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Akdemir G, Heimans L, Bergstra SA, Goekoop RJ, van Oosterhout M, van Groenendael JHLM, Peeters AJ, Steup-Beekman GM, Lard LR, de Sonnaville PBJ, Grillet BAM, Huizinga TWJ, Allaart CF. Clinical and radiological outcomes of 5-year drug-free remission-steered treatment in patients with early arthritis: IMPROVED study. Ann Rheum Dis 2017; 77:111-118. [DOI: 10.1136/annrheumdis-2017-211375] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/29/2017] [Accepted: 09/15/2017] [Indexed: 11/04/2022]
Abstract
ObjectivesTo determine the 5-year outcomes of early remission induction therapy followed by targeted treatment aimed at drug-free remission (DFR) in patients with early arthritis.MethodsIn 12 hospitals, 610 patients with early (<2 years) rheumatoid arthritis (RA) or undifferentiated arthritis (UA) started on methotrexate (MTX) 25 mg/week and prednisone (60 mg/day tapered to 7.5 mg/day). Patients not in early remission (Disease Activity Score <1.6 after 4 months) were randomised (single blind) to arm 1, adding hydroxychloroquine 400 mg/day and sulfasalazine 2000 mg/day, or arm 2, switching to MTX plus adalimumab 40 mg/2 weeks. Treatment adjustments over time aimed at DFR. Outcomes were remission percentages, functional ability, toxicity and radiological damage progression after 5 years.ResultsAfter 4 months, 387 patients were in early remission, 83 were randomised to arm 1 and 78 to arm 2. After 5 years, 295/610 (48%) patients were in remission, 26% in sustained DFR (SDFR) (≥1 year) (220/387 (57%) remission and 135/387 (35%) SDFR in the early remission group, 50% remission, 11% SDFR in the randomisation arms without differences between the arms). More patients with UA (37% vs 23% RA, p=0.001) and more anticitrullinated protein antibody (ACPA)-negative patients (37% vs 18% ACPA-positive, p<0.001) achieved SDFR.Overall, mean Health Assessment Questionnaire was 0.6 (0.5), and median (IQR) damage progression was 0.5 (0–2.7) Sharp/van der Heijde points, with only five patients showing progression >25 points in 5 years.ConclusionsFive years of DFR-steered treatment in patients with early RA resulted in almost normal functional ability without clinically relevant joint damage across treatment groups. Patients who achieved early remission had the best clinical outcomes. There were no differences between the randomisation arms. SDFR is a realistic treatment goal.
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Keystone EC, Taylor PC, Tanaka Y, Gaich C, DeLozier AM, Dudek A, Zamora JV, Cobos JAC, Rooney T, Bono SD, Arora V, Linetzky B, Weinblatt ME. Patient-reported outcomes from a phase 3 study of baricitinib versus placebo or adalimumab in rheumatoid arthritis: secondary analyses from the RA-BEAM study. Ann Rheum Dis 2017; 76:1853-1861. [PMID: 28798049 PMCID: PMC5705852 DOI: 10.1136/annrheumdis-2017-211259] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 11/08/2022]
Abstract
Background To assess the effect of baricitinib on patient-reported outcomes (PROs) in patients with active rheumatoid arthritis and an inadequate response to methotrexate (MTX). Methods In this double-blind phase 3 study, patients were randomised 3:3:2 to placebo (n=488), baricitinib 4 mg once daily (n=487), or adalimumab 40 mg biweekly (n=330) with background MTX. PROs included the SF-36, EuroQol 5-D (EQ-5D) index scores and visual analogue scale, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Health Assessment Questionnaire-Disability Index (HAQ-DI), Patient’s Global Assessment of Disease Activity (PtGA), patient’s assessment of pain and Work Productivity and Activity Impairment Questionnaire-Rheumatoid Arthritis (WPAI-RA), and measures collected in electronic patient daily diaries: duration and severity of morning joint stiffness (MJS), Worst Ttiredness and Worst Joint Pain. The primary study endpoint was at week 12. Treatment comparisons were assessed with logistic regression for categorical measures or analysis of covariance for continuous variables. Results Compared with placebo and adalimumab, baricitinib showed statistically significant improvements (p≤0.05) in HAQ-DI, PtGA, pain, FACIT-F, SF-36 physical component score, EQ-5D index scores and WPAI-RA daily activity at week 12. Improvements were maintained for measures assessed to week 52. Statistically significant improvement in patient diary measures (MJS duration and severity), worst tiredness and worst joint pain were observed for baricitinib versus placebo and adalimumab at week 12 (p≤0.05). Conclusions Baricitinib provided significantly greater improvement in most PROs compared with placebo and adalimumab, including physical function MJS, pain, fatigue and quality of life. Improvement was maintained to the end of the study (week 52). Trial registration NCT01710358.
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Affiliation(s)
- Edward C Keystone
- The Rebecca MacDonald Centre for Arthritis, Mt. Sinai Hospital, Toronto, Canada
| | - Peter C Taylor
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Fukuoka, Japan
| | - Carol Gaich
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | | | | | | | | | - Vipin Arora
- Eli Lilly and Company, Indianapolis, Indiana, USA
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53
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Konijn NPC, van Tuyl LHD, Boers M, den Uyl D, ter Wee MM, van der Wijden LKM, Bultink IEM, Kerstens PJSM, Voskuyl AE, van Schaardenburg D, Nurmohamed MT, Lems WF. Similar efficacy and safety of initial COBRA-light and COBRA therapy in rheumatoid arthritis: 4-year results from the COBRA-light trial. Rheumatology (Oxford) 2017; 56:1586-1596. [DOI: 10.1093/rheumatology/kex223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Indexed: 12/26/2022] Open
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54
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Smolen JS, Landewé RBM, van der Heijde D. Response to: '2016 update of the EULAR recommendations for the management of rheumatoid arthritis: no utopia for patients in low/middle-income countries?' by Misra et al. Ann Rheum Dis 2017; 76:e48. [PMID: 28478402 DOI: 10.1136/annrheumdis-2017-211455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 03/30/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Désirée van der Heijde
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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55
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Emery P, Blanco R, Maldonado Cocco J, Chen YC, Gaich CL, DeLozier AM, de Bono S, Liu J, Rooney T, Chang CHC, Dougados M. Patient-reported outcomes from a phase III study of baricitinib in patients with conventional synthetic DMARD-refractory rheumatoid arthritis. RMD Open 2017; 3:e000410. [PMID: 28405473 PMCID: PMC5372156 DOI: 10.1136/rmdopen-2016-000410] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/24/2017] [Accepted: 03/01/2017] [Indexed: 01/21/2023] Open
Abstract
Objectives To evaluate the effect of baricitinib on patient-reported outcomes (PROs) in patients with active rheumatoid arthritis (RA) and an inadequate response or intolerance to conventional synthetic disease-modifying antirheumatic drugs. Methods In this phase III study, patients were randomised 1:1:1 to placebo (N=228), baricitinib 2 mg once daily (QD, N=229) or baricitinib 4 mg QD (N=227). PROs included the Health Assessment Questionnaire-Disability Index (HAQ-DI), Patient's Global Assessment of Disease Activity (PtGA), patient's assessment of pain, measures from patient electronic daily diaries (duration and severity of morning joint stiffness (MJS), Worst Tiredness, Worst Joint Pain), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), SF-36, EuroQol 5-D index scores and visual analogue scales (VAS) and the Work Productivity and Activity Impairment Questionnaire-RA. The primary time point for the study was week 12. Treatment comparisons were assessed with logistic regression for categorical measures and analysis of covariance for continuous variables. Results Statistically significant improvements were observed for both baricitinib groups versus placebo in HAQ-DI, PtGA, pain, daily diary measures, EuroQoL index scores and SF-36 physical component score at week 12 and for those measures when assessed at week 24. Baricitinib 2 mg and baricitinib 4 mg were statistically significantly improved versus placebo for the EuroQoL VAS and FACIT-F, respectively, at week 24. Conclusions Baricitinib 2 or 4 mg provided significant improvement versus placebo in PROs across different domains of RA, including physical function, MJS, fatigue, pain and quality of life. Trial registration number NCT01721057; Results.
