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Świerkot J, Batko B, Wiland P, Jędrzejewski M, Stajszczyk M. Methotrexate treatment for rheumatoid arthritis in Poland: Retrospective analysis of patients in routine clinical practice. Reumatologia 2018; 56:3-9. [PMID: 29686436 PMCID: PMC5911651 DOI: 10.5114/reum.2018.74741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 02/21/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate methotrexate (MTX) treatment administered by Polish rheumatologists in everyday practice. MATERIAL AND METHODS The study was based on a retrospective analysis of a cohort of 1957 patients with rheumatoid arthritis (RA). It was conducted among 100 rheumatologists, each of whom received 20 questionnaires and completed them based on the data from their rheumatoid arthritis patients. RESULTS Methotrexate was taken by 91% of patients, and 80% of them continued the treatment either as a monotherapy (65%) or concomitantly with other disease-modifying anti-rheumatic drugs. In 60% of the cases, therapy was initiated within six months of diagnosis. Dose modifications were observed in 76% of cases and were contingent on different factors, e.g. lack of efficacy, presence of adverse events. The most prevalent adverse events were nausea and vomiting, weakness, and elevated liver enzyme activity. The most common initial dose of MTX was 10 or 15 mg/week. An increase in dose to the maximum of 25 mg/week was observed in 36% of cases, with continuation for 27% of patients. Treatment interruption was noted in 21% of patients, predominantly due to MTX intolerance; however, in 13% of cases, it was due to patient choice. CONCLUSIONS Methotrexate is the most common agent used to treat rheumatoid arthritis. Dose modifications are often applied to maximise efficacy and reduce adverse reactions, which could lead to withdrawal. Methotrexate is an effective drug for treatment of RA when used according to current recommendations. To optimise MTX therapy, regular medical visits are required.
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Affiliation(s)
- Jerzy Świerkot
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | - Bogdan Batko
- Department of Rheumatology, J. Dietl Specialist Hospital, Krakow, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | | | - Marcin Stajszczyk
- Department of Rheumatology and Autoimmune Diseases, Silesian Rheumatology Centre, Ustron, Poland
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Municio C, Dominguez-Soto Á, Fuentelsaz-Romero S, Lamana A, Montes N, Cuevas VD, Campos RG, Pablos JL, González-Álvaro I, Puig-Kröger A. Methotrexate limits inflammation through an A20-dependent cross-tolerance mechanism. Ann Rheum Dis 2018; 77:752-759. [PMID: 29431121 PMCID: PMC5909749 DOI: 10.1136/annrheumdis-2017-212537] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/21/2017] [Accepted: 01/15/2018] [Indexed: 12/29/2022]
Abstract
Objectives Methotrexate (MTX) is the anchor drug for treatment of rheumatoid arthritis (RA), but the mechanism of its anti-inflammatory action is not fully understood. In RA, macrophages display a proinflammatory polarisation profile that resembles granulocyte-macrophage colony-stimulating factor (GM-CSF)-differentiated macrophages and the response to MTX is only observed in thymidylate synthase+ GM-CSF-dependent macrophages. To determine the molecular basis for the MTX anti-inflammatory action, we explored toll-like receptor (TLR), RA synovial fluid (RASF) and tumour necrosis factor receptor (TNFR)-initiated signalling in MTX-exposed GM-CSF-primed macrophages. Methods Intracellular responses to TLR ligands, TNFα or RASF stimulation in long-term low-dose MTX-exposed human macrophages were determined through quantitative real-time PCR, western blot, ELISA and siRNA-mediated knockdown approaches. The role of MTX in vivo was assessed in patients with arthritis under MTX monotherapy and in a murine sepsis model. Results MTX conditioned macrophages towards a tolerant state, diminishing interleukin (IL)-6 and IL-1β production in LPS, LTA, TNFα or RASF-challenged macrophages. MTX attenuated LPS-induced MAPK and NF-κB activation, and toll/IL-1R domain-containing adaptor inducing IFN-beta (TRIF1)-dependent signalling. Conversely, MTX increased the expression of the NF-κB suppressor A20 (TNFAIP3), itself a RA-susceptibility gene. Mechanistically, MTX-induced macrophage tolerance was dependent on A20, as siRNA-mediated knockdown of A20 reversed the MTX-induced reduction of IL-6 expression. In vivo, TNFAIP3 expression was significantly higher in peripheral blood cells of MTX-responsive individuals from a cohort of patients with arthritis under MTX monotherapy, whereas MTX-treated mice exhibited reduced inflammatory responses to LPS. Conclusions MTX impairs macrophage proinflammatory responses through upregulation of A20 expression. The A20-mediated MTX-induced innate tolerance might limit inflammation in the RA synovial context, and positions A20 as a potential MTX-response biomarker.
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Affiliation(s)
- Cristina Municio
- Laboratorio de Inmuno-Metabolismo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Sara Fuentelsaz-Romero
- Laboratorio de Inmuno-Metabolismo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Amalia Lamana
- Servicio de Reumatología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Hospital Universitario La Princesa, Madrid, Spain
| | - Nuria Montes
- Servicio de Reumatología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Hospital Universitario La Princesa, Madrid, Spain
| | | | - Raquel García Campos
- Laboratorio de Inmuno-Metabolismo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - José L Pablos
- Servicio de Reumatología, Instituto de Investigación Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Isidoro González-Álvaro
- Servicio de Reumatología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Hospital Universitario La Princesa, Madrid, Spain
| | - Amaya Puig-Kröger
- Laboratorio de Inmuno-Metabolismo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Piao J, Ning J, Chambers CD, Xu R. Semiparametric model and inference for spontaneous abortion data with a cured proportion and biased sampling. Biostatistics 2018; 19:54-70. [PMID: 28525542 DOI: 10.1093/biostatistics/kxx024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 04/12/2017] [Indexed: 11/14/2022] Open
Abstract
Evaluating and understanding the risk and safety of using medications for autoimmune disease in a woman during her pregnancy will help both clinicians and pregnant women to make better treatment decisions. However, utilizing spontaneous abortion (SAB) data collected in observational studies of pregnancy to derive valid inference poses two major challenges. First, the data from the observational cohort are not random samples of the target population due to the sampling mechanism. Pregnant women with early SAB are more likely to be excluded from the cohort, and there may be substantial differences between the observed SAB time and those in the target population. Second, the observed data are heterogeneous and contain a "cured" proportion. In this article, we consider semiparametric models to simultaneously estimate the probability of being cured and the distribution of time to SAB for the uncured subgroup. To derive the maximum likelihood estimators, we appropriately adjust the sampling bias in the likelihood function and develop an expectation-maximization algorithm to overcome the computational challenge. We apply the empirical process theory to prove the consistency and asymptotic normality of the estimators. We examine the finite sample performance of the proposed estimators in simulation studies and illustrate the proposed method through an application to SAB data from pregnant women.
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Affiliation(s)
- Jin Piao
- Department of Biostatistics, The University of Texas School of Public Health, 1200 Pressler Street, Houston, TX 77030, USA
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030, USA
| | - Christina D Chambers
- Department of Pediatrics, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92093, USA and Department of Family Medicine and Public Health, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92093, USA
| | - Ronghui Xu
- Department of Family Medicine and Public Health, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92093, USA and Department of Mathematics, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92093, USA
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Similar short-term clinical response to high-dose versus low-dose methotrexate in monotherapy and combination therapy in patients with rheumatoid arthritis. Arthritis Res Ther 2017; 19:258. [PMID: 29166919 PMCID: PMC5700534 DOI: 10.1186/s13075-017-1468-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/07/2017] [Indexed: 11/17/2022] Open
Abstract
Background Aiming at rapid decrease of disease activity, there has been a trend to start with higher doses of methotrexate (MTX) in patients newly diagnosed with rheumatoid arthritis (RA), both as monotherapy and in combination with other antirheumatic drugs. We aimed to study the relationship between clinical response and MTX dose as monotherapy or combination therapy in patients with early RA. Methods Disease-modifying anti-rheumatic drug (DMARD)-naive patients with early RA, from a large international observational database, the METEOR database, were selected if MTX was part of their initial treatment. Patients were divided into four groups: MTX monotherapy, MTX + convention synthetic (cs)DMARDs, MTX + glucocorticoids or MTX + biologic (b)DMARDs. MTX dose was dichotomized: low dose ≤10 mg/week; high dose ≥15 mg/week. Linear mixed model analyses for the Disease Activity Score (DAS), DAS in 28 joints (DAS28) and Health Assessment Questionnaire (HAQ) were performed in each medication group, with MTX dose and time as covariates. Outcomes were assessed from baseline until 3–6 months follow up. Associations were adjusted for potential confounding by indication using propensity score (PS) modelling. Results For patients starting MTX monotherapy (n = 523), MTX + csDMARDs (n = 266) or MTX + glucocorticoids (n = 615), the PS-adjusted effects of MTX dose (high versus low) on the DAS, DAS28 and HAQ were small and not clinically meaningful. Patients starting MTX + bDMARDs were disregarded due to low numbers (n =11). Conclusions In patients newly diagnosed with RA, no clinical benefit of high compared to low initial MTX doses was found for MTX monotherapy or for MTX combination therapy with csDMARDs or glucocorticoids. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1468-9) contains supplementary material, which is available to authorized users.
