of Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Junxiang Wang
- Department of Rheumatology, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yun-Yun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Qing-Jun Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Qun Shi
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Wen-Jie Zheng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Feng-Chun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Fu-Lin Tang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China
| | - Peter E Lipsky
- Formerly National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA. .,AMPEL BioSolutions, Charlottesville, VA, 22901, USA.
| | - Xuan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, The Ministry of Education Key Laboratory, Beijing, 100730, China.
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Bahuaud M, Beaudouin-Bazire C, Husson M, Molto A, Launay O, Batteux F, Dougados M. Immunogenicity and persistence of a prime-boost re-vaccination strategy for pneumococcal vaccines in patients with rheumatoid arthritis. Hum Vaccin Immunother 2018; 14:1464-1470. [PMID: 29432051 DOI: 10.1080/21645515.2018.1438091] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Patients with rheumatoid arthritis (RA) are at an increased risk of Pneumococcal infections. Immunogenicity and persistence of a prime-boost revaccination strategy using 13-valent/23-valent anti-pneumococcal vaccines was evaluated in patients with RA treated by Methotrexate (MTX) and anti-TNF. METHOD Twenty-four patients with RA received one dose of PCV13 (Prevenar13®; Pfizer) followed two months later by one dose of PPV23 (Pneumovax®, Merck). Concentrations of IgG specific for 7 serotypes common to both vaccines and 3 uncommon serotypes, included only in the PPV23 were measured by ELISA and Opsonophagocytic Assay (OPA) at baseline and after 4, 12 and 24 months post-vaccine. RESULTS Similar percentages of protection were found at 4 months (63% vs. 55%), 12 months (54% vs. 50%) and 24 months (52% vs. 55%) for the 7 common and 3 uncommon serotypes when antibody titers were assayed by ELISA. Based on functional antibody measurements by OPA, a decrease of protected patients was observed 24 months after vaccine with only 19% of patients protected compared to 29% at baseline. CONCLUSION Although the combined pneumococcal revaccination strategy induces good protection in the short term in RA patients, this protection does not persist beyond two years with levels of functional antibody decreasing below pre-vaccine levels. We did not observe a higher efficacy of the conjugate vaccine compared to the polysaccharide vaccine. Our results clearly question the advantage of the prime-boost strategy as it highlight the possible hyporesponse induced by PPV23 against the immune response elicited by the primo-injection of the PCV13 vaccine.
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Affiliation(s)
- Mathilde Bahuaud
- a Plateforme d'Immunomonotoring Vaccinal, Laboratoire d'Immunologie , Groupe hospitalier Cochin-Broca-Hôtel Dieu, AP-HP , Paris , France
| | | | - Marine Husson
- a Plateforme d'Immunomonotoring Vaccinal, Laboratoire d'Immunologie , Groupe hospitalier Cochin-Broca-Hôtel Dieu, AP-HP , Paris , France
| | - Anna Molto
- b Service de Rhumatologie B , Groupe hospitalier Cochin-Broca-Hôtel Dieu, APHP , Paris , France
| | - Odile Launay
- c Centre d'Investigation Clinique Cochin-Pasteur (CIC1417) , Groupe hospitalier Cochin-Broca-Hôtel Dieu, AP-HP , Paris , France
| | - Frédéric Batteux
- a Plateforme d'Immunomonotoring Vaccinal, Laboratoire d'Immunologie , Groupe hospitalier Cochin-Broca-Hôtel Dieu, AP-HP , Paris , France
| | - Maxime Dougados
- b Service de Rhumatologie B , Groupe hospitalier Cochin-Broca-Hôtel Dieu, APHP , Paris , France
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99
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Clinical connection between rheumatoid arthritis and liver damage. Rheumatol Int 2018; 38:715-724. [PMID: 29627896 DOI: 10.1007/s00296-018-4021-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 03/26/2018] [Indexed: 12/15/2022]
Abstract
When liver damage is present in rheumatoid arthritis (RA) patients, it is sometimes difficult to determine whether it is a hepatic manifestation of RA, associated primary liver disease or hepatotoxic liver disease which developed during the treatment of RA. Liver damage during RA is most common in the form of asymptomatic abnormal liver tests. Occasionally, liver damage may progress to cirrhosis. Patients with RA are more susceptible to an associated autoimmune liver disease. Medications used in rheumatology are often hepatotoxic and it is difficult to differentiate between hepatic manifestations of the primary disease and potential hepatotoxicity of the administered medications. The significance of the paper is in the fact that it includes the most relevant and the latest information on this commonly present problem in clinical practice. The aim of the author is to provide comprehensive but at the same time concise data which will be useful to the doctors who come into contact with RA patients with symptomatic or asymptomatic liver disease. Timely diagnosis and treatment of liver disease in RA patients can significantly influence the course and outcome of rheumatoid arthritis.
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100
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Yu MB, Firek A, Langridge WHR. Predicting methotrexate resistance in rheumatoid arthritis patients. Inflammopharmacology 2018. [DOI: 10.1007/s10787-018-0459-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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