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Affiliation(s)
- Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds , Leeds , UK
| | - Ricardo Blanco
- Department of Rheumatology , Hospital Universitario Marqués de Valdecilla, IDIVAL , Santander, Cantabria , Spain
| | - Jose Maldonado Cocco
- Buenos Aires University School of Medicine, University of Buenos Aires , Buenos Aires , Argentina
| | - Ying-Chou Chen
- Division of Rheumatology, Department of Internal Medicine , Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine , Kaohsiung , Taiwan
| | | | | | | | - Jiajun Liu
- Eli Lilly and Company , Indianapolis, Indiana , USA
| | | | | | - Maxime Dougados
- Department of Rheumatology , Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, INSERM (U1151), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris Descartes University , Paris , France
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56
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Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, Nam J, Ramiro S, Voshaar M, van Vollenhoven R, Aletaha D, Aringer M, Boers M, Buckley CD, Buttgereit F, Bykerk V, Cardiel M, Combe B, Cutolo M, van Eijk-Hustings Y, Emery P, Finckh A, Gabay C, Gomez-Reino J, Gossec L, Gottenberg JE, Hazes JMW, Huizinga T, Jani M, Karateev D, Kouloumas M, Kvien T, Li Z, Mariette X, McInnes I, Mysler E, Nash P, Pavelka K, Poór G, Richez C, van Riel P, Rubbert-Roth A, Saag K, da Silva J, Stamm T, Takeuchi T, Westhovens R, de Wit M, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017; 76:960-977. [PMID: 28264816 DOI: 10.1136/annrheumdis-2016-210715] [Citation(s) in RCA: 1731] [Impact Index Per Article: 247.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 01/05/2017] [Accepted: 02/09/2017] [Indexed: 02/07/2023]
Abstract
Recent insights in rheumatoid arthritis (RA) necessitated updating the European League Against Rheumatism (EULAR) RA management recommendations. A large international Task Force based decisions on evidence from 3 systematic literature reviews, developing 4 overarching principles and 12 recommendations (vs 3 and 14, respectively, in 2013). The recommendations address conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GC); biological (b) DMARDs (tumour necrosis factor (TNF)-inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (Janus kinase (Jak) inhibitors tofacitinib, baricitinib). Monotherapy, combination therapy, treatment strategies (treat-to-target) and the targets of sustained clinical remission (as defined by the American College of Rheumatology-(ACR)-EULAR Boolean or index criteria) or low disease activity are discussed. Cost aspects were taken into consideration. As first strategy, the Task Force recommends MTX (rapid escalation to 25 mg/week) plus short-term GC, aiming at >50% improvement within 3 and target attainment within 6 months. If this fails stratification is recommended. Without unfavourable prognostic markers, switching to-or adding-another csDMARDs (plus short-term GC) is suggested. In the presence of unfavourable prognostic markers (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), any bDMARD (current practice) or Jak-inhibitor should be added to the csDMARD. If this fails, any other bDMARD or tsDMARD is recommended. If a patient is in sustained remission, bDMARDs can be tapered. For each recommendation, levels of evidence and Task Force agreement are provided, both mostly very high. These recommendations intend informing rheumatologists, patients, national rheumatology societies, hospital officials, social security agencies and regulators about EULAR's most recent consensus on the management of RA, aimed at attaining best outcomes with current therapies.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.,2nd Department of Medicine, Hietzing Hospital, Vienna, Austria
| | - Robert Landewé
- Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Johannes Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | | | | | - Jackie Nam
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Ronald van Vollenhoven
- Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Martin Aringer
- Division of Rheumatology, Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Chris D Buckley
- Birmingham NIHR Wellcome Trust Clinical Research Facility, Rheumatology Research Group, Institute of Inflammation and Ageing (IIA), University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Vivian Bykerk
- Department of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA.,Rebecca McDonald Center for Arthritis & Autoimmune Disease, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mario Cardiel
- Centro de Investigación Clínica de Morelia SC, Michoacán, México
| | - Bernard Combe
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Maurizio Cutolo
- Research Laboratory and Division of Clinical Rheumatology, University of Genoa, Genoa, Italy
| | - Yvonne van Eijk-Hustings
- Department of Patient & Care and Department of Rheumatology, University of Maastricht, Maastricht, The Netherlands
| | - Paul Emery
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Axel Finckh
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Cem Gabay
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Juan Gomez-Reino
- Fundación Ramón Dominguez, Hospital Clinico Universitario, Santiago, Spain
| | - Laure Gossec
- Department of Rheumatology, Sorbonne Universités, Pitié Salpêtrière Hospital, Paris, France
| | - Jacques-Eric Gottenberg
- Institut de Biologie Moléculaire et Cellulaire, Immunopathologie, et Chimie Thérapeutique, Strasbourg University Hospital and University of Strasbourg, CNRS, Strasbourg, France
| | - Johanna M W Hazes
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tom Huizinga
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Meghna Jani
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Dmitry Karateev
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Marios Kouloumas
- European League Against Rheumatism, Zurich, Switzerland.,Cyprus League against Rheumatism, Nicosia, Cyprus
| | - Tore Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Xavier Mariette
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, INSERM U1184, Center for Immunology of viral Infections and Autoimmune Diseases (IMVA), Le Kremlin Bicêtre, France
| | - Iain McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | - Peter Nash
- Department of Medicine, University of Queensland, Queensland, Australia
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Gyula Poór
- National Institute of Rheumatology and Physiotherapy, Semmelweis University, Budapest, Hungary
| | - Christophe Richez
- Rheumatology Department, FHU ACRONIM, Pellegrin Hospital and UMR CNRS 5164, Bordeaux University, Bordeaux, France
| | - Piet van Riel
- Department of Rheumatology, Bernhoven, Uden, The Netherlands
| | | | - Kenneth Saag
- Division of Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jose da Silva
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra Praceta Mota Pinto, Coimbra, Portugal
| | - Tanja Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten de Wit
- Department Medical Humanities, VU Medical Centre, Amsterdam, The Netherlands
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57
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Schneider M. [New options for the practice : Update S1/S2 guidelines on rheumatoid arthritis?]. Z Rheumatol 2017; 76:125-132. [PMID: 28102443 DOI: 10.1007/s00393-016-0261-5] [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: 10/20/2022]
Abstract
Guidelines are important tools for evidence-based pharmacological treatment of patients suffering from rheumatoid arthritis. Recommendations assist physicians in identifying the best form of treatment but ultimately, the final decision is based on joint participation by the patient and physician. Nowadays, general concepts, such as treat to target seem to be more important in rheumatoid arthritis than differencies between various drugs or drug classes. The universal recommendation to use methotrexate as the initial disease-modifying antirheumatic drug (DMARD) is driven more by economic reasons than by scientific data, which is not completely wrong but should be disclosed. For the future, more differentiated recommendations need better individual risk stratification and more distinct profiling of the different substances.
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Affiliation(s)
- M Schneider
- Poliklinik und Funktionsbereich für Rheumatologie, Hiller Forschungszentrum, Heinrich-Heine-Universität Universitätsklinikum Düsseldorf, HHUD Moorenstr. 5, 40225, Düsseldorf, Deutschland.
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58
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Matthijssen XME, Akdemir G, Markusse IM, Stijnen T, Riyazi N, Han KH, Bijkerk C, Kerstens PJSM, Lems WF, Huizinga TWJ, Allaart CF. Age affects joint space narrowing in patients with early active rheumatoid arthritis. RMD Open 2016; 2:e000338. [PMID: 27843577 PMCID: PMC5073549 DOI: 10.1136/rmdopen-2016-000338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/15/2016] [Accepted: 09/21/2016] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Joint space narrowing (JSN) in rheumatoid arthritis (RA) may be a manifestation of (primary) osteoarthritis becoming more prominent with age. We investigated the severity and predictors of JSN progression among different age groups. METHODS 10-year follow-up data of the BeSt study, a randomised controlled treat-to-target trial in early RA were used. Annual X-rays of hands and feet were scored using the Sharp/van der Heijde score (SHS). Subgroups were defined by age at baseline: ≥55, ≥40<55 and <40 years. JSN progression predictors were assessed by Poisson regression. RESULTS Baseline JSN scores (median (IQR)) were higher in patients ≥55 (2.0 (0.0-6.0)) compared with the other age groups: 1.0 (0.0-3.0) ≥40<55 and 0.3 (0.0-3.0) <40, p<0.001. After 10 years, total JSN and SHS were similar in all age groups. In patients ≥55 the mean erythrocyte sedimentation rate (ESR) over time (relative risk 1.02 (95% CI 1.00 to 1.03)) and the combined presence of rheumatoid factor and anticitrullinated protein antibodies (RF+/ACPA+) (3.27 (1.25-8.53)) were significantly correlated with JSN progression. In patients <40 the baseline swollen joint count (SJC; 1.09 (1.01-1.18)) and ESR over time (1.04 (1.02-1.06)) were significantly associated. CONCLUSIONS At baseline, patients with RA ≥55 years had more JSN than younger patients but after 10 years JSN scores were similar between age groups. Independent risk factors for JSN progression were baseline SJC and ESR over time in patients <40, RF+/ACPA+ and ESR over time in patients ≥55 years. This suggests that mechanisms leading to JSN progression are related to (residual) rheumatoid inflammation and vary between age groups. These mechanisms remain to be elucidated. TRIAL REGISTRATION NUMBERS NTR262, NTR265.
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Affiliation(s)
| | - G Akdemir
- Department of Rheumatology , LUMC Leiden , Leiden , The Netherlands
| | - I M Markusse
- Department of Rheumatology , LUMC Leiden , Leiden , The Netherlands
| | - T Stijnen
- Department of Rheumatology , LUMC Leiden , Leiden , The Netherlands
| | - N Riyazi
- Haga Hospital , The Hague , The Netherlands
| | - K H Han
- Department of Rheumatology , Maasstad Hospital Rotterdam , Rotterdam , The Netherlands
| | - C Bijkerk
- Department of Rheumatology , Reinier de Graaf Gasthuis Delft , Delft , The Netherlands
| | - P J S M Kerstens
- Department of Rheumatology , Reade Amsterdam , Amsterdam , The Netherlands
| | - W F Lems
- Department of Rheumatology, Reade Amsterdam, Amsterdam, The Netherlands; VUMC Amsterdam, Amsterdam, The Netherlands
| | - T W J Huizinga
- Department of Rheumatology , LUMC Leiden , Leiden , The Netherlands
| | - C F Allaart
- Department of Rheumatology , LUMC Leiden , Leiden , The Netherlands
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59
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Smolen JS, Kremer JM, Gaich CL, DeLozier AM, Schlichting DE, Xie L, Stoykov I, Rooney T, Bird P, Sánchez Bursón JM, Genovese MC, Combe B. Patient-reported outcomes from a randomised phase III study of baricitinib in patients with rheumatoid arthritis and an inadequate response to biological agents (RA-BEACON). Ann Rheum Dis 2016; 76:694-700. [PMID: 27799159 PMCID: PMC5530360 DOI: 10.1136/annrheumdis-2016-209821] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/09/2016] [Accepted: 10/05/2016] [Indexed: 01/12/2023]
Abstract
Objectives To assess baricitinib on patient-reported outcomes (PROs) in patients with moderately to severely active rheumatoid arthritis, who had insufficient response or intolerance to ≥1 tumour necrosis factor inhibitors (TNFis) or other biological disease-modifying antirheumatic drugs (bDMARDs). Methods In this double-blind phase III study, patients were randomised to once-daily placebo or baricitinib 2 or 4 mg for 24 weeks. PROs included the Short Form-36, EuroQol 5-D, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Health Assessment Questionnaire-Disability Index (HAQ-DI), Patient's Global Assessment of Disease Activity (PtGA), patient's assessment of pain, duration of morning joint stiffness (MJS) and Work Productivity and Activity Impairment Questionnaire-Rheumatoid Arthritis. Treatment comparisons were performed with logistic regression for categorical measures or analysis of covariance for continuous variables. Results 527 patients were randomised (placebo, 176; baricitinib 2 mg, 174; baricitinib 4 mg, 177). Both baricitinib-treated groups showed statistically significant improvements versus placebo in most PROs. Improvements were generally more rapid and of greater magnitude for patients receiving baricitinib 4 mg than 2 mg and were maintained to week 24. At week 24, more baricitinib-treated patients versus placebo-treated patients reported normal physical functioning (HAQ-DI <0.5; p≤0.001), reductions in fatigue (FACIT-F ≥3.56; p≤0.05), improvements in PtGA (p≤0.001) and pain (p≤0.001) and reductions in duration of MJS (p<0.01). Conclusions Baricitinib improved most PROs through 24 weeks compared with placebo in this study of treatment-refractory patients with previously inadequate responses to bDMARDs, including at least one TNFi. PRO results aligned with clinical efficacy data for baricitinib. Trial registration number NCT01721044; Results.
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Affiliation(s)
- Josef S Smolen
- Medical University of Vienna and Hietzing Hospital, Vienna, Austria
| | | | | | | | | | - Li Xie
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - Paul Bird
- University of New South Wales, Sydney, New South Wales, Australia
| | | | - Mark C Genovese
- Stanford University Medical Center, Palo Alto, California, USA
| | - Bernard Combe
- Lapeyronie Hospital, Montpellier University, Montpellier, France
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60
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Rheumatologists' adherence to a disease activity score steered treatment protocol in early arthritis patients is less if the target is remission. Clin Rheumatol 2016; 36:317-326. [PMID: 27680540 PMCID: PMC5290046 DOI: 10.1007/s10067-016-3405-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 01/25/2023]
Abstract
To compare rheumatologists' adherence to treatment protocols for rheumatoid arthritis (RA) targeted at Disease Activity Score (DAS) ≤2.4 or <1.6. The BeSt-study enrolled 508 early RA (1987) patients targeted at DAS ≤2.4. The IMPROVED-study included 479 early RA (2010) and 122 undifferentiated arthritis patients targeted at DAS <1.6. We evaluated rheumatologists' adherence to the protocols and assessed associated opinions and conditions during 5 years. Protocol adherence was higher in BeSt than in IMPROVED (86 and 70 %), with a greater decrease in IMPROVED (from 100 to 48 %) than in BeSt (100 to 72 %). In BeSt, 50 % of non-adherence was against treatment intensification/restart, compared to 63 % in IMPROVED and 50 vs. 37 % were against tapering/discontinuation. In both studies, non-adherence was associated with physicians' disagreement with DAS or with next treatment step and if patient's visual analogue scale (VAS) for general health was ≥20 mm higher than the physician's VAS. In IMPROVED, also discrepancies between swelling, pain, erythrocyte sedimentation rate, and VASgh were associated with non-adherence. Adherence to DAS steered treatment protocols was high but decreased over 5 years, more in a DAS <1.6 steered protocol. Non-adherence was more likely if physicians disagreed with DAS or next treatment step. In the DAS <1.6 steered protocol, non-adherence was also associated with discrepancies between subjective and (semi)objective disease outcomes, and often against required treatment intensification. These results may indicate that adherence to DAS-steered protocols appears to depend in part on the height of the target and on how physicians perceive the DAS reflects RA activity.