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Kostuj T, Rehart S, Matta-Hurtado R, Biehl C, Willburger RE, Schmidt K. Pilot study for the registry of complications in rheumatic diseases from the German Society of Surgery (DGORh): evaluation of methods and data from the first 1000 patients. BMJ Open 2017; 7:e015987. [PMID: 29018066 PMCID: PMC5640080 DOI: 10.1136/bmjopen-2017-015987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Most patients suffering with rheumatic diseases who undergo surgical treatment are receiving immune-modulating therapy. To determine whether these medications affect their outcomes a national registry was established in Germany by the German Society of Surgery (DGORh). Data from the first 1000 patients were used in a pilot study to identify relevant corisk factors and to determine whether such a registry is suitable for developing accurate and relevant recommendations. DESIGN AND PARTICIPANTS Data were collected from patients undergoing surgical treatments with their written consent. A second consent form was used, if complications occurred. During this pilot study, in order to obtain a quicker overview, risk factors were considered only in patients with complications. Only descriptive statistical analysis was employed in this pilot study due to limited number of observed complications and inhomogeneous data regarding the surgery and the medications the patients received. Analytical statistics will be performed to confirm the results in a future outcome study. RESULTS Complications occurred in 26 patients and were distributed equally among the different types of surgeries. Twenty one of these patients were receiving immune-modulating therapy at the time, while five were not. Infections were observed in 2.3% of patients receiving and in 5.1% not receiving immunosuppression. CONCLUSIONS Due to the low number of cases, inhomogeneity in the diseases and the treatments received by the patients in this pilot study, it is not possible to develop standardised best-practice recommendations to optimise their care. Based on this observation we conclude that in order to be suitable to develop accurate and relevant recommendations a national registry must include the most important and relevant variables that impact the care and outcomes of these patients.
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Affiliation(s)
- Tanja Kostuj
- Department of Orthopedics and Traumatology, Catholic Hospital Bochum, St. Josefs Hospital, University Hospital of Ruhr University Bochum, Bochum, Germany
- Institute for Medical Biometry and Epidemiology, University of Witten/Herdecke, Witten, Germany
| | - Stefan Rehart
- Clinic for Orthopedics and Traumatology, Agaplesion Markus Hospital, Teaching Hospital of Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Ronald Matta-Hurtado
- Department of Orthopedics, Rheumatic Orthopedics and Traumatology Clinic, Catholic Hospital, Dortmund, Germany
| | - Christoph Biehl
- Department of Orthopedics, Rheumatic Orthopedics and Traumatology Clinic, Catholic Hospital, Dortmund, Germany
- Orthopedic and Rheumaorthopedic Clinic-Diakonie Hospital, Bad-Kreuznach, Germany
| | - Roland E Willburger
- Department of Rheumatic Orthopedics, Catholic Hospital Bochum, St. Elisabeth Hospital, University Hospital of Ruhr University Bochum, Bochum, Germany
| | - Klaus Schmidt
- Department of Orthopedics, Rheumatic Orthopedics and Traumatology Clinic, Catholic Hospital, Dortmund, Germany
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Howley MM, Browne ML, Van Zutphen AR, Richardson SD, Blossom SJ, Broussard CS, Carmichael SL, Druschel CM. Maternal autoimmune disease and birth defects in the National Birth Defects Prevention Study. ACTA ACUST UNITED AC 2017; 106:950-962. [PMID: 27891777 DOI: 10.1002/bdra.23527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 04/28/2016] [Accepted: 05/02/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Little is known about the association between maternal autoimmune disease or its treatment and the risk of birth defects. We examined these associations using data from the National Birth Defects Prevention Study, a multi-site, population-based, case-control study. METHODS Analyses included 25,116 case and 9897 unaffected control infants with estimated delivery dates between 1997 and 2009. Information on autoimmune disease, medication use, and other pregnancy exposures was collected by means of telephone interview. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for birth defects with five or more exposed cases; crude ORs and exact 95% CIs were estimated for birth defects with three to four exposed cases. RESULTS Autoimmune disease was reported by 373 mothers (279 case and 94 control mothers). The majority of birth defects evaluated were not associated with autoimmune disease; however, a statistically significant association between maternal autoimmune disease and encephalocele was observed (OR, 4.64; 95% CI, 1.95-11.04). Eighty-two mothers with autoimmune disease used an immune modifying/suppressing medication during pregnancy; this was associated with encephalocele (OR, 7.26; 95% CI, 1.37-24.61) and atrial septal defects (OR, 3.01; 95% CI, 1.16-7.80). CONCLUSION Our findings suggest maternal autoimmune disease and treatment are not associated with the majority of birth defects, but may be associated with some defects, particularly encephalocele. Given the low prevalence of individual autoimmune diseases and the rare use of specific medications, we were unable to examine associations of specific autoimmune diseases and medications with birth defects. Other studies are needed to confirm these findings. Birth Defects Research (Part A) 106:950-962, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Meredith M Howley
- Congenital Malformations Registry, New York State Department of Health, Albany, New York
| | - Marilyn L Browne
- Congenital Malformations Registry, New York State Department of Health, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
| | - Alissa R Van Zutphen
- Congenital Malformations Registry, New York State Department of Health, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
| | - Sandra D Richardson
- Congenital Malformations Registry, New York State Department of Health, Albany, New York
| | - Sarah J Blossom
- Department of Pediatrics, Arkansas Children's Hospital Research Institute, Little Rock, Arkansas
| | - Cheryl S Broussard
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Charlotte M Druschel
- Congenital Malformations Registry, New York State Department of Health, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
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108
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Wells AU, Kokosi MA. Rebuttal From Drs Wells and Kokosi. Chest 2017; 152:922-923. [PMID: 28943277 DOI: 10.1016/j.chest.2017.08.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/09/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, England.
| | - Maria A Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, England
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109
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Conway R, Carey JJ. Risk of liver disease in methotrexate treated patients. World J Hepatol 2017; 9:1092-1100. [PMID: 28989565 PMCID: PMC5612840 DOI: 10.4254/wjh.v9.i26.1092] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/20/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
Methotrexate is the first line drug treatment for a number of rheumatic and non-rheumatic diseases. It is effective in controlling disease activity and preventing disease-related damage, and significantly cheaper than many alternatives. Use in rheumatoid arthritis infers a significant morbidity and mortality benefit. Methotrexate is generally well tolerated but can cause symptomatic adverse events. Multiple serious adverse events have been attributed to methotrexate, based largely on older reports using high or daily doses, and subsequent case reports and circumstantial evidence. The risk with modern dosing regimens: Lower doses, weekly schedules, and concomitant folic acid is less clear. Clarification and dissemination of the actual risk is crucial so appropriate judgements can be made for patients who may benefit from this treatment. Methotrexate has been associated with a range of liver related adverse events ranging from asymptomatic transaminase elevations to fibrosis and fatal hepatic necrosis. Concern over potential liver toxicity has resulted in treatment avoidance, cessation, or recommendations for investigations which may be costly, invasive and unwarranted. Modern laboratory monitoring of liver blood tests may also influence the risk of more serious complications. The majority of present day studies report an approximate doubling of the relative risk of elevated transaminases in methotrexate treated patients but no increased risk of symptomatic or severe liver related adverse events. In this article we will review the evidence around methotrexate and liver related adverse events.
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Affiliation(s)
- Richard Conway
- Centre for Arthritis and Rheumatic Diseases, St. Vincent’s University Hospital, Dublin 4, Ireland
- CARD Newman Research Fellow, University College Dublin, Belfield, Dublin 4, Ireland
| | - John J Carey
- Department of Rheumatology, Galway University Hospitals, Merlin Park, Galway H91 YR71, Ireland
- Clinical Sciences Institute, National University of Ireland Galway, Galway H91 TK33, Ireland
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Gaujoux-Viala C, Rincheval N, Dougados M, Combe B, Fautrel B. Optimal methotrexate dose is associated with better clinical outcomes than non-optimal dose in daily practice: results from the ESPOIR early arthritis cohort. Ann Rheum Dis 2017; 76:2054-2060. [DOI: 10.1136/annrheumdis-2017-211268] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/17/2017] [Accepted: 07/31/2017] [Indexed: 12/21/2022]
Abstract
BackgroundAlthough methotrexate (MTX) is the consensual first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA), substantial heterogeneity remains with its prescription and dosage, which are often not optimal.ObjectiveTo evaluate the symptomatic and structural impact of optimal MTX dose in patients with early RA in daily clinical practice over 2 years.MethodsPatients included in the early arthritis ESPOIR cohort who fulfilled the ACR-EULAR (American College of Rheumatology/European League against Rheumatism) criteria for RA and received MTX as a first DMARD were assessed. Optimal MTX dose was defined as ≥10 mg/week during the first 3 months, with escalation to ≥20 mg/week or 0.3 mg/kg/week at 6 months without Disease Activity Score in 28 joints remission. Symptomatic and structural efficacy with and without optimal MTX dose was assessed by generalised logistic regression with adjustment for appropriate variables.ResultsWithin the first year of follow-up, 314 patients (53%) with RA received MTX as a first DMARD (mean dose 12.2±3.8 mg/week). Only 26.4% (n=76) had optimal MTX dose. After adjustment, optimal versus non-optimal MTX dose was more efficient in achieving ACR-EULAR remission at 1 year (OR 4.28 (95% CI 1.86 to 9.86)) and normal functioning (Health Assessment Questionnaire ≤0.5; OR at 1 year 4.36 (95% CI 2.03 to 9.39)), with no effect on radiological progression. Results were similar during the second year.ConclusionOptimal MTX dose is more efficacious than non-optimal dose for remission and function in early arthritis in daily practice, with no impact on radiological progression over 2 years.
