Impact of obesity on the response to tumor necrosis factor inhibitors in axial spondyloarthritis

Association between concomitant csDMARDs and clinical response to TNF inhibitors in overweight patients with axial spondyloarthritis

Background

The aim of our study was to investigate the influence of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and body mass index (BMI) on circulating drug levels and clinical response to tumour necrosis factor inhibitor (TNFi) therapy in axial spondyloarthritis (axSpA) patients.

Methods

Prospective observational study during 1 year with 2 cohorts (Madrid and Amsterdam) including 180 axSpA patients treated with standard doses of infliximab or adalimumab. Patients were stratified by BMI, being 78 (43%) normal weight (18.5–24.9 kg/m²) and 102 (57%) overweight/obese (≥ 25.0 kg/m²). After the first year of treatment, TNFi trough levels were measured by capture ELISA. Clinical response to TNFi was defined as ∆BASDAI ≥ 2 and clinical remission as BASDAI < 2 and CRP ≤ 5 mg/L. Logistic regression models were employed to analyse the association between concomitant csDMARDs and BMI with drug levels and clinical response.

Results

Seventy-nine patients (44%) received concomitant csDMARDs. The administration of concomitant csDMARDs (OR 3.82; 95% CI 1.06–13.84) and being normal weight (OR 18.38; 95% CI 2.24–150.63) were independently associated with serum TNFi drug persistence. Additionally, the use of concomitant csDMARDs contributed positively to achieve clinical response (OR 7.86; 95% CI 2.39–25.78) and remission (OR 4.84; 95% CI 1.09–21.36) in overweight/obese patients, but no association was found for normal-weight patients (OR 1.10; 0.33–3.58).

Conclusions

The use of concomitant csDMARDs with TNFi may increase the probability of achieving clinical response in overweight/obese axSpA patients. Further research studies including larger cohorts of patients need to be done to confirm it.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1849-3) contains supplementary material, which is available to authorized users.

Extremely poor patient-reported outcomes are associated with lack of clinical response and decreased retention rate of tumour necrosis factor inhibitor treatment in patients with axial spondyloarthritis

OBJECTIVE

To investigate whether axial spondyloarthritis (axSpA) patients with extremely poor patient-reported outcomes (PROs) at start of first tumour necrosis factor inhibitor (TNFi) treatment have poorer treatment response and shorter treatment retention than other patients.

METHOD

This observational cohort study was based on the nationwide DANBIO registry. Patients with axSpA who started first TNFi during 2011-2016 were stratified according to baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI ≥ 0.0 to ≤ 4.0, > 4.0 to ≤ 5.0, > 5.0 to ≤ 6.0, > 6.0 to ≤ 7.0, > 7.0 to ≤ 8.0, > 8.0 to ≤ 9.0, and > 9.0 to ≤ 10.0). An extremely poor BASDAI was defined as BASDAI > 9.0 to ≤ 10.0. Treatment responses after 6 months [≥ 50% improvement from baseline BASDAI (BASDAI50), ≥ 40% improvement in Assessment of SpondyloArthritis international Society (ASAS40) response, and ASAS partial remission] in patients with extremely poor PROs were compared with other patients by chi-squared tests, and retention rates by log-rank tests. Similar analyses were done for Bath Ankylosing Spondylitis Functional Index (BASFI), pain score, and patient global score.

RESULTS

The study included 1396 patients (median age 39 years, 60% men). Patients with extremely poor baseline BASDAI [63 patients (5%)] were more often women, ever smokers, and human leucocyte antigen-B27 negative, and had higher body mass index. Response rates were poorer in patients with extremely poor BASDAI vs remaining patients (BASDAI50 19% and 41%, respectively, p < 0.001; ASAS40 16% and 35%, p = 0.002; ASAS partial remission 6% and 22%, p < 0.001). Patients with extremely poor BASDAI had lower 1 year treatment retention (51% and 68%, p < 0.001). Largely similar results were found for patients with extremely poor BASFI, pain score, and patient global score.