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Inui K, Koike T. Combination therapy with biologic agents in rheumatic diseases: current and future prospects. Ther Adv Musculoskelet Dis 2016; 8:192-202. [PMID: 27721905 DOI: 10.1177/1759720x16665330] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Strategies in rheumatoid arthritis (RA) based on 'treat to target' aim to control disease activity, minimize structural damage, and promote longer life. Several disease-modifying antirheumatic drugs (DMARDs) have been shown to be effective including biological DMARDs (bDMARDs). Treatment guidelines and recommendations for RA have also been published. According to those guidelines, conventional synthetic DMARDs (csDMARDs), as monotherapy or combination therapy, should be used in DMARD-naïve patients, irrespective of the addition of glucocorticoids (GCs). Combination therapies with bDMARDs are also essential for conducting treatment strategies for RA, because in every recommendation or guideline for the management of RA, combination therapies of csDMARDs with bDMARDs are recommended for RA patients with moderate or high disease activity after failure of csDMARD treatment. bDMARDs are more efficacious if used concomitantly with methotrexate (MTX) than with MTX monotherapy or bDMARD monotherapy. Thus, retention has been reported to be longer when combined with MTX. The superior efficacy of combination therapy compared with MTX monotherapy or bDMARD monotherapy could be because: (1) it could help to minimize MTX toxicity by reducing the dose of MTX, thus retention rate of the same therapeutic regimen would become high; (2) anti-bDMARD antibodies are observed at lower concentrations when using MTX concomitantly, so less clearance of bDMARDs via less formation of bDMARD and an anti-bDMARD immune complex; (3) of the additive effects of MTX to bDMARD, especially the combination of tumor necrosis factor inhibitors (TNFis) with MTX. Hence, evidence suggests that combination therapy with bDMARDs is more efficacious than monotherapy using a csDMARD or bDMARD, and that MTX is the best drug for this purpose (if MTX is not contraindicated). Finding the most effective drug regimen at the lowest cost will be the aim of RA treatment in the future.
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Affiliation(s)
- Kentaro Inui
- Department of Rheumatosurgery, Osaka City University Medical School, Abenoku, Asahimachi 1-4-3, Osaka 545-8585, Japan
| | - Tatsuya Koike
- Center for Senile Degenerative Disorders (CSDD), Osaka City University Medical School, Abenoku, Asahimachi, Osaka, and Search Institute for Bone and Arthritis Disease (SINBAD), Shirahama Foundation for Health and Welfare, Nishimurogun, Shirahamacho, Wakayama, Japan
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Wang Q, Shu Z, Xing N, Xu B, Wang C, Sun G, Sun X, Kuang H. A pure polysaccharide from Ephedra sinica treating on arthritis and inhibiting cytokines expression. Int J Biol Macromol 2016; 86:177-88. [DOI: 10.1016/j.ijbiomac.2016.01.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/01/2016] [Accepted: 01/03/2016] [Indexed: 10/22/2022]
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Norling LV, Headland SE, Dalli J, Arnardottir HH, Haworth O, Jones HR, Irimia D, Serhan CN, Perretti M. Proresolving and cartilage-protective actions of resolvin D1 in inflammatory arthritis. JCI Insight 2016; 1:e85922. [PMID: 27158677 PMCID: PMC4855303 DOI: 10.1172/jci.insight.85922] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rheumatoid arthritis (RA) is a debilitating disease characterized by persistent accumulation of leukocytes within the articular cavity and synovial tissue. Metabololipidomic profiling of arthritic joints from omega-3 supplemented mice identified elevated levels of specialized proresolving lipid mediators (SPM) including resolvin D1 (RvD1). Profiling of human RA synovial fluid revealed physiological levels of RvD1, which - once applied to human neutrophils - attenuated chemotaxis. These results prompted analyses of the antiarthritic properties of RvD1 in a model of murine inflammatory arthritis. The stable epimer 17R-RvD1 (100 ng/day) significantly attenuated arthritis severity, cachexia, hind-paw edema, and paw leukocyte infiltration and shortened the remission interval. Metabololipidomic profiling in arthritic joints revealed 17R-RvD1 significantly reduced PGE2 biosynthesis, while increasing levels of protective SPM. Molecular analyses indicated that 17R-RvD1 enhanced expression of genes associated with cartilage matrix synthesis, and direct intraarticular treatment induced chondroprotection. Joint protective actions of 17R-RvD1 were abolished in RvD1 receptor-deficient mice termed ALX/fpr2/3-/- . These investigations open new therapeutic avenues for inflammatory joint diseases, providing mechanistic substance for the benefits of omega-3 supplementation in RA.
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Affiliation(s)
- Lucy V. Norling
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Sarah E. Headland
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Jesmond Dalli
- Center for Experimental Therapeutics and Reperfusion Injury, Harvard Institutes of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital (BWH) and Harvard Medical School, Boston, Massachusetts, USA
| | - Hildur H. Arnardottir
- Center for Experimental Therapeutics and Reperfusion Injury, Harvard Institutes of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital (BWH) and Harvard Medical School, Boston, Massachusetts, USA
| | - Oliver Haworth
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Hefin R. Jones
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Daniel Irimia
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Shriners Hospital for Children, Boston, Massachusetts, USA
| | - Charles N. Serhan
- Center for Experimental Therapeutics and Reperfusion Injury, Harvard Institutes of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital (BWH) and Harvard Medical School, Boston, Massachusetts, USA
| | - Mauro Perretti
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
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Akdemir G, Markusse IM, Dirven L, Riyazi N, Steup-Beekman GM, Kerstens P, Lems WF, Huizinga T, Allaart CF. Effectiveness of four dynamic treatment strategies in patients with anticitrullinated protein antibody-negative rheumatoid arthritis: a randomised trial. RMD Open 2016; 2:e000143. [PMID: 27099776 PMCID: PMC4823586 DOI: 10.1136/rmdopen-2015-000143] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 12/18/2015] [Accepted: 02/07/2016] [Indexed: 11/09/2022] Open
Abstract
Objective To determine the most effective treatment strategy among anticitrullinated protein antibodies (ACPA)-negative patients with early rheumatoid arthritis. Methods In the BeSt study, 184 ACPA-negative patients were randomised to: (1) sequential monotherapy, (2) step-up therapy, (3) initial combination including prednisone, (4) initial combination including infliximab. Treatment was targeted at the disease activity score (DAS) ≤2.4. Early response and 10-year outcomes were compared between the four strategy-arms in ACPA-negative patients. Results ACPA-negative patients achieved more short-term functional improvement from initial combination therapy than when on monotherapy (at month 3, mean Health Assessment Questionnaire (HAQ) 0.71 vs 0.98, p=0.006; at month 6, 0.59 vs 0.87, p=0.004). Functional ability over time was comparable between the strategy-arms (p=0.551) with a mean HAQ of 0.6 at year 10 (p=0.580 for comparison across the strategy-arms). 10-year radiographic progression was negligible (median 0.5) and comparable between the 4 strategy-arms (p=0.082). At year 10, remission was achieved by 11/40 (28%), 9/45 (20%), 17/56 (30%) and 17/43 patients (40%) in strategy-arms 1–4, respectively (p=0.434). Over time, similar remission percentages were achieved in all strategy-arms (p=0.815). 18%, 16%, 20% and 21% in strategy-arms 1 to 4 (p=0.742) were in drug-free remission at year 10, with a median duration of 60 months across the arms. Conclusions Initial combination therapy with methotrexate, sulfasalazine and prednisone, or methotrexate and infliximab, is the most effective treatment strategy for ACPA-negative patients, resulting in earlier functional improvement than when on initial methotrexate monotherapy. After 10 years of targeted treatment, in all strategy-arms favourable clinical outcomes were achieved and radiographic progression was limited. Trial registration number NTR262, NTR265.
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Affiliation(s)
- G Akdemir
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
| | - I M Markusse
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
| | - L Dirven
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
| | - N Riyazi
- Department of Rheumatology , Haga Hospital , The Hague , The Netherlands
| | - G M Steup-Beekman
- Department of Rheumatology , Bronovo Hospital , The Hague , The Netherlands
| | - Pjsm Kerstens
- Department of Rheumatology , Reade , Amsterdam , The Netherlands
| | - W F Lems
- Department of Rheumatology, Reade, Amsterdam, The Netherlands; Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands
| | - Twj Huizinga
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
| | - C F Allaart
- Department of Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
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Markusse IM, Dirven L, Han KH, Ronday HK, de Sonnaville PBJ, Kerstens PJSM, Lems WF, Huizinga TWJ, Allaart CF. Evaluating Adherence to a Treat-to-Target Protocol in Recent-Onset Rheumatoid Arthritis: Reasons for Compliance and Hesitation. Arthritis Care Res (Hoboken) 2016; 68:446-53. [DOI: 10.1002/acr.22681] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/26/2015] [Accepted: 07/21/2015] [Indexed: 01/20/2023]
Affiliation(s)
- I. M. Markusse
- Leiden University Medical Center; Leiden The Netherlands
| | - L. Dirven
- Leiden University Medical Center; Leiden The Netherlands
| | - K. H. Han
- Maasstad Hospital; Rotterdam The Netherlands
| | | | | | | | - W. F. Lems
- Reade Hospital and VU Medical Center; Amsterdam The Netherlands
| | | | - C. F. Allaart
- Leiden University Medical Center; Leiden The Netherlands
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González-Álvaro I, García-Vicuña R. Artritis reumatoide a día de hoy. Med Clin (Barc) 2016; 146:112-4. [DOI: 10.1016/j.medcli.2015.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/04/2015] [Indexed: 10/23/2022]
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Heimans L, Akdemir G, Boer KVCWD, Goekoop-Ruiterman YP, Molenaar ET, van Groenendael JHLM, Peeters AJ, Steup-Beekman GM, Lard LR, de Sonnaville PBJ, Grillet BAM, Huizinga TWJ, Allaart CF. Two-year results of disease activity score (DAS)-remission-steered treatment strategies aiming at drug-free remission in early arthritis patients (the IMPROVED-study). Arthritis Res Ther 2016; 18:23. [PMID: 26794605 PMCID: PMC4721018 DOI: 10.1186/s13075-015-0912-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/29/2015] [Indexed: 12/11/2022] Open
Abstract
Background Early suppression of disease activity in (rheumatoid) arthritis (RA) patients may result in drug-free remission and prevent damage. We assessed 2-year clinical and radiological outcomes of two disease activity score (DAS)-remission-steered treatment strategies in early arthritis patients. Methods Patients (n = 610) with early RA or undifferentiated arthritis (UA) were treated with methotrexate (MTX) and tapered high dose of prednisone. Patients in early remission (44/53 joints DAS <1.6) after 4 months tapered and stopped medication. Patients who did not achieve early DAS-remission were randomized to either MTX plus hydroxychloroquine plus sulphasalazine plus low dose prednisone (arm 1) or to MTX + adalimumab (arm 2). At four-monthly intervals, medication was tapered and stopped if DAS was <1.6 but restarted, increased or switched if DAS was ≥1.6. Proportions of (drug-free) DAS-remission (DFR) after 2 years and Sharp-van der Heijde scores (SHS) were analyzed separately for the treatment strategies and patients with RA and UA. Results After 2 years, 301/610 (49 %) patients were in DAS-remission and 131/610 (21 %) in DFR. In the early remission group 241/387 patients (62 %) were in DAS-remission and 111/387 (29 %) DFR. In arm 1 22/83 (27 %) and in arm 2 24/78 (31 %) were in DAS-remission, and 6/83 (7 %) and 7/78 (9 %), respectively, were in DFR. RA and UA patients achieved DAS-remission in comparable percentages (RA: 234/479 (49 %), UA: 64/122 (52 %), p = 0.25). More UA patients achieved DFR (41/122 (34 %)) compared to RA patients (89/479 (19 %), p<0.001). Mean (SD) DAS over time was 1.74 (0.58) across all patients, and median (IQR) SHS progression was 0 (0–0). Conclusions After 2 years remission-steered treatment in early RA and UA patients, DAS-remission and DFR percentages were relatively low. Patients who achieved early remission more often achieved (drug-free) remission after 2 years than patients who needed additional treatment steps in the randomization arms, and more UA than RA patients achieved DFR. Overall, disease activity and radiologic damage progression in all patients were well suppressed. Trial registration http://www.controlled-trials.com/ISRCTN11916566 Registered 07/11/2006 and EudraCT number 2006-06186-16 Registered 16/07/2007. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0912-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lotte Heimans
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | - Gülşah Akdemir
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | - Kirsten V C Wevers-de Boer
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | | | | | | | - Andreas J Peeters
- Department of Rheumatology, Reinier de Graaf Gasthuis, Delft, The Netherlands.