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111
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Bergstra SA, Allaart CF, Stijnen T, Landewé RBM. Meta-Regression of a Dose-Response Relationship of Methotrexate in Mono- and Combination Therapy in Disease-Modifying Antirheumatic Drug-Naive Early Rheumatoid Arthritis Patients. Arthritis Care Res (Hoboken) 2017; 69:1473-1483. [PMID: 27992656 DOI: 10.1002/acr.23164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/02/2016] [Accepted: 12/06/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate a possible short-term dose-response relationship of initial treatment with methotrexate (MTX) in monotherapy and combination therapy in recent-onset rheumatoid arthritis (RA) patients. METHODS A systematic literature search was performed on trials and cohorts, including early, disease-modifying antirheumatic drug (DMARD)-naive RA patients treated with MTX, with data on clinical results within 6 months from treatment start. Cohen's effect sizes were calculated for the Health Assessment Questionnaire (HAQ), erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) level, and/or Disease Activity Score (DAS)/in 28 joints (DAS28) in 4 treatment groups: MTX monotherapy, or MTX in combination with synthetic (cs) DMARDs, biologic (b) DMARDs, or glucocorticoids. Random-effects meta-regression analyses were performed for each outcome, with treatment group as the predictor corrected for baseline HAQ or disease activity and assessment point. RESULTS Thirty-one studies including 5,589 patients were included. The meta-regression did not support higher effectiveness of increasing MTX dose in monotherapy. The number of treatment groups using combination therapy with csDMARDs was too small to perform meta-regression analyses. In combination therapy with glucocorticoids, a higher MTX dose was associated with higher (worse) outcome HAQ, but not with DAS/DAS28 or ESR/CRP level. In combination therapy with bDMARDs, a higher MTX dose was associated with higher outcome HAQ and DAS/DAS28, but not with ESR/CRP level. All effect sizes were small. CONCLUSION In DMARD-naive, early RA patients who start MTX, either as monotherapy or in combination with bDMARDs or glucocorticoids, a higher initial dose of MTX was not associated with better clinical outcomes. This finding suggests that there is little short-term gain from starting with high compared to low MTX doses.
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Affiliation(s)
- S A Bergstra
- Leiden University Medical Center, Leiden, The Netherlands
| | - C F Allaart
- Leiden University Medical Center, Leiden, The Netherlands
| | - T Stijnen
- Leiden University Medical Center, Leiden, The Netherlands
| | - R B M Landewé
- Amsterdam Rheumatology & Immunology Center, Zuyderland Medical Center Heerlen, The Netherlands
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112
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Ultrasound imaging of synovial inflammation in juvenile idiopathic arthritis. Pediatr Radiol 2017; 47:1160-1170. [PMID: 28779188 DOI: 10.1007/s00247-017-3934-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/05/2017] [Accepted: 06/23/2017] [Indexed: 01/17/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic entity of childhood. The hallmark feature of all subtypes is joint inflammation. Imaging is used to evaluate the extent and severity of inflammation, degree of joint damage and response to treatment, which in turn impacts patient management. Ultrasound has become a useful adjunct to clinical examination because it shows promise in evaluating clinical and subclinical inflammation (synovitis, enthesitis) as well as cartilage and bone erosive changes. However more collaborative research is needed to help define the normal appearance of the growing skeleton, clarify the significance of subclinical findings and develop useful definitions, imaging protocols and scoring systems of disease.
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113
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Warren RB, Weatherhead SC, Smith CH, Exton LS, Mohd Mustapa MF, Kirby B, Yesudian PD. British Association of Dermatologists' guidelines for the safe and effective prescribing of methotrexate for skin disease 2016. Br J Dermatol 2017; 175:23-44. [PMID: 27484275 DOI: 10.1111/bjd.14816] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 12/25/2022]
Affiliation(s)
- R B Warren
- The Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M6 8HD, U.K
| | - S C Weatherhead
- Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - B Kirby
- St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - P D Yesudian
- Glan Clwyd Hospital, Sarn Lane, Rhyl, LL18 5UJ, U.K
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Costs of Providing Infusion Therapy for Rheumatoid Arthritis in a Hospital-based Infusion Center Setting. Clin Ther 2017; 39:1600-1617. [DOI: 10.1016/j.clinthera.2017.06.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/05/2017] [Accepted: 06/09/2017] [Indexed: 11/21/2022]
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115
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Luime JJ, Buisman LR, Oppe M, Hazes JMW, Rutten-van Mölken MPMH. Cost-Effectiveness Model for Evaluating New Diagnostic Tests in the Evaluation of Patients With Inflammatory Arthritis at Risk of Having Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2017; 68:927-35. [PMID: 26555013 DOI: 10.1002/acr.22776] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/27/2015] [Accepted: 10/27/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVE New opportunities have emerged for early diagnosis with the arrival of new technologies that assess the impact of genomics, proteomics, metabolomics, and cytomics on rheumatoid arthritis (RA) risk. This early health technology assessment study assesses the short-term cost effectiveness of 4 add-on diagnostic tests in early inflammatory arthritis patients at risk of RA. METHODS We modeled 4 diagnostic add-on tests to the American College of Rheumatology/European League Against Rheumatism 2010 RA classification criteria, covering the first year after diagnosis, using Rotterdam Early Arthritis Cohort data. Sensitivity, specificity, and costs were assigned to the magnetic resonance imaging of hands and feet (sensitivity 0.90, specificity 0.60, cost €756), interleukin-6 (IL-6) serum level test (sensitivity 0.70, specificity 0.53, cost €50), B cell-related gene expression (sensitivity 0.60, specificity 0.90, cost €150), and gene assay for RA (sensitivity 0.40, specificity 0.85, cost €750), based on literature and expert opinion. Outcomes were evaluated using the unweighted diagnostic net benefit (UDNB) and the incremental cost-effectiveness ratio (ICER) in all patients (n = 552), intermediate-risk patients (n = 263), and seronegative patients (n = 329). RESULTS The highest UDNB was found when using the B cell assay in intermediate-risk patients (43%, ICER €5,314), while the IL-6 test in seronegative patients resulted in the lowest UDNB (-11.4%, ICER €7,650). If a threshold of €20,000 is applied, the B cell assay would be preferred over the other alternatives, with a 78% probability of being cost effective for intermediate-risk patients, 57% for all patients, and 73% for seronegative patients. CONCLUSION Diagnostic add-on tests favoring specificity over sensitivity with a headroom less than €370 per test are cost effective, with the largest diagnostic benefit occurring in intermediate-risk patients.
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Affiliation(s)
- Jolanda J Luime
- Erasmus Medical Center and Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Leander R Buisman
- Erasmus Medical Center and Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Mark Oppe
- Erasmus University Rotterdam, and EuroQol Research Foundation, Rotterdam, The Netherlands
| | - Johanna M W Hazes
- Johanna M. W. Hazes, MD, PhD: Erasmus Medical Center, Rotterdam, The Netherlands
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Takeuchi T, Ishida K, Shiraki K, Yoshiyasu T. Safety and effectiveness of tacrolimus add-on therapy for rheumatoid arthritis patients without an adequate response to biological disease-modifying anti-rheumatic drugs (DMARDs): Post-marketing surveillance in Japan. Mod Rheumatol 2017. [PMID: 28649878 DOI: 10.1080/14397595.2017.1332471] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Post-marketing surveillance (PMS) was conducted to assess the safety and effectiveness of tacrolimus (TAC) add-on therapy for patients with rheumatoid arthritis (RA) and an inadequate response to biological disease-modifying anti-rheumatic drugs (DMARDs). METHODS Patients with RA from 180 medical sites across Japan were registered centrally with an electronic investigation system. The observational period was 24 weeks from the first day of TAC administration concomitantly with biological DMARDs. RESULTS Safety and effectiveness populations included 624 and 566 patients, respectively. Patients were predominantly female (81.1%), with a mean age of 61.9 years. Overall, 125 adverse drug reactions (ADRs) occurred in 94 patients (15.1%), and 15 serious ADRs occurred in 11 patients (1.8%). These incidences were lower compared with previously reported incidences after TAC treatment in PMS, and all of the observed ADRs were already known. A statistically significant improvement was observed in the primary effectiveness variable of Simplified Disease Activity Index after TAC treatment; 62.7% of patients achieved remission or low disease activity at week 24. CONCLUSIONS TAC is well tolerated and effective when used as an add-on to biological DMARDs in Japanese patients with RA who do not achieve an adequate response to biological DMARDs in a real-world clinical setting.
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Affiliation(s)
- Tsutomu Takeuchi
- a Division of Rheumatology, Department of Internal Medicine, School of Medicine , Keio University , Tokyo , Japan
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Risk of Adverse Pregnancy Outcome After Paternal Exposure to Methotrexate Within 90 Days Before Pregnancy. Obstet Gynecol 2017; 129:707-714. [PMID: 28277353 DOI: 10.1097/aog.0000000000001936] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To study the association between paternal exposure to methotrexate within the 90-day period before pregnancy and congenital malformations and stillbirth in the offspring. METHODS We conducted a nationwide register study. Our cohort consisted of all live births in Denmark between 1997 and 2011 identified from the Medical Birth Registry. Methotrexate-exposed fathers were identified from the National Prescription Registry. From the national Hospital Registry we identified paternity, live births, and stillbirths as well as discharge diagnoses on congenital malformations. RESULTS We identified 849,676 live births with known paternity. There were 127 live births of methotrexate-exposed fathers. Of these, four (3.2%) had major malformations compared with 28,814 (3.4%) of the unexposed. The odds ratio (OR) for major congenital malformation among exposed fathers compared with unexposed was 0.93 (95% confidence interval [CI] 0.34-2.51) and when adjusted for year of birth, maternal age, educational length, household income, and parity, the adjusted OR was 1.01 (95% CI 0.37-2.74). There were no stillbirths in the methotrexate-exposed group compared with 2,541 (0.3%) in the unexposed group and no increased risk of preterm birth (adjusted OR 1.31, 95% CI 0.66-2.59) among the children from exposed fathers. CONCLUSION We found no association between paternal exposure to methotrexate within 90 days before pregnancy and congenital malformations, stillbirths, or preterm birth. Available data suggest that prepregnancy paternal methotrexate exposure should not be of major concern. Multinational recommendations should be changed accordingly.