CONCLUSION

Patients who reported an unusually large symptom burden at baseline had poor response rates and low retention rate. In such cases, competing causes of pain should carefully be taken into account when considering treatment with TNFi.

Inflammation, obesity and rheumatic disease: common mechanistic links. A narrative review

Obesity represents a rising global health concern, linked to significant social, psychological and physical burden to the individual affected, people around them and the society as a whole. Obesity has been described as a low-grade inflammatory condition, associated with increased production of pro-inflammatory mediators like tumor necrosis factor alpha or interleukin 6 and altered expression of adipokines. Adipokines, mainly produced by adipose tissue, have mixed pro- and anti-inflammatory properties. Obesity rarely exists on its own; instead, it tends to coexist with (often multiple) other comorbidities, including metabolic, cardiovascular, and rheumatic and musculoskeletal diseases (RMDs). In the case of RMDs, evidence is rapidly accumulating on common mechanistic pathways implicated in the inflammatory states seen between RMDs and obesity. Although there remain unanswered questions on the exact mechanisms of inflammation that link obesity to RMDs, what is becoming increasingly known is the association between obesity and adverse clinical outcomes in RMDs. This narrative review discusses insights into mechanisms of inflammation linking obesity and RMDs and evidence on the impact of obesity on treatment response and important disease outcomes. We highlight the importance of targeting obesity, a common and modifiable comorbidity, as part of the routine care of people with RMDs.

Baricitinib in Patients with Rheumatoid Arthritis and an Inadequate Response to Conventional Disease-Modifying Antirheumatic Drugs in United States and Rest of World: A Subset Analysis

INTRODUCTION

This article evaluates the efficacy and safety of baricitinib 4 mg versus placebo in United States including Puerto Rico (US) and rest of the world (ROW) subpopulations using data pooled from RA-BEAM and RA-BUILD, which enrolled patients with moderate-to-severe adult-onset rheumatoid arthritis (RA).

METHODS

In RA-BEAM, patients with an inadequate response (IR) to methotrexate, at least one X-ray erosion, and high sensitivity C-reactive protein (hsCRP) ≥ 6 mg/L were randomized to placebo or orally administered baricitinib 4 mg daily or subcutaneously administered adalimumab 40 mg every other week. In RA-BUILD, patients with an IR to at least one conventional synthetic disease-modifying antirheumatic drug (csDMARD) and with hsCRP ≥ 3.6 mg/L were randomized to placebo or baricitinib 2 or 4 mg daily. Patients in both trials were biologic naive. In this post hoc analysis, data from both studies were pooled (714 baricitinib 4 mg-treated, 716 placebo-treated patients).

RESULTS

Overall, 188 US and 1242 ROW patients were included. Subgroups differed in baseline characteristics including race, weight, age, time since RA diagnosis, current corticosteroid use, and previous csDMARD use. At weeks 12 and 24, baricitinib-treated patients had larger responses compared to placebo-treated patients for multiple efficacy outcomes: American College of Rheumatology 20/50/70 response, low disease activity, remission, Disease Activity Score 28-C-reactive protein, and Health Assessment Questionnaire-Disability Index. Overall, similar efficacy was observed in US and ROW subgroups with no notable safety differences between subgroups at weeks 12 or 24.

CONCLUSION

Baricitinib 4 mg was efficacious compared to placebo in US and ROW subpopulations. Safety was similar between subgroups.

FUNDING

Eli Lilly & Company and Incyte Corporation.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers, NCT01721057; NCT01710358.

Impact of obesity on the efficacy of different biologic agents in inflammatory diseases: A systematic review and meta-analysis

OBJECTIVE

Obesity is a worldwide epidemic and a growing body of evidence suggests that it may affect the body's response to biologic agents. We investigated the influence of obesity on the efficacy of different biologic agents used to treat inflammatory diseases.