| | | | - Leroy R Lard
- Department of Rheumatology, MCH Antoniushove, Leidschendam, The Netherlands.
| | | | | | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
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Gvozdenović E, Wolterbeek R, van der Heijde D, Huizinga T, Allaart C, Landewé R. DAS steered therapy in clinical practice; cross-sectional results from the METEOR database. BMC Musculoskelet Disord 2016; 17:33. [PMID: 26774261 PMCID: PMC4715330 DOI: 10.1186/s12891-016-0878-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 01/06/2016] [Indexed: 12/26/2022] Open
Abstract
Background Little is known on how well targeted treatment, for instance targeting towards low DAS, is implemented in clinical practice. Our aim was to evaluate treatment adjustments in response to DAS in RA patients in clinical practice. Methods We used data from one referral centre, multiple rheumatologists, from the METEOR database. Generalized Estimating Equations (GEE) were used to assess whether in case of non-low disease activity (DAS > 2.4) treatment intensifications in DMARD therapy occurred ((change or increase in dose or number of DMARDs, including synthetic (s)DMARDs, biologic (b)DMARDs and corticosteroids compared to the visit before)). Determinants of not intensifying the treatment when DAS > 2.4 were investigated using GEE. Results Five thousand one hundred fifty-seven registered visits of 1202 patients were available for the analyses. A DAS > 2.4 was weakly (OR: 1.19; 95 % CI 1.07–1.33) associated with a treatment intensification. In 69 % (n = 3577) of the visits patients were in low disease activity. In 66 % (n = 1028) of the visits with DAS > 2.4 treatment was not intensified. These patients had a higher tender joint count and received more often methotrexate plus a bDMARD, or csDMARD monotherapy, as compared to patients that received treatment intensification. Conclusion In the majority of visits in the METEOR database patients were already in a state of low disease activity, reflecting appropriate treatment intensity. When DAS was greater than 2.4, treatment was often not intensified due to high tender joint count or specific treatment combinations. This data suggest that while aiming for low DAS, physicians per patient weigh whether all DAS elements indicate disease activity or will respond to DMARD adjustment or not, and make treatment decisions accordingly. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-0878-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emilia Gvozdenović
- Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - Ron Wolterbeek
- Department of Biostatistics, Leiden University Medical Center, Leiden, Netherlands
| | - Désirée van der Heijde
- Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Tom Huizinga
- Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Cornelia Allaart
- Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Robert Landewé
- Academic Medical Center, Amsterdam & Atrium Medical Center, Heerlen, Netherlands
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Amouzougan A, Deygat A, Trombert B, Constant E, Denarié D, Marotte H, Thomas T. Spectacular improvement in vitamin D status in elderly osteoporotic women: 8-year analysis of an osteoporotic population treated in a dedicated fracture liaison service. Osteoporos Int 2015; 26:2869-75. [PMID: 26104797 DOI: 10.1007/s00198-015-3206-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 06/10/2015] [Indexed: 01/22/2023]
Abstract
UNLABELLED In a population of postmenopausal women with a fragility fracture, we found a drastic reduction in the proportion of women with severe (<25 nmol/L) and moderate (25 to 75 nmol/L) hypovitaminosis D, especially from 2009 onwards. These results show that supplementation has been very widely integrated into current practice. INTRODUCTION Vitamin D (25(OH)D) is essential for bone health. In institutionalised osteoporotic women, it reduces the risk of fragility fractures. Numerous articles suggesting the possibility of extraosseous effects have generated a growing number of publications and recommendations on more widespread administration, to limit the risks of moderate or severe hypovitaminosis D. We assessed the impact on clinical practice of these recommendations concerning 25(OH)D supplementation in elderly at-risk populations. METHODS A total of 1486 postmenopausal osteoporotic women were seen in the context of a fracture liaison service (i.e. a rheumatology consultation following a peripheral fragility fracture), between May 2005 and December 2012. Of these, 1107 had a 25(OH)D assay (femur, n = 520; humerus, n = 207; wrist, n = 380). RESULTS The average age of the total population was 76.7 ± 9.9 years, while for women with an available 25(OH)D assay, the average age was 75.1 ± 11.8 years. The average 25(OH)D (nmol/L) level was similar for the three fracture sites: femur, 30 ± 36.2; humerus, 27.5 ± 24; and wrist, 31 ± 26. A drastic reduction in the proportion of women with severe (<25 nmol/L) and moderate (25 to 75 nmol/L) hypovitaminosis D was observed, especially from 2009 onwards, with a mean prevalence of 69 and 30 % respectively before that year and 35 and 52 % thereafter. Conversely, the proportion of women with 25(OH)D at the threshold value of 75 nmol/L increased from 1.2 to 24 %. Overall, mean serum 25(OH)D levels were significantly higher when comparing the two periods 2005-2008 and 2009-1012 (17.6 ± 14.6 and 48.4 ± 39.2 nmol/L, respectively; p < 0.0001). CONCLUSION These results show that supplementation has been very widely integrated into current practice. We can expect it to yield beneficial effects in osseous and extraosseous terms in osteoporotic women, particularly the very elderly.
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Affiliation(s)
- A Amouzougan
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Université de Lyon, Lyon, France
- Rheumatology Department, University Hospital of Saint-Etienne, 42023, Saint-Etienne, France
| | - A Deygat
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Université de Lyon, Lyon, France
- Rheumatology Department, University Hospital of Saint-Etienne, 42023, Saint-Etienne, France
| | - B Trombert
- SSPIM, University Hospital of Saint-Etienne, Saint-Etienne, France
- EA SNA-EPIS, PRES Lyon, Saint-Etienne, France
| | - E Constant
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Université de Lyon, Lyon, France
- Rheumatology Department, University Hospital of Saint-Etienne, 42023, Saint-Etienne, France
| | - D Denarié
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Université de Lyon, Lyon, France
- Rheumatology Department, University Hospital of Saint-Etienne, 42023, Saint-Etienne, France
| | - H Marotte
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Université de Lyon, Lyon, France
- Rheumatology Department, University Hospital of Saint-Etienne, 42023, Saint-Etienne, France
| | - T Thomas
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Université de Lyon, Lyon, France.
- Rheumatology Department, University Hospital of Saint-Etienne, 42023, Saint-Etienne, France.
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Zampeli E, Vlachoyiannopoulos PG, Tzioufas AG. Treatment of rheumatoid arthritis: Unraveling the conundrum. J Autoimmun 2015; 65:1-18. [PMID: 26515757 DOI: 10.1016/j.jaut.2015.10.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 11/28/2022]
Abstract
Rheumatoid arthritis (RA) is a heterogeneous disease with a complex and yet not fully understood pathophysiology, where numerous different cell-types contribute to a destructive process of the joints. This complexity results into a considerable interpatient variability in clinical course and severity, which may additionally involve genetics and/or environmental factors. After three decades of focused efforts scientists have now achieved to apply in clinical practice, for patients with RA, the "treat to target" approach with initiation of aggressive therapy soon after diagnosis and escalation of the therapy in pursuit of clinical remission. In addition to the conventional synthetic disease modifying anti-rheumatic drugs, biologics have greatly improved the management of RA, demonstrating efficacy and safety in alleviating symptoms, inhibiting bone erosion, and preventing loss of function. Nonetheless, despite the plethora of therapeutic options and their combinations, unmet therapeutic needs in RA remain, as current therapies sometimes fail or produce only partial responses and/or develop unwanted side-effects. Unfortunately the mechanisms of 'nonresponse' remain unknown and most probable lie in the unrevealed heterogeneity of the RA pathophysiology. In this review, through the effort of unraveling the complex pathophysiological pathways, we will depict drugs used throughout the years for the treatment of RA, the current and future biological therapies and their molecular or cellular targets and finally will suggest therapeutic algorithms for RA management. With multiple biologic options, there is still a need for strong predictive biomarkers to determine which drug is most likely to be effective, safe, and durable in a given individual. The fact that available biologics are not effective in all patients attests to the heterogeneity of RA, yet over the long term, as research and treatment become more aggressive, efficacy, toxicity, and costs must be balanced within the therapeutic equation to enhance the quality of life in patients with RA.
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Affiliation(s)
- Evangelia Zampeli
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
| | | | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece.