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Humphreys JH, Costello R, Verstappen SMM, Dixon WG. Response to: Quantifying the hepatotoxic risk of alcohol consumption in patients with rheumatoid arthritis by Kremer and Weinblatt. Ann Rheum Dis 2017; 77:e5. [DOI: 10.1136/annrheumdis-2017-211670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/08/2017] [Indexed: 11/04/2022]
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Salinas-Sánchez DO, Jiménez-Ferrer E, Sánchez-Sánchez V, Zamilpa A, González-Cortazar M, Tortoriello J, Herrera-Ruiz M. Anti-Inflammatory Activity of a Polymeric Proanthocyanidin from Serjania schiedeana. Molecules 2017; 22:molecules22060863. [PMID: 28587132 PMCID: PMC6152783 DOI: 10.3390/molecules22060863] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 01/16/2023] Open
Abstract
The ethyl acetate extract (SsAcOEt) from Serjania schiedeana, select fractions (F-6, F-12, F-13, F-14), and one isolated compound, were evaluated in 12-O-tetradecanoylphorbol 13-acetate (TPA) ear edema and kaolin/carrageenan (KC)-induced monoarthritis assays. SsEtOAc induced edema inhibition of 90% (2.0 mg/ear), fractions showed activity within a range of 67–89%. Due to the fact F-14 showed the highest effect, it was separated, yielding a proanthocyanidin-type called epicatechin–(4β → 8)–epicatechin–(4β → 8, 2β → O → 7) epicatechin (ETP). This compound (2.0 mg/ear) provoked 72% of edema inhibition (ED50 = 0.25 mg/ear, Emax = 52.9%). After 9 days of treatment, joint inflammation was decreasing, and on the last day, SsEtOAc (400 mg/kg), F-14 and ETP (10 mg/kg), SsEtOAc (200 mg/kg), methotrexate (MTX) 1.0 mg/kg and meloxicam (MEL) 1.5 mg/kg, produced an inhibition articulate edema of 94, 62, 36, 21, 80, and 54%, respectively. In the joint, pro-inflammatory molecules were elevated in animals without treatment (vehicle group, VEH). Treatments from S. schiedeana induced a decrease in the concentration of interleukin (IL)-1β, IL-17, and IL-6, and SsEtOAc at a higher dose diminished tumor necrosis factor (TNF-α). IL-10 and IL-4 were fewer in the VEH group in comparison with healthy mice; the animals with treatments from S. schiedeana induced an increment in the levels of these cytokines in joint and spleen.
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Affiliation(s)
- David Osvaldo Salinas-Sánchez
- Biomedical Research Center of the South (IMSS), Argentina 1, Col. Centro, Xochitepec 62790, Morelos, Mexico.
- Biodiversity and Conservation Research Center (UAEM), Av. Universidad 1001, Col. Chamilpa, Cuernavaca 62209, Morelos, Mexico.
| | - Enrique Jiménez-Ferrer
- Biomedical Research Center of the South (IMSS), Argentina 1, Col. Centro, Xochitepec 62790, Morelos, Mexico.
| | - Veronica Sánchez-Sánchez
- Biomedical Research Center of the South (IMSS), Argentina 1, Col. Centro, Xochitepec 62790, Morelos, Mexico.
- Faculty of Biological Sciences (FBC), UAEM, Av. Universidad 1001, Col. Chamilpa, Cuernavaca 62209, Morelos, Mexico.
| | - Alejandro Zamilpa
- Biomedical Research Center of the South (IMSS), Argentina 1, Col. Centro, Xochitepec 62790, Morelos, Mexico.
| | - Manasés González-Cortazar
- Biomedical Research Center of the South (IMSS), Argentina 1, Col. Centro, Xochitepec 62790, Morelos, Mexico.
| | - Jaime Tortoriello
- Biomedical Research Center of the South (IMSS), Argentina 1, Col. Centro, Xochitepec 62790, Morelos, Mexico.
| | - Maribel Herrera-Ruiz
- Biomedical Research Center of the South (IMSS), Argentina 1, Col. Centro, Xochitepec 62790, Morelos, Mexico.
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Tran-Minh ML, Sousa P, Maillet M, Allez M, Gornet JM. Hepatic complications induced by immunosuppressants and biologics in inflammatory bowel disease. World J Hepatol 2017; 9:613-626. [PMID: 28539989 PMCID: PMC5424291 DOI: 10.4254/wjh.v9.i13.613] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/01/2017] [Accepted: 04/24/2017] [Indexed: 02/06/2023] Open
Abstract
The incidence of inflammatory bowel diseases (IBD) is rising worldwide. The therapeutic options for IBD are expanding, and the number of drugs with new targets will rapidly increase in coming years. A rapid step-up approach with close monitoring of intestinal inflammation is extensively used. The fear of side effects represents one the most limiting factor of their use. Despite a widespread use for years, drug induced liver injury (DILI) management remains a challenging situation with Azathioprine and Methotrexate. DILI seems less frequent with anti-tumor necrosis factor agents and new biologic therapies. The aim of this review is to report incidence, physiopathology and practical guidelines in case of DILI occurrence with the armamentarium of old and new drugs in the field of IBD.
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Alam MM, Han HS, Sung S, Kang JH, Sa KH, Al Faruque H, Hong J, Nam EJ, Kim IS, Park JH, Kang YM. Endogenous inspired biomineral-installed hyaluronan nanoparticles as pH-responsive carrier of methotrexate for rheumatoid arthritis. J Control Release 2017; 252:62-72. [DOI: 10.1016/j.jconrel.2017.03.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 01/19/2023]
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Abstract
Fertility is impaired in women with rheumatoid arthritis (RA), whereas less is known about male fertility problems. Pregnancy outcome in patients with RA is slightly less favorable compared with the general population, especially in patients with active disease. Disease activity usually improves during pregnancy, but less than previously thought. Although several antirheumatic drugs are contraindicated in pregnancy, more treatment options are available. There is evidence on the safety of TNF inhibitors in pregnancy. Given the impact of active disease on fertility and pregnancy outcome, a treat-to-target strategy is recommended for patients who are pregnant or have a wish to conceive.
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Shetty A, Cho W, Alazawi W, Syn WK. Methotrexate Hepatotoxicity and the Impact of Nonalcoholic Fatty Liver Disease. Am J Med Sci 2017; 354:172-181. [PMID: 28864376 DOI: 10.1016/j.amjms.2017.03.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/10/2017] [Accepted: 03/08/2017] [Indexed: 01/01/2023]
Abstract
Methotrexate (MTX) is commonly used to treat individuals with rheumatological and dermatologic disorders. Current American College of Rheumatology (ACR) and American Association of Dermatology (AAD) guidelines identify diabetes and obesity as risk factors for MTX-induced liver injury. Both diabetes and obesity are components of the metabolic syndrome, and are also risk factors for nonalcoholic fatty liver disease (NAFLD). NAFLD affects approximately 40% of the U.S. population, and those with more advanced NAFLD (i.e., nonalcoholic steatohepatitis with or without fibrosis) are likely to develop progressive liver disease. As such, individuals who are treated with MTX may need to be screened for advanced NAFLD, as this may put them at an increased risk of MTX-induced liver injury. In this mini-review, we review the current ACR and AAD guidelines on MTX hepatotoxicity, discuss the evidence (or lack thereof) of the impact of metabolic risk factors on MTX-induced liver injury and highlight the areas that need further research.
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Affiliation(s)
- Akshay Shetty
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - WonKyung Cho
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - William Alazawi
- Department of Hepatology, Barts Health NHS Trust, London, United Kingdom; Centre for Immunobiology, Blizzard Institute, Queen Mary University of London, London, United Kingdom
| | - Wing-Kin Syn
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina; Section of Gastroenterology, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.
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Extrahepatic Autoimmune Diseases in Patients with Autoimmune Liver Diseases: A Phenomenon Neglected by Gastroenterologists. Gastroenterol Res Pract 2017; 2017:2376231. [PMID: 28191014 PMCID: PMC5278196 DOI: 10.1155/2017/2376231] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 11/03/2016] [Indexed: 12/13/2022] Open
Abstract
Autoimmune liver diseases (AILDs) often coexist with other extrahepatic autoimmune diseases (EHAIDs). The spectrum of EHAIDs in patients with AILDs is similar, whereas the incidence is different. Notably, autoimmune thyroid disease and Sjogren's syndrome are the most common EHAIDs. Associated extrahepatic diseases may predate the appearance of AILDs or coincide with their onset. More frequently, they may appear during the course and even occur years after the diagnosis of AILDs. Importantly, associated EHAIDs may influence the natural course and prognosis of AILDs. To date, a definite pathophysiological pathway which contributes to the coexistence of AILDs and EHAIDs is still lacking. The current view of autoimmunity clustering involves a common susceptibility genetic background which applies to related pathologies. Herein, we review the current published researches regarding EHAIDs in patients with AILDs, particularly in relation to their clinical impact and pathophysiology. In managing patients with AILDs, gastroenterologists should be aware of the possibly associated EHAIDs to ensure a prompt diagnosis and better outcome.