METHODS

Medline, EMBASE and the Cochrane Database were searched using relevant MeSH and keyword terms for obesity and bDMARDs. Articles were selected if they reported a clinical response in obese subjects relative to other BMI categories. Response and remission outcomes were assessed using meta-analysis and all other reported outcomes were summarized.

RESULTS

Among the 3850 records retrieved, 24 articles met the inclusion criteria, including 10 on rheumatoid arthritis (RA), 4 on axial spondyloarthritis (axSpA), 4 on Crohn's disease (CD), 4 on psoriasis (Ps) and 2 on psoriasic arthritis (PsA). Four biological disease-modifying anti-rheumatic drugs (bDMARDs) - anti-TNF agents, T cell co-stimulation inhibitor (abatacept), IL-6 inhibitor (tocilizumab), and B-cell depletion therapy (rituximab) - were involved. The meta-analysis showed that the odds to reach a good response or achieve remission were lower in obese (BMI>30kg/m²) than non-obese (BMI≤30kg/m²) patients who were treated with anti-TNF agents (good responder % in RA: OR 0.34, 95% CI 0.18-0.64; remission% in RA: OR 0.36, 95% CI 0.21-0.59; BASDAI50% in axSpA: OR 0.41, 95% CI 0.21-0.83), but no significant difference between obese and non-obese was found in patients treated with abatacept (good responder % in RA: OR 0.75, 95% CI 0.42-1.36; remission% in RA: OR 0.84, 95% CI 0.65-1.09) and tocilizumab (good responder % in RA: OR 1.08, 95% CI 0.44-2.63; remission% in RA: OR 0.91, 95% CI 0.50-1.66).

CONCLUSION

Obesity hampered the effect of anti-TNF agents, but not those of abatacept and tocilizumab, suggesting that a personalized treatment strategy should be considered for obese patients with inflammatory diseases.

Age determines response to anti-TNFα treatment in patients with ankylosing spondylitis and is related to TNFα-producing CD8 cells

Younger age is a predictor of good clinical response to treatment with tumour necrosis factor (TNF) α inhibitors in ankylosing spondylitis (AS) patients; therefore, the aim of the study was to determine age-related differences in cellular functions, which can predict the response. High disease activity AS patients were treated with TNFα inhibitors for 12 weeks. Based on the percentage of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) improvement, patients were divided into responding or non-responding groups. Cytometric and clinical assessment were determined at baseline, 4, and 12 weeks after initiation of anti-TNFα treatment. Expression of activation markers on T cells and intracellular cytokine staining was performed. Baseline percentage of TNFα-producing CD8 cells was lower in responders than in non-responders (20.8 ± 2.9 vs 40.7 ± 8.2; P = 0.04 in T test) and increased in the responding group during the first month of treatment (20.8 ± 2.9 vs 30.3 ± 2.5; P = 0.02). Moreover, its baseline level correlated with age (r = 0.7; P = 0.0009) but not with BASDAI improvement adjusted for age. There were no differences in the baseline percentage of IL-4, IL-17A, and IFNγ within CD4 and CD8 cells nor in the expression of CD25, CD28, and CD69 on these cells between responders and non-responders. However, baseline level of CD4+CD28null cells correlated with the percentage of BASDAI improvement while analysed as a continuous variable adjusted for age (r = − 0.4; P = 0.048). Clinical predictors of response were also determined. Influence of age on the response to anti-TNFα treatment in AS patients could be mediated by TNFα-producing CD8 cells.

Long-term efficacy and predictors of remission following adalimumab treatment in peripheral spondyloarthritis: 3-year results from ABILITY-2

Objectives

Describe efficacy and safety of 3 years of adalimumab treatment in patients with peripheral spondyloarthritis (pSpA) and identify predictors of remission.

Methods

Patients with pSpA were randomised to adalimumab 40 mg every other week or placebo for 12 weeks; a 144-week open-label extension followed (NCT01064856). Remission was assessed by the Peripheral SpA Response Criteria (PSpARC) and Ankylosing Spondylitis Disease Activity Score inactive disease (ASDAS ID). Logistic regression analyses were performed to determine predictors of remission at 1 and 3 years and sustained remission (≥24 consecutive weeks).