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Markusse IM, Dirven L, Gerards AH, van Groenendael JHLM, Ronday HK, Kerstens PJSM, Lems WF, Huizinga TWJ, Allaart CF. Disease flares in rheumatoid arthritis are associated with joint damage progression and disability: 10-year results from the BeSt study. Arthritis Res Ther 2015; 17:232. [PMID: 26321751 PMCID: PMC4553940 DOI: 10.1186/s13075-015-0730-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/28/2015] [Indexed: 01/04/2023] Open
Abstract
Introduction Flares in patients with rheumatoid arthritis are suggested to sometimes spontaneously resolve. Targeted therapy could then entail possible overtreatment. We aimed to determine the flare prevalence in patients who are treated-to-target and to evaluate associations between flares and patient-reported outcomes and radiographic progression. Methods In the BeSt study, 508 patients were treated-to-target for 10 years. After initial treatment adjustments to achieve disease activity score ≤2.4, a flare was defined from the second year of follow-up onwards, according to three definitions. The first definition is a disease activity score >2.4 with an increase of ≥0.6 regardless of the previous disease activity score. The other definitions will be described in the manuscript. Results The flare prevalence was 4–11 % per visit; 67 % of the patients experienced ≥1 flare during 9 years of treatment (median 0 per patient per year). During a flare, functional ability decreased with a mean difference of 0.25 in health assessment questionnaire (p < 0.001), and the odds ratios (95 % confidence intervals) for an increase in patients’ assessment of disease activity, pain and morning stiffness of ≥20 mm on a visual analogue scale were 8.5 (7.3–9.8), 8.4 (7.2–9.7) and 5.6 (4.8–6.6), respectively, compared to the absence of a flare. The odds ratio for radiographic progression was 1.7 (1.1–2.8) in a year with a flare compared to a year without a flare. The more flares a patient experienced, the higher the health assessment questionnaire at year 10 (p < 0.001) and the more radiographic progression from baseline to year 10 (p = 0.005). Conclusion Flares were associated with concurrent increase in patient’s assessment of disease activity, pain and morning stiffness, functional deterioration and development of radiographic progression with a dose–response-effect, both during the flare and long term. This suggests that intensifying treatment during a flare outweighs the risk of possible overtreatment. Trial registration Dutch trial registry NTR262 (7 September 2005) and NTR265 (8 September 2005).
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Affiliation(s)
- Iris M Markusse
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Linda Dirven
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Andreas H Gerards
- Department of Rheumatology, Vlietland Hospital, Schiedam, The Netherlands.
| | | | - H Karel Ronday
- Department of Rheumatology, Haga Hospital, the Hague, The Netherlands.
| | | | - Willem F Lems
- Department of Rheumatology, Reade, Amsterdam, The Netherlands. .,Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands.
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
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73
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Nagy G, van Vollenhoven RF. Sustained biologic-free and drug-free remission in rheumatoid arthritis, where are we now? Arthritis Res Ther 2015; 17:181. [PMID: 26235544 PMCID: PMC4522973 DOI: 10.1186/s13075-015-0707-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The advent of new medications and new treatment strategies for rheumatoid arthritis has made it possible to achieve remission in more patients than before. Furthermore, recent clinical trials and register studies suggest that some patients who initially required aggressive therapy may achieve biologic-free remission or even the ultimate goal of therapy, drug-free remission, resembling recovery. Here, we present a discursive review of the most important studies addressing these issues. Based on the overall results, it remains unclear if achieving biologic-free and drug-free remissions are primarily due to the natural course of the disease or to the early therapeutic intervention according to the 'window of opportunity' hypothesis. Although medication-free remission is only achievable in a small subset of patients, characterizing this patient cohort may provide important information about beneficial prognostic factors and the underlying mechanisms. In summary, in a subset of patients biologic-free and even drug-free remission can be achieved; pursuing these possibilities in practice may decrease the risk for long-term side effects and attenuate the economic burden of the disease.
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Affiliation(s)
- György Nagy
- Department of Rheumatology, Semmelweis University, Faculty of Medicine, Semmelweis University, Budapest, 1023, Hungary. .,Department of Genetics, Cell and Immunobiology, Faculty of Medicine, Semmelweis University, Budapest, 1089, Hungary.
| | - Ronald F van Vollenhoven
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), The Karolinska Institute, Stockholm, 17176, Sweden.
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Sanmartí R, García-Rodríguez S, Álvaro-Gracia JM, Andreu JL, Balsa A, Cáliz R, Fernández-Nebro A, Ferraz-Amaro I, Gómez-Reino JJ, González-Álvaro I, Martín-Mola E, Martínez-Taboada VM, Ortiz AM, Tornero J, Marsal S, Moreno-Muelas JV. 2014 update of the Consensus Statement of the Spanish Society of Rheumatology on the use of biological therapies in rheumatoid arthritis. ACTA ACUST UNITED AC 2015; 11:279-94. [PMID: 26051464 DOI: 10.1016/j.reuma.2015.05.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/05/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To establish recommendations for the management of patients with rheumatoid arthritis (RA) to serve as a reference for all health professionals involved in the care of these patients, and focusing on the role of available synthetic and biologic disease-modifying antirheumatic drugs (DMARDs). METHODS Consensual recommendations were agreed on by a panel of 14 experts selected by the Spanish Society of Rheumatology (SER). The available scientific evidence was collected by updating three systematic reviews (SR) used for the EULAR 2013 recommendations. A new SR was added to answer an additional question. The literature review of the scientific evidence was made by the SER reviewer's group. The level of evidence and the degree of recommendation was classified according to the Oxford Centre for Evidence-Based Medicine system. A Delphi panel was used to evaluate the level of agreement between panellists (strength of recommendation). RESULTS Thirteen recommendations for the management of adult RA were emitted. The therapeutic objective should be to treat patients in the early phases of the disease with the aim of achieving clinical remission, with methotrexate playing a central role in the therapeutic strategy of RA as the reference synthetic DMARD. Indications for biologic DMARDs were updated and the concept of the optimization of biologicals was introduced. CONCLUSIONS We present the fifth update of the SER recommendations for the management of RA with synthetic and biologic DMARDs.
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Affiliation(s)
- Raimon Sanmartí
- Servicio de Reumatología, Hospital Clínic de Barcelona, Barcelona, España.
| | | | | | - José Luis Andreu
- Servicio de Reumatología, Hospital Universitario Puerta de Hierro, Madrid, España
| | - Alejandro Balsa
- Servicio de Reumatología, Hospital Universitario La Paz, Madrid, España
| | - Rafael Cáliz
- Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Granada, España
| | - Antonio Fernández-Nebro
- Unidad de Gestión Clínica de Reumatología, Instituto de Investigación Biomédica de Málaga, Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, España
| | - Iván Ferraz-Amaro
- Servicio de Reumatología, Hospital Universitario de Canarias, Tenerife, España
| | - Juan Jesús Gómez-Reino
- Servicio de Reumatología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, España
| | | | | | | | - Ana M Ortiz
- Servicio de Reumatología, Hospital Universitario de la Princesa, Madrid, España
| | - Jesús Tornero
- Servicio de Reumatología, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Sara Marsal
- Servicio de Reumatología, Hospital Universitario Vall d́Hebron, Barcelona, España
| | - José Vicente Moreno-Muelas
- Servicio de Reumatología, Hospital Universitario Vall d́Hebron, Barcelona, España; Sociedad Española de Reumatología, Madrid, España
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Merashli M, Jawad AS. Rheumatoid arthritis in the Kingdom of Saudi Arabia. Saudi Med J 2015; 36:638. [PMID: 25935189 PMCID: PMC4436765 DOI: 10.15537/smj.2015.5.11639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mira Merashli
- Department of Rheumatology, The Royal London Hospital, London, United Kingdom. E-mail.
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76
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Michaud TL, Rho YH, Shamliyan T, Kuntz KM, Choi HK. The comparative safety of tumor necrosis factor inhibitors in rheumatoid arthritis: a meta-analysis update of 44 trials. Am J Med 2014; 127:1208-32. [PMID: 24950486 DOI: 10.1016/j.amjmed.2014.06.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 05/22/2014] [Accepted: 06/09/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The study objective was to evaluate and update the safety data from randomized controlled trials of tumor necrosis factor inhibitors in patients treated for rheumatoid arthritis. METHODS A systematic literature search was conducted from 1990 to May 2013. All studies included were randomized, double-blind, controlled trials of patients with rheumatoid arthritis that evaluated adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab treatment. The serious adverse events and discontinuation rates were abstracted, and risk estimates were calculated by Peto odds ratios (ORs). RESULTS Forty-four randomized controlled trials involving 11,700 subjects receiving tumor necrosis factor inhibitors and 5901 subjects receiving placebo or traditional disease-modifying antirheumatic drugs were included. Tumor necrosis factor inhibitor treatment as a group was associated with a higher risk of serious infection (OR, 1.42; 95% confidence interval [CI], 1.13-1.78) and treatment discontinuation due to adverse events (OR, 1.23; 95% CI, 1.06-1.43) compared with placebo and traditional disease-modifying antirheumatic drug treatments. Specifically, patients taking adalimumab, certolizumab pegol, and infliximab had an increased risk of serious infection (OR, 1.69, 1.98, and 1.63, respectively) and showed an increased risk of discontinuation due to adverse events (OR, 1.38, 1.67, and 2.04, respectively). In contrast, patients taking etanercept had a decreased risk of discontinuation due to adverse events (OR, 0.72; 95% CI, 0.55-0.93). Although ORs for malignancy varied across the different tumor necrosis factor inhibitors, none reached statistical significance. CONCLUSIONS These meta-analysis updates of the comparative safety of tumor necrosis factor inhibitors suggest a higher risk of serious infection associated with adalimumab, certolizumab pegol, and infliximab, which seems to contribute to higher rates of discontinuation. In contrast, etanercept use showed a lower rate of discontinuation. These data may help guide clinical comparative decision making in the management of rheumatoid arthritis.
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Affiliation(s)
- Tzeyu L Michaud
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Young Hee Rho
- Section of Rheumatology and the Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Mass
| | - Tatyana Shamliyan
- Evidence-Based Medicine Quality Assurance Elsevier, Clinical Solutions, Philadelphia, PA
| | - Karen M Kuntz
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Hyon K Choi
- Section of Rheumatology and the Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Mass.
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Cutolo M, Spies CM, Buttgereit F, Paolino S, Pizzorni C. The supplementary therapeutic DMARD role of low-dose glucocorticoids in rheumatoid arthritis. Arthritis Res Ther 2014; 16 Suppl 2:S1. [PMID: 25608624 PMCID: PMC4249490 DOI: 10.1186/ar4685] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The management of rheumatoid arthritis (RA) is primarily based on the use of disease-modifying antirheumatic drugs (DMARDs), mainly comprising synthetic chemical compounds (that is, methotrexate or leflunomide) and biological agents (tumor necrosis factor inhibitors or abatacept). On the other hand, glucocorticoids (GCs), used for decades in the treatment of RA, are effective in relieving signs and symptoms of the disease, but also interfere with radiographic progression, either as monotherapy or in combination with conventional synthetic DMARDs. GCs exert most of their biological effects through a genomic action, using the cytosolic GC receptor and then interacting with the target genes within target cells that can result in increased expression of regulatory - including anti-inflammatory - proteins (transactivation) or decreased production of proinflammatory proteins (transrepression). An inadequate secretion of GCs from the adrenal gland, in relation to stress and inflammation, seems to play an important role in the pathogenesis and disease progression of RA. At present there is clear evidence that GC therapy, especially long-term low-dose treatment, slows radiographic progression by at least 50% when given to patients with early RA, hence satisfying the conventional definition of a DMARD. In addition, long-term follow-up studies suggest that RA treatment strategies which include GC therapy may favorably alter the disease course even after their discontinuation. Finally, a low-dose, modified night-release formulation of prednisone, although administered in the evening (replacement therapy), has been developed to counteract the circadian (night) rise in proinflammatory cytokine levels that contributes to disease activity, and might represent the way to further optimize the DMARD activity exerted by GCs in RA.