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Tornero Molina J, Calvo Alen J, Ballina J, Belmonte MÁ, Blanco FJ, Caracuel MÁ, Carbonell J, Corominas H, Chamizo E, Hidalgo C, Ivorra JR, Marenco JL, Moreno Muelas JV, Muñoz-Fernández S, Nolla JM, Pérez T, Sanmarti R, Trenor P, Urrego C, Vidal J, Rosas Gomez de Salazar J. Recommendations for the use of parenteral methotrexate in rheumatic diseases. ACTA ACUST UNITED AC 2017; 14:142-149. [PMID: 28082032 DOI: 10.1016/j.reuma.2016.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/22/2016] [Accepted: 12/01/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop recommendations for the use of parenteral methotrexate (MTX) in rheumatic diseases, mainly rheumatoid arthritis, based on best evidence and experience. METHODS A group of 21 experts on parenteral MTX use was selected. The coordinator formulated 13 questions about parenteral MTX (indications, efficacy, safety and cost-effectiveness). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (involving Medline, EMBASE and the Cochrane Library). Three different reviewers selected the articles. Evidence tables were created. Abstracts from the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) were evaluated. Based on this evidence, the coordinator proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Center for Evidence-Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). RESULTS Most of the evidence involved rheumatoid arthritis. A total of 13 preliminary recommendations on the use of parenteral MTX were proposed; 11 of them were accepted. Two of the 13 were not voted and are commented on in the main text. CONCLUSIONS The manuscript aims to solve frequent questions and help in decision-making strategies when treating patients with parenteral MTX.
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Affiliation(s)
| | | | - Javier Ballina
- Hospital Universitario Central de Asturias, Oviedo, España
| | | | | | | | | | | | | | - Cristina Hidalgo
- Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | | | | | | | | | - Joan M Nolla
- Hospital Universitari de Bellvitge, Barcelona, España
| | | | | | | | | | - Javier Vidal
- Servicio de Reumatología, Hospital de Guadalajara, Guadalajara, España
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127
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Combe B, Landewe R, Daien CI, Hua C, Aletaha D, Álvaro-Gracia JM, Bakkers M, Brodin N, Burmester GR, Codreanu C, Conway R, Dougados M, Emery P, Ferraccioli G, Fonseca J, Raza K, Silva-Fernández L, Smolen JS, Skingle D, Szekanecz Z, Kvien TK, van der Helm-van Mil A, van Vollenhoven R. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2016. [PMID: 27979873 DOI: 10.1136/annrheumdis-2016-210602 10.1136/annrheumdis-2016-210602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Since the 2007 recommendations for the management of early arthritis have been presented, considerable research has been published in the field of early arthritis, mandating an update of the 2007 European League Against Rheumatism (EULAR) recommendations for management of early arthritis. METHODS In accordance with the 2014 EULAR Standardised Operating Procedures, the expert committee pursued an approach that was based on evidence in the literature and on expert opinion. The committee involved 20 rheumatologists, 2 patients and 1 healthcare professional representing 12 European countries. The group defined the focus of the expert committee and target population, formulated a definition of 'management' and selected the research questions. A systematic literature research (SLR) was performed by two fellows with the help of a skilled librarian. A set of draft recommendations was proposed on the basis of the research questions and the results of the SLR. For each recommendation, the categories of evidence were identified, the strength of recommendations was derived and the level of agreement was determined through a voting process. RESULTS The updated recommendations comprise 3 overarching principles and 12 recommendations for managing early arthritis. The selected statements involve the recognition of arthritis, referral, diagnosis, prognostication, treatment (information, education, pharmacological and non-pharmacological interventions), monitoring and strategy. Eighteen items were identified as relevant for future research. CONCLUSIONS These recommendations provide rheumatologists, general practitioners, healthcare professionals, patients and other stakeholders with an updated EULAR consensus on the entire management of early arthritis.
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Affiliation(s)
- Bernard Combe
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Robert Landewe
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology Center, Amsterdam and Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Claire I Daien
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Charlotte Hua
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Jose María Álvaro-Gracia
- Biological Therapies Unit, Servicio de Reumatología. Hospital Universitario de la Princesa, IIS-IP, Madrid, Spain
| | - Margôt Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Berlin, Germany
| | - Catalin Codreanu
- Department of Rheumatology, Center for Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Richard Conway
- Department of Rheumatology, Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Dublin, Ireland
| | - Maxime Dougados
- Medicine Faculty, APHP, Rheumatology B Department, Paris Descartes University, Cochin Hospital, Paris, France
| | - Paul Emery
- Leeds NIHR Musculoskeletal Biomedical Research Unit, LTHT, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Gianfranco Ferraccioli
- Fondazione Policlinico Gemelli Academic Hospital, Catholic University School of Medicine, Rome, Italy
| | - Joao Fonseca
- Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon.,Instituto de Medicina Molecular, Faculdade de Medicina Universidade de Lisboa, Portugal
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Lucía Silva-Fernández
- Rheumatology Department, Complexo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Diana Skingle
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Zoltan Szekanecz
- Faculty of Medicine, Department of Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ronald van Vollenhoven
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, Amsterdam, The Netherlands
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Combe B, Landewe R, Daien CI, Hua C, Aletaha D, Álvaro-Gracia JM, Bakkers M, Brodin N, Burmester GR, Codreanu C, Conway R, Dougados M, Emery P, Ferraccioli G, Fonseca J, Raza K, Silva-Fernández L, Smolen JS, Skingle D, Szekanecz Z, Kvien TK, van der Helm-van Mil A, van Vollenhoven R. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2016; 76:948-959. [PMID: 27979873 DOI: 10.1136/annrheumdis-2016-210602] [Citation(s) in RCA: 315] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/24/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Since the 2007 recommendations for the management of early arthritis have been presented, considerable research has been published in the field of early arthritis, mandating an update of the 2007 European League Against Rheumatism (EULAR) recommendations for management of early arthritis. METHODS In accordance with the 2014 EULAR Standardised Operating Procedures, the expert committee pursued an approach that was based on evidence in the literature and on expert opinion. The committee involved 20 rheumatologists, 2 patients and 1 healthcare professional representing 12 European countries. The group defined the focus of the expert committee and target population, formulated a definition of 'management' and selected the research questions. A systematic literature research (SLR) was performed by two fellows with the help of a skilled librarian. A set of draft recommendations was proposed on the basis of the research questions and the results of the SLR. For each recommendation, the categories of evidence were identified, the strength of recommendations was derived and the level of agreement was determined through a voting process. RESULTS The updated recommendations comprise 3 overarching principles and 12 recommendations for managing early arthritis. The selected statements involve the recognition of arthritis, referral, diagnosis, prognostication, treatment (information, education, pharmacological and non-pharmacological interventions), monitoring and strategy. Eighteen items were identified as relevant for future research. CONCLUSIONS These recommendations provide rheumatologists, general practitioners, healthcare professionals, patients and other stakeholders with an updated EULAR consensus on the entire management of early arthritis.
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Affiliation(s)
- Bernard Combe
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Robert Landewe
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology Center, Amsterdam and Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Claire I Daien
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Charlotte Hua
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Jose María Álvaro-Gracia
- Biological Therapies Unit, Servicio de Reumatología. Hospital Universitario de la Princesa, IIS-IP, Madrid, Spain
| | - Margôt Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Berlin, Germany
| | - Catalin Codreanu
- Department of Rheumatology, Center for Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Richard Conway
- Department of Rheumatology, Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Dublin, Ireland
| | - Maxime Dougados
- Medicine Faculty, APHP, Rheumatology B Department, Paris Descartes University, Cochin Hospital, Paris, France
| | - Paul Emery
- Leeds NIHR Musculoskeletal Biomedical Research Unit, LTHT, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Gianfranco Ferraccioli
- Fondazione Policlinico Gemelli Academic Hospital, Catholic University School of Medicine, Rome, Italy
| | - Joao Fonseca
- Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon.,Instituto de Medicina Molecular, Faculdade de Medicina Universidade de Lisboa, Portugal
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Lucía Silva-Fernández
- Rheumatology Department, Complexo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Diana Skingle
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Zoltan Szekanecz
- Faculty of Medicine, Department of Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ronald van Vollenhoven
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW Early effective treatment has led to major improvements in patients with rheumatoid arthritis. This review aims to address the treatment of early rheumatoid arthritis, in particular the different therapeutic strategies evaluated in clinical trials to achieve optimal disease control. RECENT FINDINGS The use of biological disease-modifying antirheumatic drugs (bDMARDs) has significantly improved patient outcomes. Overall, studies using bDMARD induction have shown early clinical improvements, with high proportions achieving remission with minimal radiographic progression. As these drugs are still relatively costly, conventional synthetic DMARDs, as monotherapy or in combination, remain the mainstay of treatment initiation. Good, albeit somewhat slower, responses can be achieved with these drugs. Strategies incorporating glucocorticoids and a treat-to-target approach (i.e. regular monitoring of disease activity and early treatment escalation with a conventional synthetic or b-DMARD, if needed) have shown additional benefit. In patients achieving low disease activity or remission, bDMARD dose reduction and withdrawal, and even drug-free remission have been possible in some. SUMMARY In patients with early rheumatoid arthritis, conventional synthetic DMARDs and glucocorticoids used within a treat-to-target setting, and the addition of a bDMARD if required, outcomes have improved significantly. A proportion of patients are able to deescalate treatment after bDMARD therapy, with a significant minority achieving drug-free remission.