Results

In 165 patients, ASDAS ID was achieved by 47% at 1 year and 39% at 3 years; 36% and 33% achieved PSpARC remission, respectively. Sustained ASDAS ID and PSpARC remission were achieved by 52% (86/165) and 42% (70/165) of patients, respectively. Achieving ASDAS ID at week 12 significantly predicted 1 year (OR, 8.64 (95% CI 2.97 to 25.14)), 3 year (OR, 36.12 (95% CI 2.29 to 569.08)) and sustained ASDAS ID (OR, 8.01 (95% CI 2.47 to 25.97)); achieving PSpARC remission at week 12 consistently predicted 1 year (OR, 6.47 (95% CI 1.91 to 21.95)), 3 years (OR, 15.66 (95% CI 4.19 to 58.56)) and sustained PSpARC remission (OR, 20.27 (95% CI 5.37 to 76.46)). No baseline variables consistently predicted 1-year or 3-year remission or sustained remission. The safety profile of adalimumab was consistent with observations in other SpA disease indications.

Conclusions

In patients with pSpA, early response to adalimumab, but not baseline demographics or disease characteristics, was a better predictor of long-term remission.

Relationship between monocytes to lymphocytes ratio and axial spondyloarthritis

BACKGROUND

Axial spondyloarthritis (axSpA) is a progressive, chronic, inflammatory skeletal disorder affecting the spine and sacroiliac joints. Many studies have shown that neutrophils, lymphocytes, monocytes, platelets, and red blood cells (RBCs) play important roles in the inflammatory process of axSpA. Neutrophils to lymphocytes ratio (NLR) and red blood cell distribution width (RDW) have been reported to be simple and inexpensive markers to indicate the disease activity of axSpA. However, the role of monocytes to lymphocytes ratio (MLR) and platelets to lymphocytes ratio (PLR) in axSpA was rarely mentioned.

OBJECTIVE

The study's aim was to determine the role of MLR and PLR in axSpA patients and to investigate their relationships with disease severity.

METHODS

AxSpA patients who fulfilled the Assessment in Ankylosing Spondylitis International Society classification criteria published in 2009 were enrolled in this study and divided into nonradiographic axial spondyloarthritis (nr-axSpA) group and ankylosing spondylitis (AS) group. Healthy age and gender-matched subjects were also enrolled as control group. MLR, PLR, NLR, RDW, C-reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) level were assessed. The correlation between the variables with finger-to-floor distance, Modified Schober test, and occiput-to-wall distance were tested with Pearson correlation. Furthermore, area under curve (AUC) value, sensitivity, specificity, and the optimal cutoff values were determined using receiver operating characteristic (ROC) curves.

RESULTS

A total of 148 axSpA patients (67 nr-axSpA patients and 81 AS patients) and 58 healthy subjects were included in the study. The MLR, NLR, PLR, and RDW in axSpA group were higher than those in the control group (P < 0.05). Among them, MLR and RDW were highly increased in AS group compared with the nr-axSpA group (P < 0.05). MLR, NLR, PLR, and RDW were all positively correlated with ESR level and CRP level (P < 0.05). MLR and RDW were positively correlated with finger-to-floor distance and negatively correlated with Modified Schober test (P < 0.05). RDW was positively correlated with occiput-to-wall distance (P < 0.05). ROC curve results showed MLR yielded a higher AUC than NLR, PLR, and RDW (P < 0.05). In addition, the optimal cutoff value of MLR for axSpA was 0.22, with a specificity of 70.9% and sensitivity of 68.4%.

CONCLUSIONS

MLR was elevated in AS patients compared to nr-axSpA patients and had a close relationship with CRP level, ESR level, and spine movements. MLR may be a reliable, cost-effective, and novel potential parameter to evaluate disease severity in axSpA.