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78
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Hwang YG, Moreland LW. Induction therapy with combination TNF inhibitor and methotrexate in early rheumatoid arthritis. Curr Rheumatol Rep 2014; 16:417. [PMID: 24619653 DOI: 10.1007/s11926-014-0417-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
With the introduction of more objective disease activity measures and the development of biological therapies, there were dramatic changes in the treatment of rheumatoid arthritis (RA). The combination therapy with tumor necrosis factor (TNF) inhibitor and methotrexate (MTX) has unprecedentedly improved prognosis and outcomes, and very low disease activity or remission has been achievable goal in RA. Although the concept of remission induction and maintenance was first discussed in longstanding RA patients, several clinical trials have demonstrated that there is a therapeutic window of opportunity, and early effective control of inflammation in early RA could lead to less joint damage and better long-term outcomes. Emerging evidence suggests that early combination therapy with TNF inhibitor and MTX leads to rapid clinical remission and thereby improved quality of life. Furthermore, remission status may be sustained in some patients even if a TNF inhibitor is discontinued after sustained remission in early RA patients. While there are many potential benefits of early remission induction therapy with the combination of a TNF inhibitor and MTX, the best therapeutic regimen and strategy for remission induction and maintenance in early RA remain controversial. There are no data to decide a priori when and in whom TNF blocker drugs are indicated in early disease-modifying anti-rheumatic drug (DMARD)-naïve RA.
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Affiliation(s)
- Yong Gil Hwang
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, S703 Biomedical Science Tower, 3500 Terrace Street, Pittsburgh, PA, USA,
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79
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Markusse IM, de Vries-Bouwstra JK, Han KH, van der Lubbe PAHM, Schouffoer AA, Kerstens PJSM, Lems WF, Huizinga TWJ, Allaart CF. Feasibility of tailored treatment based on risk stratification in patients with early rheumatoid arthritis. Arthritis Res Ther 2014; 16:430. [PMID: 25253199 PMCID: PMC4203912 DOI: 10.1186/s13075-014-0430-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 08/18/2014] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Personalized medicine is the holy grail of medicine. The EULAR recommendations for the management of rheumatoid arthritis (RA) support differential treatment between patients with baseline characteristics suggestive of a non-poor prognosis (non-PP) or poor prognosis (PP) (presence of autoantibodies, a high inflammatory activity and damage on radiographs). We aimed to determine which prognostic risk groups benefit more from initial monotherapy or initial combination therapy. METHODS 508 patients were randomized to initial monotherapy (iMono) or initial combination therapy (iCombo). Disease outcomes of iMono and iCombo were compared within non-PP or PP groups as determined on baseline characteristics RESULTS PP patients treated with iCombo after three months more often achieved ACR20 (70% vs 38%, P <0.001), ACR50 (48% vs 13%, P <0.001) and ACR70 response (24% vs 4%, P <0.001) than those treated with iMono, and had more improvement in HAQ (median decrease 0.75 vs 0.38, P <0.001). After 1 year, differences in ACR20 response and DAS-remission remained; PP patients treated with iCombo (vs iMono) had less radiographic progression (median 0.0 vs 1.5, P =0.001). CONCLUSIONS Since PP and non-PP patients benefit equally from iCombo through earlier clinical response and functional improvement than with iMono, we conclude that personalized medicine as suggested in the guidelines is not yet feasible. The choice of treatment strategy should depend more on rapid relief of symptoms than on prognostic factors. TRIAL REGISTRATION Netherlands Trial Register NTR262 (registered 7 September 2005) and NTR265 (8 September 2005).
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80
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The new 2010 ACR/EULAR criteria as predictor of clinical and radiographic response in patients with early arthritis. Clin Rheumatol 2014; 34:51-9. [DOI: 10.1007/s10067-014-2737-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 06/29/2014] [Indexed: 01/14/2023]
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81
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Recommendations of the French Society for Rheumatology for managing rheumatoid arthritis. Joint Bone Spine 2014; 81:287-97. [DOI: 10.1016/j.jbspin.2014.05.002] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 11/21/2022]
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82
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Gaujoux-Viala C, Gossec L, Cantagrel A, Dougados M, Fautrel B, Mariette X, Nataf H, Saraux A, Trope S, Combe B. Recommandations de la Société française de rhumatologie pour la prise en charge de la polyarthrite rhumatoïde. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.rhum.2014.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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83
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Gaujoux-Viala C, Gossec L. When and for how long should glucocorticoids be used in rheumatoid arthritis? International guidelines and recommendations. Ann N Y Acad Sci 2014; 1318:32-40. [DOI: 10.1111/nyas.12452] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Cécile Gaujoux-Viala
- Department of Rheumatology; Nîmes University Hospital; Montpellier 1 University; Nîmes France
| | - Laure Gossec
- Pierre Louis Institute of Epidemiology and Public Health; The Pierre and Marie Curie University (UPMC); Sorbonne University, and Department of Rheumatology; Pitié Salpêtrière Hospital; Paris France
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84
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Meek IL, Vonkeman HE, van de Laar MAFJ. Cardiovascular case fatality in rheumatoid arthritis is decreasing; first prospective analysis of a current low disease activity rheumatoid arthritis cohort and review of the literature. BMC Musculoskelet Disord 2014; 15:142. [PMID: 24779371 PMCID: PMC4046075 DOI: 10.1186/1471-2474-15-142] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 03/17/2014] [Indexed: 02/06/2023] Open
Abstract
Background Previous studies found increased case fatality after myocardial infarction and more frequent sudden death in RA patients compared to non-RA subjects. The RA associated CV risk might be explained by the combined effects of chronic systemic inflammation and increased lifestyle associated cardiovascular risk factors, and modified by the use of medication such as non steroidal anti-inflammatory drugs, corticosteroids and disease modifying anti-rheumatic drugs. Trends in case fatality rate in RA after the introduction of potent anti-inflammatory biologic therapies and treat-to-target treatment strategies aiming at remission are not known. This study was performed to examine the cardiovascular fatality rate in current low disease activity RA, and to evaluate trends in RA associated CV case fatality over time. Methods Prospective study to determine the incidence of fatal and nonfatal CV events in 480 RA patients included in the ACT-CVD cohort between February 2009 and December 2011. Patients with prior CV disease were excluded. Cox regression analysis was performed to determine CV event risk and contributing risk factors over time. The results of the cohort analysis were put into the context of a review of the literature to evaluate trends in RA associated CV fatality rate over time. Results The study included 480 RA patients, 72.3% female with median disease duration of 4.2 years, 72.1% being in clinical remission (Disease Activity Score in 28 joints). During a mean follow up of 2.9 years 29 patients (6%) experienced a first CV event, 2 fatal and 27 non-fatal, corresponding to a 6.9% case fatality rate. Comparison with previous studies in cohorts with successive enrolment periods shows a trend towards a decrease in CV case fatality in RA from 52.9% in 1998 to 6.9% in our study. Conclusion CV case fatality in current low disease activity RA is importantly lower than in previous studies, and a trend towards decreasing CV fatality in RA is suggested.
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Affiliation(s)
- Inger L Meek
- Arthritis Center Twente, University Twente and Medisch Spectrum Twente, 7500KA Enschede, Netherlands.
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85
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Treatment comparison in rheumatoid arthritis: head-to-head trials and innovative study designs. BIOMED RESEARCH INTERNATIONAL 2014; 2014:831603. [PMID: 24839607 PMCID: PMC4009266 DOI: 10.1155/2014/831603] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/15/2014] [Indexed: 02/01/2023]
Abstract
Over the last decades, the increasing knowledge in the area of rheumatoid arthritis has progressively expanded the arsenal of available drugs, especially with the introduction of novel targeted therapies such as biological disease modifying antirheumatic drugs (DMARDs). In this situation, rheumatologists are offered a wide range of treatment options, but on the other side the need for comparisons between available drugs becomes more and more crucial in order to better define the strategies for the choice and the optimal sequencing. Indirect comparisons or meta-analyses of data coming from different randomised controlled trials (RCTs) are not immune to conceptual and technical challenges and often provide inconsistent results. In this review we examine some of the possible evolutions of traditional RCTs, such as the inclusion of active comparators, aimed at individualising treatments in real-life conditions. Although head-to-head RCTs may be considered the best tool to directly compare the efficacy and safety of two different DMARDs, surprisingly only 20 studies with such design have been published in the last 25 years. Given the recent advent of the first RCTs truly comparing biological DMARDs, we also review the state of the art of head-to-head trials in RA.
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86
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Kavanaugh A, Wells AF. Benefits and risks of low-dose glucocorticoid treatment in the patient with rheumatoid arthritis. Rheumatology (Oxford) 2014; 53:1742-51. [PMID: 24729402 PMCID: PMC4165844 DOI: 10.1093/rheumatology/keu135] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Glucocorticosteroids (GCs) have been employed extensively for the treatment of rheumatoid arthritis (RA) and other autoimmune and systemic inflammatory disorders. Their use is supported by extensive literature and their utility is reflected in their incorporation into current treatment guidelines for RA and other conditions. Nevertheless, there is still some concern regarding the long-term use of GCs because of their potential for clinically important adverse events, particularly with an extended duration of treatment and the use of high doses. This article systematically reviews the efficacy for radiological and clinical outcomes for low-dose GCs (defined as ≤10 mg/day prednisone equivalent) in the treatment of RA. Results reviewed indicated that low-dose GCs, usually administered in combination with synthetic DMARDs, most often MTX, significantly improve structural outcomes and decrease symptom severity in patients with RA. Safety data indicate that GC-associated adverse events are dose related, but still occur in patients receiving low doses of these agents. Concerns about side effects associated with GCs have prompted the development of new strategies aimed at improving safety without compromising efficacy. These include altering the structure of existing GCs and the development of delayed-release GC formulations so that drug delivery is timed to match greatest symptom severity. Optimal use of low-dose GCs has the potential to improve long-term outcomes for patients with RA.
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Affiliation(s)
- Arthur Kavanaugh
- Department of Medicine, University of California, San Diego, La Jolla, CA and Department of Rheumatology, Duke University Medical Center, Durham, NC, USA.
| | - Alvin F Wells
- Department of Medicine, University of California, San Diego, La Jolla, CA and Department of Rheumatology, Duke University Medical Center, Durham, NC, USA
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Kanbe K, Hara R, Chiba J, Inoue Y, Taguchi M, Tanaka Y. Application of a new immunohistology scoring system (IH score): analysis of TNF-α in synovium related to disease activity score in infliximab-treated patients with rheumatoid arthritis. Mod Rheumatol 2014; 24:910-4. [PMID: 24670132 DOI: 10.3109/14397595.2014.887047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES This study aimed to analyze the relationship between the expression of tumor necrosis factor alpha (TNF-α) or interleukin-6 (IL-6) in synovium and the disease activity score (DAS) 28 (C-reactive protein, CRP) in treatment of infliximab for rheumatoid arthritis (RA). METHODS Synovial tissues were obtained from 16 infliximab-treated patients and assessed for TNF-α and IL-6 with a new immunohistology (IH) scoring system. The validation of IH score was performed and applied for the analysis of correlation between synovial TNF-α or IL-6 and DAS28 (CRP) in addition to Rooney score. RESULTS The IH score had high internal validity; the IH score of TNF-α strongly correlated with serum CRP and matrix metalloprotease-3 (MMP-3), as well as DAS28 (CRP) and the Rooney score. IL-6 did not correlate with DAS28 (CRP). CONCLUSIONS This study indicates that the IH score is useful as a new procedure to assess the cytokine expression easily and TNF-α in synovium correlates with disease activity in patients with RA treated with infliximab.