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Management of connective tissue diseases associated interstitial lung disease: a review of the published literature. Curr Opin Rheumatol 2016; 28:236-45. [PMID: 27027811 DOI: 10.1097/bor.0000000000000270] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Interstitial lung disease (ILD), though a common and often a severe manifestation of many connective tissue diseases (CTD), is challenging to manage because of its variable presentation and the relative lack of guidelines to assist the clinician. In this review, we discuss the approach to diagnosis, treatment, and monitoring patients with CTD-associated ILD, with a focus on systemic sclerosis (SSc), rheumatoid arthritis (RA), and idiopathic inflammatory myopathy (IIM). RECENT FINDINGS High-resolution computed tomography scan and pulmonary function testing can be reliably used to diagnose ILD and monitor progression, and often to determine its likely histologic subtype and severity. In SSc-ILD, randomized controlled trials show ILD stabilization with cyclophosphamide treatment; preliminary data from another randomized controlled trial demonstrates similar findings with mycophenolate. There are no robust clinical trials supporting specific treatments for RA-ILD or IIM-ILD, but rituximab in RA-ILD, and cyclophosphamide, mycophenolate and calcineurin inhibitors in IIM-ILD show promise. SUMMARY Though ILD contributes substantially to morbidity and mortality in patients with CTD, there are minimal data to guide its management except in SSc-ILD.
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131
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Hernández-Cruz B, Márquez-Saavedra E, Caliz-Caliz R, Navarro-Sarabia F. Comparative effectiveness of treatment with the first TNF antagonist in monotherapy, the first TNF antagonist plus one conventional synthetic disease-modifying antirheumatic drug, and the first TNF antagonist plus two or more conventional synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis. Arthritis Res Ther 2016; 18:259. [PMID: 27821150 PMCID: PMC5100281 DOI: 10.1186/s13075-016-1137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 09/26/2016] [Indexed: 11/16/2022] Open
Abstract
Background Rheumatoid arthritis (RA) patients are treated with a mean of 3–4 conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) with or without glucocorticoids (GCs), before the first biologic prescription. The main reasons for change are inefficacy in 30–40 % of patients, and toxicity ≈ 10 %. Thus, they are treated with the first TNF antagonists in monotherapy. The aim of this study was to analyse the csDMARD and GC prescription patterns before and during treatment with the first TNF antagonist, and compare their effectiveness in three groups of patients. Methods An observational, prospective, multicentre study in common clinical practice was designed. Treating rheumatologists recorded patient variables, including previous and concomitant csDMARDs and GCs in a database. The data were analysed using descriptive, inferential and multivariate statistics. Results There were 1136 patients included; 21 % received the first TNF antagonist in monotherapy, 67 % received the first TNF antagonist plus one csDMARD, and 12 % the first TNF antagonist plus two or more csDMARDs. Most patients were female (73 %), RF+, and ACPA+, and had erosions; mean age was 53.2 (±13.0) years, and duration of disease was 9.1 (±7.6) years. They had high activity with DAS28 of 5.8 ± 1.1, and poor physical function with HAQ of 1.43 ± 0.63, and significant differences between groups in clinical variables and comorbidities; 94 % had received treatment with GCs, MTX, LFN, or SSZ at any time before the first TNF antagonist, 5 % (n = 52) had been treated with CLQ or HCLQ, and 1 % (n = 13) had received neither GCs nor csDMARDs. Before the first TNF antagonist, the drugs most commonly used were GCs (78 %), MTX (50 %), LFN (44 %), and SSZ (21 %). Concomitantly with the first TNF antagonist, 977 patients (85 %) were receiving GCs, MTX, LFN, or SSZ; 15 % (n = 173) received their first TNF antagonist without any concomitant GCs or csDMARDs, true monotherapy, and 6 % received their first TNF antagonist with GCs. The drug most commonly used at the time of first TNF antagonist initiation was MTX (58 %). All treatment groups had clinically and statistically significant improvements in DAS and HAQ scores. Effectiveness analysis (controlling for confounders) showed mean drug survival of 16.7, 20.1 and 11.7 months in each group, respectively (p < 0.001). The model that best explained a good EULAR response included the baseline and 6-month DAS28. Conclusions The three groups of patiernts, have different comorbidities and disease characteristics. Treatment with low or very low doses of GCs is common. True monotherapy with the first TNF antagonist without prednisone or csDMARDs is infrequent. After controlling for potential confounders, effectiveness was a little different.
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Affiliation(s)
- Blanca Hernández-Cruz
- Rheumatologist and Investigator, Rheumatology Clinical Unit, Virgen de la Macarena University Hospital, Andalusian Health Service, Seville, Spain. .,Servicio de Reumatología. Planta Semisótano, Hospital Universitario Virgen Macarena, Av, Dr Fedriani No 3, Seville, CP 41007, Spain.
| | - Esther Márquez-Saavedra
- Pharmaceutical Supplies and Services, Central Services, Reina Sofia University Hospital, Andalusian Health Service, Cordoba, Spain
| | - Rafael Caliz-Caliz
- Rheumatologist, Head of Service., Virgen de las Nieves University Hospital, Andalusian Health Service, Granada, Spain
| | - Federico Navarro-Sarabia
- Rheumatologist and Investigator, Rheumatology Clinical Unit, Virgen de la Macarena University Hospital, Andalusian Health Service, Seville, Spain
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Kłak A, Paradowska-Gorycka A, Kwiatkowska B, Raciborski F. Personalized medicine in rheumatology. Reumatologia 2016; 54:177-186. [PMID: 27826172 PMCID: PMC5090026 DOI: 10.5114/reum.2016.62472] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/12/2016] [Indexed: 12/27/2022] Open
Abstract
In the era of the 21st century, rheumatoid arthritis (RA) is still poorly characterized. Rheumatoid arthritis is a common but heterogeneous disease, not only in the course and clinical symptoms, but also in the clinical response to treatment. Now it is known that early, correct diagnosis and starting treatment with disease-modifying drugs (DMARDs), of which methotrexate (MTX) remains the gold standard in the treatment of RA, is crucial in order to prevent joint destruction, functional disability and an unfavourable disease outcome. Early diagnosis of rheumatoid arthritis is significant in so much as the primary treatment can be started better. Pharmacogenetic and pharmacogenomic studies, which help determine the genetic profile of individual patients, may bring us closer to personalized medicine. Further studies on RA should allow for the identification of disease-specific genes at the stage when their tolerance by the organism is still preserved (before auto-aggression develops).
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Affiliation(s)
- Anna Kłak
- Department of Gerontology and Public Health, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Agnieszka Paradowska-Gorycka
- Department of Biochemistry and Molecular Biology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Brygida Kwiatkowska
- Clinic of Early Arthritis, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Filip Raciborski
- Department of Gerontology and Public Health, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
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133
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Hall JJ, Bolina M, Chatterley T, Jamali F. Interaction Between Low-Dose Methotrexate and Nonsteroidal Anti-inflammatory Drugs, Penicillins, and Proton Pump Inhibitors. Ann Pharmacother 2016; 51:163-178. [DOI: 10.1177/1060028016672035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To review the potential drug interactions between low-dose methotrexate (LD-MTX) and nonsteroidal anti-inflammatory drugs (NSAIDs), penicillins, and proton-pump inhibitors (PPIs) given the disparity between interactions reported for high-dose and low-dose MTX to help guide clinicians. Data Sources: A literature search was performed in MEDLINE (1946 to September 2016), EMBASE (1974 to September 2016), and International Pharmaceutical Abstracts (1970 to January 2015) to identify reports describing potential drug interactions between LD-MTX and NSAIDS, penicillins, or PPIs. Reference lists of included articles were reviewed to find additional eligible articles. Study Selection and Data Extraction: All English-language observational, randomized, and pharmacokinetic (PK) studies assessing LD-MTX interactions in humans were analyzed to determine clinical relevance in making recommendations to clinicians. Clinical case reports were assigned a Drug Interaction Probability Scale score. Data Synthesis: A total of 32 articles were included (28 with NSAIDs, 3 with penicillins, and 2 with PPIs [1 including both PPI and NSAID]). Although there are some PK data to describe increased LD-MTX concentrations when NSAIDs are used concomitantly, the clinical relevance remains unclear. Based on the limited data on LD-MTX with penicillins and PPIs, no clinically meaningful interaction was identified. Conclusion: Given the available evidence, the clinical importance of the interaction between LD-MTX and NSAIDs, penicillins, and PPIs cannot be substantiated. Health care providers should assess the benefit and risk of LD-MTX regardless of concomitant drug use, including factors known to predispose patients to MTX toxicity, and continue to monitor clinical and laboratory parameters per guideline recommendations.