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Affiliation(s)
- Katsuaki Kanbe
- Department of Orthopaedic Surgery, Tokyo Women's Medical University , Medical Center East, Tokyo , Japan
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Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, Emery P, Gaujoux-Viala C, Gossec L, Nam J, Ramiro S, Winthrop K, de Wit M, Aletaha D, Betteridge N, Bijlsma JWJ, Boers M, Buttgereit F, Combe B, Cutolo M, Damjanov N, Hazes JMW, Kouloumas M, Kvien TK, Mariette X, Pavelka K, van Riel PLCM, Rubbert-Roth A, Scholte-Voshaar M, Scott DL, Sokka-Isler T, Wong JB, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014; 73:492-509. [PMID: 24161836 PMCID: PMC3933074 DOI: 10.1136/annrheumdis-2013-204573] [Citation(s) in RCA: 1433] [Impact Index Per Article: 143.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 10/05/2013] [Accepted: 10/11/2013] [Indexed: 02/07/2023]
Abstract
In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
| | - Robert Landewé
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Atrium Medical Center, Heerlen, The Netherlands
| | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maya Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Maxime Dougados
- Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital, Montpellier I University, Nimes, France
| | - Laure Gossec
- Rheumatology Department, Paris 06 UPMC University, AP-HP, Pite-Salpetriere Hospital, Paris, France
| | - Jackie Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sofia Ramiro
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Hospital Garcia de Orta, Almada, Portugal
| | - Kevin Winthrop
- Oregon Health and Science University, Portland, Oregon, USA
| | - Maarten de Wit
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Neil Betteridge
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Boers
- VU University Medical Center, Amsterdam, The Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Bernard Combe
- Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
| | - Maurizio Cutolo
- Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Nemanja Damjanov
- 2nd Hospital Department, Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, Dr Molewaterplein, Rotterdam, The Netherlands
| | - Marios Kouloumas
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Xavier Mariette
- Hopitaux Universitaires Paris Sud, AP-HP, and Université Paris-Sud, Le Kremlin Bicetre, France
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Piet L C M van Riel
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Marieke Scholte-Voshaar
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - David L Scott
- King's College School of Medicine, Weston Education Centre, London, UK
| | | | - John B Wong
- Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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Gaujoux-Viala C, Nam J, Ramiro S, Landewé R, Buch MH, Smolen JS, Gossec L. Efficacy of conventional synthetic disease-modifying antirheumatic drugs, glucocorticoids and tofacitinib: a systematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis. Ann Rheum Dis 2014; 73:510-5. [PMID: 24395555 PMCID: PMC3932966 DOI: 10.1136/annrheumdis-2013-204588] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/02/2013] [Accepted: 12/11/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To update a previous systematic review assessing the efficacy of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) in rheumatoid arthritis (RA). METHODS Two systematic reviews of the literature using PubMed, Embase and the Cochrane library were performed from 2009 until January 2013 to assess the efficacy of csDMARDs (as monotherapy or combination therapy) in adults with RA, and the efficacy of glucocorticoids in early RA. A third systematic review was performed until March 2013 to assess the efficacy of tofacitinib by meta-analysis. RESULTS For glucocorticoids, of 222 hits, five publications relating to four new trials were analysed for efficacy, confirming that initial treatment of RA with low-dose prednisone plus methotrexate (MTX) results in better clinical and structural outcomes at 1 and 2 years than treatment with MTX alone. For csDMARDs, of 498 studies, only two new studies were randomised controlled trials comparing MTX monotherapy with MTX in combination with another csDMARD without differences in glucocorticoid usage. Using tight control principles, clinical outcomes were no better with immediate triple therapy than with 'step-up' therapy. For tofacitinib, the pooled analysis of 10 trials showed that tofacitinib was more efficacious on signs and symptoms, disability and appeared to be more efficacious on structural damage than control treatment with placebo (OR (95% CI)--American College of Rheumatology 20% (ACR20) response: 2.44 (1.97 to 3.02)) or treatment with MTX (ACR20 response: 2.38 (1.66 to 3.43)). CONCLUSIONS Addition of low-dose glucocorticoids to csDMARD therapy produces benefits in early RA. Under tight control conditions, combination therapy with csDMARDs is no better than MTX monotherapy. Tofacitinib is a new DMARD with proven efficacy.
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Affiliation(s)
- Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital; EA 2415, Montpellier I University, Nîmes, France
| | - Jackie Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sofia Ramiro
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Rheumatology, Hospital Garcia de Orta, Almada, Portugal
| | - Robert Landewé
- Department of Clinical Immunology & Rheumatology, Academic Medical Center/University of Amsterdam & Atrium Medical Center, Heerlen, The Netherlands
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
| | - Laure Gossec
- Department of Rheumatology, UPMC Univ Paris 06, GRC-UPMC 08 (EEMOIS); AP-HP, Pitié Salpêtrière Hospital, Paris, France
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Girolomoni G, Griffiths CEM, Krueger J, Nestle FO, Nicolas JF, Prinz JC, Puig L, Ståhle M, van de Kerkhof PCM, Allez M, Emery P, Paul C. Early intervention in psoriasis and immune-mediated inflammatory diseases: A hypothesis paper. J DERMATOL TREAT 2014; 26:103-12. [DOI: 10.3109/09546634.2014.880396] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Smolen JS, Emery P, Fleischmann R, van Vollenhoven RF, Pavelka K, Durez P, Guérette B, Kupper H, Redden L, Arora V, Kavanaugh A. Adjustment of therapy in rheumatoid arthritis on the basis of achievement of stable low disease activity with adalimumab plus methotrexate or methotrexate alone: the randomised controlled OPTIMA trial. Lancet 2014; 383:321-32. [PMID: 24168956 DOI: 10.1016/s0140-6736(13)61751-1] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Biological agents offer good control of rheumatoid arthritis, but the long-term benefits of achieving low disease activity with a biological agent plus methotrexate or methotrexate alone are unclear. The OPTIMA trial assessed different treatment adjustment strategies in patients with early rheumatoid arthritis attaining (or not) stable low disease activity with adalimumab plus methotrexate or methotrexate monotherapy. METHODS This trial was done at 161 sites worldwide. Patients with early (<1 year duration) rheumatoid arthritis naive to methotrexate were randomly allocated (by interactive voice response system, in a 1:1 ratio, block size four) to adalimumab (40 mg every other week) plus methotrexate (initiated at 7·5 mg/week, increased by 2·5 mg every 1-2 weeks to a maximum weekly dose of 20 mg by week 8) or placebo plus methotrexate for 26 weeks (period 1). Patients in the adalimumab plus methotrexate group who completed period 1 and achieved the stable low disease activity target (28-joint disease activity score with C-reactive protein [DAS28]<3·2 at weeks 22 and 26) were randomised to adalimumab-continuation or adalimumab-withdrawal for an additional 52 weeks (period 2). Patients achieving the target with initial methotrexate continued methotrexate-monotherapy. Inadequate responders were offered adalimumab plus methotrexate. All patients and investigators were masked to treatment allocation in period 1. During period 2, treatment reallocation of patients who achieved the target was masked to patients and investigators; patients who did not achieve the target remained masked to original randomisation, but were aware of the subsequent assignment. The primary endpoint was a composite measure of DAS28 of less than 3·2 at week 78 and radiographic non-progression from baseline to week 78, compared between adalimumab-continuation and methotrexate-monotherapy. Adverse events were monitored throughout period 2. This trial is registered with ClinicalTrials.gov, number NCT00420927. FINDINGS The study was done between Dec 28, 2006, and Aug 3, 2010. 1636 patients were assessed and 1032 were randomised in period 1 (515 to adalimumab plus methotrexate; 517 to placebo plus methotrexate). 466 patients in the adalimumab plus methotrexate group completed period 1; 207 achieved the stable low disease activity target, of whom 105 were rerandomised to adalimumab-continuation. 460 patients in the placebo plus methotrexate group completed period 1; 112 achieved the stable low disease activity target and continued methotrexate-monotherapy. 73 of 105 (70%) patients in the adalimumab-continuation group and 61 of 112 (54%) patients in the methotrexate-monotherapy group achieved the primary endpoint at week 78 (mean difference 15% [95% CI 2-28%], p=0·0225). Patients achieving the stable low disease activity target on adalimumab plus methotrexate who withdrew adalimumab mostly maintained their good responses. Overall, 706 of 926 patients in period 2 had an adverse event, of which 82 were deemed serious; however, distribution of adverse events did not differ between groups. INTERPRETATION Treatment to a stable low disease activity target resulted in improved clinical, functional, and structural outcomes, with both adalimumab-continuation and methotrexate-monotherapy. However, a higher proportion of patients treated with initial adalimumab plus methotrexate achieved the low disease activity target compared with those initially treated with methotrexate alone. Outcomes were much the same whether adalimumab was continued or withdrawn in patients who initially responded to adalimumab plus methotrexate. FUNDING AbbVie.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine Three, Medical University of Vienna, Vienna, Austria; Second Department of Medicine, Hietzing Hospital, Vienna, Austria.
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK; NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Roy Fleischmann
- Division of Rheumatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Karel Pavelka
- Institute and Clinic of Rheumatology, First Medical Faculty, Charles University, Prague, Czech Republic
| | - Patrick Durez
- Service et Pôle de Rhumatologie, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | | | - Hartmut Kupper
- AbbVie Deutschland GmbH and Company KG, Ludwigshafen, Germany
| | | | | | - Arthur Kavanaugh
- Division of Rheumatology, Allergy and Immunology, University of California San Diego, La Jolla, CA, USA
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Nam JL, Ramiro S, Gaujoux-Viala C, Takase K, Leon-Garcia M, Emery P, Gossec L, Landewe R, Smolen JS, Buch MH. Efficacy of biological disease-modifying antirheumatic drugs: a systematic literature review informing the 2013 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2014; 73:516-28. [PMID: 24399231 DOI: 10.1136/annrheumdis-2013-204577] [Citation(s) in RCA: 228] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To update the evidence for the efficacy of biological disease-modifying antirheumatic drugs (bDMARD) in patients with rheumatoid arthritis (RA) to inform the European League Against Rheumatism(EULAR) Task Force treatment recommendations. METHODS Medline, Embase and Cochrane databases were searched for articles published between January 2009 and February 2013 on infliximab, etanercept, adalimumab, certolizumab-pegol, golimumab, anakinra, abatacept, rituximab, tocilizumab and biosimilar DMARDs (bsDMARDs) in phase 3 development. Abstracts from 2011 to 2012 American College of Rheumatology (ACR) and 2011-2013 EULAR conferences were obtained. RESULTS Fifty-one full papers, and 57 abstracts were identified. The randomised controlled trials (RCT) confirmed the efficacy of bDMARD+conventional synthetic DMARDs (csDMARDs) versus csDMARDs alone (level 1B evidence). There was some additional evidence for the use of bDMARD monotherapy, however bDMARD and MTX combination therapy for all bDMARD classes was more efficacious (1B). Clinical and radiographic responses were high with treat-to-target strategies. Earlier improvement in signs and symptoms were seen with more intensive initial treatment strategies, but outcomes were similar upon addition of bDMARDs in patients with insufficient response to MTX. In general, radiographic progression was lower with bDMARD use, mainly due to initial treatment effects. Although patients may achieve bDMARD- and drug-free remission, maintenance of clinical responses was higher with bDMARD continuation (1B), but bDMARD dose reduction could be applied (1B). There was still no RCT data for bDMARD switching. CONCLUSIONS The systematic literature review confirms efficacy of biological DMARDs in RA. It addresses different treatment strategies with the potential for reduction in therapy, particularly with early disease control, and highlights emerging therapies.