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134
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Curtis JR, Xie F, Mackey D, Gerber N, Bharat A, Beukelman T, Saag KG, Chen L, Nowell B, Ginsberg S. Patient's experience with subcutaneous and oral methotrexate for the treatment of rheumatoid arthritis. BMC Musculoskelet Disord 2016; 17:405. [PMID: 27669978 PMCID: PMC5037591 DOI: 10.1186/s12891-016-1254-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/13/2016] [Indexed: 12/18/2022] Open
Abstract
Background Despite the prominent position of methotrexate (MTX) in Rheumatoid Arthiris (RA) therapeutics, its real-world effectiveness may be influenced by a relative lack of tolerability or other side effects that physicians may not be aware of but that are bothersome to patients. The aim of this study is to identify suboptimal patient experience with MTX and to raise awareness for clinicians to identify opportunities to mitigate bothersome symptoms and side effects and optimize response to MTX. Methods We conducted a prospective, cross-sectional, online survey among RA patients who were members of Creakyjoints, a large arthritis patient community. Eligible participants must have recently initiated a new biologic, subcutaneous (SQ) MTX, or oral MTX in the last 12 months and were uniquely assigned to one of these 3 groups. Descriptive statistics were used to compare patient-reported side effects and tolerability related to MTX use in the 3 medication groups (SQ MTX, oral MTX, and biologic). Results A total of 382 (85 %) of 448 eligible patients completed the survey and were grouped as: biologic (n = 218), SQ MTX (n = 49), and oral MTX (n = 115). Demographics were mean standard deviation (SD) age 48 (10) years, 92 % white, 91 % women. Symptoms significantly more prevalent in the SQ and oral MTX groups included diarrhea, fatigue, malaise, and hair loss. Injection related pain was lower with SQ MTX compared to SQ biologics. Out of a total of 8 potential symptoms and side effects examined, higher dose MTX (> = 20 mg/week) was associated with a 2.26 (1.25–4.09) greater likelihood of more side effects referent to < =10 mg/week. Conclusion Results from this real-world RA patient cohort suggest that MTX is accompanied by many patient-reported side effects and tolerability problems that may be under-recognized by physicians. These may impact both treatment satisfaction and medication adherence.
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Affiliation(s)
- J R Curtis
- University of Alabama at Birmingham, 510 20th Street South, FOT 802, Birmingham, AL, 35294, USA.
| | - F Xie
- University of Alabama at Birmingham, 510 20th Street South, FOT 802, Birmingham, AL, 35294, USA
| | - D Mackey
- University of Alabama at Birmingham, 510 20th Street South, FOT 802, Birmingham, AL, 35294, USA
| | - N Gerber
- Global Healthy Living Foundation, Upper Nyack, NY, 10960, USA
| | - A Bharat
- University of Alabama at Birmingham, 510 20th Street South, FOT 802, Birmingham, AL, 35294, USA
| | - T Beukelman
- University of Alabama at Birmingham, 510 20th Street South, FOT 802, Birmingham, AL, 35294, USA
| | - K G Saag
- University of Alabama at Birmingham, 510 20th Street South, FOT 802, Birmingham, AL, 35294, USA
| | - L Chen
- University of Alabama at Birmingham, 510 20th Street South, FOT 802, Birmingham, AL, 35294, USA
| | - B Nowell
- Global Healthy Living Foundation, Upper Nyack, NY, 10960, USA
| | - S Ginsberg
- Global Healthy Living Foundation, Upper Nyack, NY, 10960, USA
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135
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Gutierrez JC, Hwang K. The toxicity of methotrexate in male fertility and paternal teratogenicity. Expert Opin Drug Metab Toxicol 2016; 13:51-58. [PMID: 27590039 DOI: 10.1080/17425255.2017.1230198] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION There is a high prevalence of methotrexate (MTX) use in males of reproductive age. The scope of this paper reviews what is known regarding risks to fertility and partners' pregnancy outcomes with regard to MTX use in men. Areas covered: This paper reviews the evidence for current recommendations for MTX use and male fertility and aims to educate professionals regarding MTX use in reproducing males so that patients may be counseled appropriately. A literature search included peer-reviewed sources from PubMed searches and the literature referenced within. Expert opinion: There is a lack of evidence regarding effects of MTX on male fertility. The recommendation to stop MTX three months prior to conception is safe, but is not evidenced by an understanding of the impact of MTX on spermatogenesis or paternal-mediated teratogenicity but rather the timeframe of spermatogenesis. Given the unclear evidence, patients treated with MTX must be counseled on the likelihood of adverse effects of MTX and role of sperm cryopreservation. Future studies are needed to help elucidate the unclear evidence of MTX effects on male fertility and pregnancy outcomes.
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Affiliation(s)
| | - Kathleen Hwang
- b Division of Urology , Rhode Island Hospital , Providence , Rhode Island , USA
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136
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Durán J, Bockorny M, Dalal D, LaValley M, Felson D. Methotrexate dosage as a source of bias in biological trials in rheumatoid arthritis: a systematic review. Ann Rheum Dis 2016; 75:1595-8. [PMID: 27091836 PMCID: PMC4982794 DOI: 10.1136/annrheumdis-2016-209383] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/24/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To evaluate if optimal dose of either oral or injectable regimens of methotrexate (MTX) of 25 mg/week was used in the comparator arms of studies comparing biologic drugs with MTX in rheumatoid arthritis (RA). METHODS A systematic literature search was carried out in MEDLINE, EMBASE and the Cochrane Library databases for randomised controlled trials comparing biologics with MTX in RA. A systematic review was performed among studies that met predefined criteria focusing on assessment of dose of MTX used in the comparator arm. Study authors were contacted when necessary. Study quality was assessed. RESULTS A total of 3276 references were identified and 13 trials were included. We obtained maximal dose and regimen for all. The maximal dose of MTX used in the comparator arm of the trials was no more than 20 mg/week in any trial and for all but one trial, MTX was given orally and not by injection. The trial that used an injectable form reached a maximum of 15 mg/week. CONCLUSIONS A suboptimal dose of MTX was used in biological clinical trials performed in RA, particularly regarding route of administration. This may have biased findings in favour of biological agents.
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Affiliation(s)
- Josefina Durán
- Rheumatology Department, Pontificia Universidad Católica de Chile School of Medicine
| | | | - Deepan Dalal
- Division of Rheumatology, Department of Medicine, Brown University Warren Alpert School of Medicine
| | - Michael LaValley
- Clinical Epidemiology Unit, Boston University School of Medicine
| | - David Felson
- Clinical Epidemiology Unit, Boston University School of Medicine
- Arthritis Research UK Epidemiology Unit, University of Manchester and Manchester NIHR Biomedical Research Unit
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137
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Kokoszko-Bilska A, Sobkiewicz S, Fichna J. Inflammatory bowel diseases and reproductive health. Pharmacol Rep 2016; 68:859-64. [DOI: 10.1016/j.pharep.2016.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/08/2016] [Accepted: 03/11/2016] [Indexed: 02/07/2023]
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138
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Mecoli CA, Delev NG, Bingham CO. Measuring transaminases in patients with rheumatoid arthritis on weekly methotrexate: does timing of blood testing matter? Clin Rheumatol 2016; 35:3053-3056. [PMID: 27473088 DOI: 10.1007/s10067-016-3361-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/16/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
Abstract
The change in transaminase levels over a single week during therapy with methotrexate (MTX) has not been investigated or reported to date. In clinical practice, it is common to observe abnormal transaminase levels upon routine blood work for toxicity monitoring. Many have suggested that such lab abnormalities can sometimes be attributed to sampling blood for toxicity monitoring proximately following MTX dosing. The aim of our study was to evaluate changes in transaminase levels (AST/ALT) over 1 week after MTX administration in rheumatoid arthritis (RA) patients. In this small proof of concept study, we evaluated 13 patients with RA taking stable doses of methotrexate and background medications (e.g., NSAIDs and prednisone), but no other disease-modifying anti-rheumatic drugs (DMARDs). All patients were on a stable dose of folic acid. Patients received their usual doses of MTX administered at a specified time, and then sequential blood samples were obtained over the course of 7 days. Peripheral blood was obtained at each time point to measure serum transaminases. We did not observe any significant change in sequential transaminases over 1 week in relationship to MTX administration. It is possible that MTX therapy alone does not lead to significant weekly transaminase variations, contrary to our clinical expectations. The addition of other medications (i.e., NSAIDs) to stable MTX regimen may result in transaminase abnormalities.
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Affiliation(s)
- Christopher A Mecoli
- Johns Hopkins Division of Rheumatology, 5200 Eastern Avenue, MFL Center Tower, Room 404, Baltimore, MD, 21224, USA.
| | - Nikolay G Delev
- Johns Hopkins Division of Rheumatology, 5200 Eastern Avenue, MFL Center Tower, Room 404, Baltimore, MD, 21224, USA
| | - Clifton O Bingham
- Johns Hopkins Division of Rheumatology, 5200 Eastern Avenue, MFL Center Tower, Room 404, Baltimore, MD, 21224, USA
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139
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Dhaon P, Das SK, Srivastava R, Agarwal G, Asthana A. Oral Methotrexate in split dose weekly versus oral or parenteral Methotrexate once weekly in Rheumatoid Arthritis: a short-term study. Int J Rheum Dis 2016; 21:1010-1017. [PMID: 27455886 DOI: 10.1111/1756-185x.12910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate whether methotrexate (MTX) administered orally to rheumatoid arthritis (RA) patients in split doses at 2-3 days' interval, would result in equal or better efficacy, tolerability and compliance, without increasing toxicity compared to single weekly dose given orally or parenterally. MATERIALS AND METHODS One hundred and thirty-five patients fulfilling the American College of Rheumatology (ACR) 2010 criteria for RA, on 7.5 mg of MTX weekly orally, with the Simplified Disease Activity Index (SDAI) > 11 were enrolled for a 24-week period. Patients were randomly divided into three groups and were given MTX: Group 1 7.5 mg twice or thrice weekly orally, Group 2 15 mg or 22.5 mg in a single dose weekly orally and Group 3 15 mg or 22.5 mg in a single dose weekly as an intramuscular injection. The primary outcomes were low disease activity (LDA) and mean change in SDAI at week 24, whereas secondary outcomes included remission, adverse events and compliance. RESULTS At week 24, adherence to treatment was maximum in Group 1, 69% (P = 0.09). In intention-to-treat analysis at 24 weeks, Group 1, 49%, Group 2, 36% and Group 3, 47% achieved LDA (P = 0.4). There was significant difference in mean change in SDAI at week 24 from baseline (P = 0.008) among the groups. Group 3 patients were more uncomfortable with the mode of administration of MTX (P = 0.003). There was no significant difference in adverse events. CONCLUSION Oral split doses of MTX are better than an oral single dose and similar to parenteral MTX in terms of efficacy.