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Affiliation(s)
- Jackie L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, , Leeds, UK
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Abstract
Treatment of early rheumatoid arthritis has to be started very early, when the diagnosis is made, preferentially before 6 months of symptoms. Combination therapy with conventional disease-modifying anti-rheumatic drugs (DMARDs) with low-dose, oral glucocorticoids in the induction phase from the start gives the best results. The patient should be monitored systematically, at start between 1 and 3 months, and the patient should have access to additional visits if a flare or arthritis or adverse event occurs. The treatment should aim to remission (no tender and swollen joints, no signs of inflammatory activity), which can be reached by 60-80% of the patients. Intra-articular glucocorticoid injections as part of the treatment strategy increase the suppression of arthritis and retard joint destruction. Biological drugs are reserved for patients who have consistent active disease and who do not respond to conventional combinations.
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Affiliation(s)
- Marjatta Leirisalo-Repo
- Helsinki University Central Hospital, Department of Medicine, and University of Helsinki, Institute of Clinical Medicine, Helsinki, Finland.
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Rantalaiho V, Kautiainen H, Korpela M, Puolakka K, Blåfield H, Ilva K, Hannonen P, Leirisalo-Repo M, Möttönen T. Physicians' adherence to tight control treatment strategy and combination DMARD therapy are additively important for reaching remission and maintaining working ability in early rheumatoid arthritis: a subanalysis of the FIN-RACo trial. Ann Rheum Dis 2013; 73:788-90. [PMID: 24297374 DOI: 10.1136/annrheumdis-2013-204271] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Vappu Rantalaiho
- Department of Internal Medicine, Centre for Rheumatic Diseases, Tampere University Hospital, , Tampere, Finland
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Wevers-de Boer KVC, Heimans L, Visser K, Kälvesten J, Goekoop RJ, van Oosterhout M, Harbers JB, Bijkerk C, Steup-Beekman M, de Buck MPDM, de Sonnaville PBJ, Huizinga TWJ, Allaart CF. Four-month metacarpal bone mineral density loss predicts radiological joint damage progression after 1 year in patients with early rheumatoid arthritis: exploratory analyses from the IMPROVED study. Ann Rheum Dis 2013; 74:341-6. [PMID: 24285491 DOI: 10.1136/annrheumdis-2013-203749] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM To assess whether in early (rheumatoid) arthritis (RA) patients, metacarpal bone mineral density (BMD) loss after 4 months predicts radiological progression after 1 year of antirheumatic treatment. METHODS Metacarpal BMD was measured 4 monthly during the first year by digital X-ray radiogrammetry (DXR-BMD) in patients participating in the IMPROVED study, a clinical trial in 610 patients with recent onset RA (2010 criteria) or undifferentiated arthritis, treated according to a remission (disease activity score<1.6) steered strategy. With Sharp/van der Heijde progression ≥0.5 points after 1 year (yes/no) as dependent variable, univariate and multivariate logistic regression analyses were performed. RESULTS Of 428 patients with DXR-BMD results and progression scores available, 28 (7%) had radiological progression after 1 year. Independent predictors for radiological progression were presence of baseline erosions (OR (95% CI) 6.5 (1.7 to 25)) and early DXR-BMD loss (OR (95% CI) 1.5 (1.1 to 2.0)). In 366 (86%) patients without baseline erosions, early DXR-BMD loss was the only independent predictor of progression (OR (95% CI) 2.0 (1.4 to 2.9)). CONCLUSIONS In early RA patients, metacarpal BMD loss after 4 months of treatment is an independent predictor of radiological progression after 1 year. In patients without baseline erosions, early metacarpal BMD loss is the main predictor of radiological progression.
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Affiliation(s)
| | - L Heimans
- Department of Rheumatology, LUMC, Leiden, Zuid-holland, The Netherlands
| | - K Visser
- Department of Rheumatology, LUMC, Leiden, Zuid-holland, The Netherlands
| | - J Kälvesten
- Sectra, Linköping, Sweden CMIV Linköping University, Linköping, Sweden
| | - R J Goekoop
- Department of Rheumatology, Haga Hospital, The Hague, Zuid-holland, The Netherlands
| | - M van Oosterhout
- Department of Rheumatology, Groene Hart Hospital, Gouda, Zuid-holland, The Netherlands
| | - J B Harbers
- Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands
| | - C Bijkerk
- Department of Rheumatology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | - M P D M de Buck
- Department of Rheumatology, MCH, The Hague, Zuid-holland, The Netherlands
| | | | - T W J Huizinga
- Department of Rheumatology, LUMC, Leiden, Zuid-holland, The Netherlands
| | - C F Allaart
- Department of Rheumatology, LUMC, Leiden, Zuid-holland, The Netherlands
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Chalan P, Kroesen BJ, van der Geest KSM, Huitema MG, Abdulahad WH, Bijzet J, Brouwer E, Boots AMH. Circulating CD4+CD161+ T lymphocytes are increased in seropositive arthralgia patients but decreased in patients with newly diagnosed rheumatoid arthritis. PLoS One 2013; 8:e79370. [PMID: 24223933 PMCID: PMC3815125 DOI: 10.1371/journal.pone.0079370] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 09/24/2013] [Indexed: 12/05/2022] Open
Abstract
Improved understanding of the immune events discriminating between seropositive arthralgia and clinical synovitis is of key importance in rheumatology research. Ample evidence suggests a role for Th17 cells in rheumatoid arthritis. We hypothesized that CD4+CD161+ cells representing Th17 lineage cells may be modulated prior to or after development of clinical synovitis. Therefore, in a cross-sectional study, we investigated the occurrence of CD4+CD161+ T-cells in seropositive arthralgia patients who are at risk for developing rheumatoid arthritis and in newly diagnosed rheumatoid arthritis patients. In a prospective study, we evaluated the effect of methotrexate treatment on circulating CD4+CD161+ T-cells. Next, we assessed if these cells can be detected at the level of the RA joints. Precursor Th17 lineage cells bearing CD161 were found to be increased in seropositive arthralgia patients. In contrast, circulating CD4+CD161+T-cells were decreased in newly diagnosed rheumatoid arthritis patients. The decrease in CD4+CD161+ T-cells correlated inversely with C-reactive protein and with the 66 swollen joint count. Methotrexate treatment led to normalization of CD4+CD161+ T-cells and reduced disease activity. CD4+CD161+ T cells were readily detected in synovial tissues from both early and late-stage rheumatoid arthritis. In addition, synovial fluid from late-stage disease was found to be enriched for CD4+CD161+ T-cells. Notably, synovial fluid accumulated CD4+CD161+T-cells showed skewing towards the Th1 phenotype as evidenced by increased interferon-γ expression. The changes in peripheral numbers of CD4+CD161+ T-cells in seropositive arthralgia and early rheumatoid arthritis and the enrichment of these cells at the level of the joint predict a role for CD4+CD161+ T-cells in the early immune events leading to clinical synovitis. Our findings may add to the development of RA prediction models and provide opportunities for early intervention.
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Affiliation(s)
- Paulina Chalan
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
| | - Bart-Jan Kroesen
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
| | - Kornelis S. M. van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
| | - Minke G. Huitema
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
| | - Wayel H. Abdulahad
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
| | - Johan Bijzet
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
| | - Annemieke M. H. Boots
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Groningen research initiative on healthy ageing and immune longevity (GRAIL), Groningen, The Netherlands
- * E-mail:
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Eng G, Stoltenberg MB, Szkudlarek M, Bouchelouche PN, Christensen R, Bliddal H, Marie Bartels E. Efficacy of treatment intensification with adalimumab, etanercept and infliximab in rheumatoid arthritis: A systematic review of cohort studies with focus on dose. Semin Arthritis Rheum 2013; 43:144-51. [DOI: 10.1016/j.semarthrit.2013.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 01/29/2013] [Accepted: 01/31/2013] [Indexed: 11/29/2022]
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Combination with methotrexate and cyclophosphamide attenuated maturation of dendritic cells: inducing Treg skewing and Th17 suppression in vivo. Clin Dev Immunol 2013; 2013:238035. [PMID: 24194771 PMCID: PMC3806152 DOI: 10.1155/2013/238035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 08/01/2013] [Accepted: 08/15/2013] [Indexed: 01/27/2023]
Abstract
Immune disorder is considered the main pathogenesis of autoimmune diseases, such as rheumatoid arthritis (RA). The balance of the two special subsets of CD4+T cells, T helper cell 17 (Th17), and Regulator T cell (Treg) is the key factor of maintaining a normal immune response. Dendritic cells (DCs), which are the most powerful antigen-presenting cells, play an important role in regulating the balance of Th17 and Treg. The combination of disease modifying antirheumatic drugs (DMARDs) is an important strategy of RA therapy. In this study, we investigated the effect of MTX and CTX on DC maturation in ovalbumin (OVA) immunized mice. Th17 inflammatory response is stronger, while the level of DCs maturity is higher. In contrast, the immunosuppression of Treg is stronger. We found that MTX combined with CTX significantly inhibited the DCs maturity and downregulated the antigen presenting capacity of DCs. As a result, it reestablished a balance of Th17 and Treg. Our study adds a novel mechanism and therapeutic target of MTX combined with CTX for autoimmune disease treatment.
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Abstract
PURPOSE OF REVIEW Rheumatoid arthritis (RA) is a potentially destructive disease with profound impact on patients' function and quality of life. Newer therapeutic agents have revolutionized outcomes but have not resulted in best outcomes for all patients. In this article, we will review recent progress in the development of strategies to enhance outcomes in patients with early RA (ERA). RECENT FINDINGS Over the past 10 years, investigators have increasingly focused on additional means for improving long-term prognosis of patients with RA by examining the effect of different strategies to reach clinical targets reflecting optimal levels of disease control. In particular, it has become apparent that patients with ERA have the best chance to reach optimal outcomes, thus normalizing function, and halting radiographic damage. Studies show that strategies including treating to a target, computerizing targets, and combining clinical and biological or imaging targets for patients are enabling more patients to achieve remission, sustained remission, and even drug-free remission. SUMMARY Overall, the bar has been set higher in clinical research with the expectation that therapeutic approaches for all patients should be implemented to achieve high-level targeted outcomes. Studies evaluating the feasibility of implementing these in practice are needed to achieve this goal for all patients with ERA.
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