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Affiliation(s)
- Pooja Dhaon
- Department of Rheumatology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Siddharth K Das
- Department of Rheumatology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Ragini Srivastava
- Department of Rheumatology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Girdhar Agarwal
- Department of Statistics, Lucknow University, Lucknow, Uttar Pradesh, India
| | - Akash Asthana
- Department of Statistics, Lucknow University, Lucknow, Uttar Pradesh, India
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140
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Lee WS, Lee SI, Lee MS, Kim SI, Lee SS, Yoo WH. Efficacy and safety of low-dose tacrolimus for active rheumatoid arthritis with an inadequate response to methotrexate. Korean J Intern Med 2016; 31:779-87. [PMID: 26961485 PMCID: PMC4939497 DOI: 10.3904/kjim.2015.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 06/08/2015] [Accepted: 06/19/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS To determine the efficacy and safety of low-dose tacrolimus in Korean rheumatoid arthritis (RA) subjects with an inadequate response to methotrexate (MTX). METHODS This was a multicenter, open-label study conducted at five Korean sites. Fifty-six patients with active RA, despite treatment for ≥ 1 month with a stable, maximally tolerated dosage of oral MTX (median dosage, 15 mg/wk), were enrolled and received 1.5 mg/day of tacrolimus as a single oral dose once per day for 16 weeks while continuing to receive MTX. All other disease-modifying anti-rheumatic drugs were discontinued, whereas stable dosages of nonsteroidal anti-inflammatory drugs and oral corticosteroids (≤ 10 mg/day of prednisone or an equivalent corticosteroid) were allowed. The primary clinical response criterion was the American College of Rheumatology's definition of 20% improvement (ACR20) at the end of treatment. RESULTS The ACR20 response rate was 42.9% (24 of 56 patients) in patients who had received tacrolimus at least once. The overall ACR50 and ACR70 responses at the end of treatment for all patients were 30.4% and 10.7%, respectively. Throughout the treatment period, 37 patients experienced 71 adverse events (AEs) in total, and four patients left the study because of AEs. In addition, 15 patients in total experienced treatment-related AEs. Throughout the treatment period, two patients were reported to experience two serious AEs, and one patient left the study because of a serious AE. CONCLUSIONS In patients whose active RA persists despite treatment with MTX, low-dose tacrolimus in combination with MTX appears to be safe and well tolerated, and provides clinical benefit.
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Affiliation(s)
- Won-Seok Lee
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Sang-Il Lee
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Myeung-Soo Lee
- Division of Rheumatology, Department of Internal Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Sung-Il Kim
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Shin-Seok Lee
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Wan-Hee Yoo
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
- Correspondence to Wan-Hee Yoo, M.D. Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and Research Institute of Clinical Medicine of Chonbuk National University Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea Tel: +82-63-250-1672 Fax: +82-63-254-1609 E-mail:
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141
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Malaviya AN. Landmark papers on the discovery of methotrexate for the treatment of rheumatoid arthritis and other systemic inflammatory rheumatic diseases: a fascinating story. Int J Rheum Dis 2016; 19:844-51. [DOI: 10.1111/1756-185x.12862] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anand N. Malaviya
- A&R Clinic for Arthritis and Rheumatism and Department of Rheumatology; ISIC Superspeciality Hospital; Vasant Kunj New Delhi India
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142
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Durán J, Felson DT. Why methotrexate suboptimal dosing is a potential source of bias in biologic drugs clinical trials. Ann Rheum Dis 2016; 75:e53. [PMID: 27221691 DOI: 10.1136/annrheumdis-2016-209791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/29/2016] [Indexed: 11/03/2022]
Affiliation(s)
- Josefina Durán
- Department of Rheumatology, Pontificia Universidad Catolica de Chile, Santiago, Region Metropolitana, Chile
| | - David T Felson
- Clinical Epidemiology Unit, School of Medicine, Boston University, Boston, Massachusetts, USA Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester, UK
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143
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Emery P, Bingham CO, Burmester GR, Bykerk VP, Furst DE, Mariette X, van der Heijde D, van Vollenhoven R, Arendt C, Mountian I, Purcaru O, Tatla D, VanLunen B, Weinblatt ME. Certolizumab pegol in combination with dose-optimised methotrexate in DMARD-naïve patients with early, active rheumatoid arthritis with poor prognostic factors: 1-year results from C-EARLY, a randomised, double-blind, placebo-controlled phase III study. Ann Rheum Dis 2016; 76:96-104. [PMID: 27165179 PMCID: PMC5264210 DOI: 10.1136/annrheumdis-2015-209057] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 04/08/2016] [Accepted: 04/09/2016] [Indexed: 11/13/2022]
Abstract
Objectives To assess the efficacy and safety of certolizumab pegol (CZP)+dose-optimised methotrexate (MTX) versus placebo (PBO)+dose-optimised MTX in inducing and sustaining clinical remission in DMARD-naïve patients with moderate-to-severe, active, progressive rheumatoid arthritis (RA), with poor prognostic factors over 52 weeks. Methods DMARD-naïve patients with ≤1 year of active RA were randomised (3:1) in a double-blind manner to CZP (400 mg Weeks 0, 2, 4, then 200 mg Q2W to Week 52)+MTX or PBO+MTX (the mean optimised-MTX dose=21 and 22 mg/week, respectively). Sustained remission (sREM) and sustained low disease activity (sLDA; DAS28(ESR)<2.6 and DAS28(ESR)≤3.2, respectively, at both Weeks 40 and 52) were the primary and secondary endpoints. Results Patients were randomised to CZP+MTX (n=660) and PBO+MTX (n=219). At Week 52, significantly more patients assigned to CZP+MTX compared with PBO+MTX achieved sREM (28.9% vs 15.0%, p<0.001) and sLDA (43.8% vs 28.6%, p<0.001). Inhibition of radiographic progression and improvements in physical functioning were significantly greater for CZP+MTX versus PBO+MTX (van der Heijde modified total Sharp score (mTSS) mean absolute change from baseline (CFB): 0.2 vs 1.8, p<0.001, rate of mTSS non-progressors: 70.3% vs 49.7%, p<0.001; least squares (LS) mean CFB in Health Assessment Questionnaire-Disability Index (HAQ-DI): −1.00 vs −0.82, p<0.001). Incidence of adverse events (AEs) and serious AEs was similar between treatment groups. Infection was the most frequent AE, with higher incidence for CZP+MTX (71.8/100 patient-years (PY)) versus PBO+MTX (52.7/100 PY); the rate of serious infection was similar between CZP+MTX (3.3/100 PY) and PBO+MTX (3.7/100 PY). Conclusions CZP+dose-optimised MTX treatment of DMARD-naïve early RA resulted in significantly more patients achieving sREM and sLDA, improved physical function and inhibited structural damage compared with PBO+dose-optimised MTX. Trial registration number NCT01519791.
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Affiliation(s)
- P Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - C O Bingham
- Johns Hopkins University, Baltimore, Maryland, USA
| | - G R Burmester
- Rheumatology and Clinical Immunology, Charité-University Medicine, Berlin, Germany
| | - V P Bykerk
- Division of Rheumatology, Weill Cornell Medical College, Hospital for Special Surgery, New York, New York, USA
| | - D E Furst
- Division of Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - X Mariette
- Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, Le Kremlin Bicêtre, France
| | - D van der Heijde
- Deprtment of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - R van Vollenhoven
- Unit for Clinical Therapy Research, Inflammatory Disease, Karolinska Institute, Stockholm, Sweden
| | | | | | | | - D Tatla
- UCB Pharma, Raleigh, North Carolina, USA
| | | | - M E Weinblatt
- UCB Pharma, Raleigh, North Carolina, USA.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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144
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Haraoui B. Limitations in the Full Reporting of Systematic Literature Review. J Rheumatol 2016; 43:994. [PMID: 27134279 DOI: 10.3899/jrheum.151175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Boulos Haraoui
- Institut de rhumatologie de Montréal, Montreal, Quebec, Canada; for the Canadian Dermatology-Rheumatology Comorbidity Initiative.
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145
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Factors Associated with Myelosuppression Related to Low-Dose Methotrexate Therapy for Inflammatory Rheumatic Diseases. PLoS One 2016; 11:e0154744. [PMID: 27128679 PMCID: PMC4851368 DOI: 10.1371/journal.pone.0154744] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/18/2016] [Indexed: 12/12/2022] Open
Abstract
Objective Severe myelosuppression is a serious concern in the management of rheumatic disease patients receiving methotrexate (MTX) therapy. This study was intended to explore factors associated with the development of MTX-related myelosuppression and its disease severity. Methods We retrospectively examined a total of 40 cases of MTX-related myelosuppression that had been filed in the registries of participating rheumatology and hematology divisions. Data before onset were compared with those of 120 controls matched for age and sex. Cytopenia was graded according to the National Cancer Institute criteria for adverse events. Data before and at onset were compared between the severe and non-severe groups. Results Non-use of folic acid supplements, concurrent medications, and low renal function were significantly associated with the development of myelosuppression (p < 0.001, p < 0.001, and p = 0.002, respectively). In addition, significantly lower MTX dosages, higher blood cell counts, and lower hemoglobin levels were seen in the myelosuppression group (p < 0.001). No patients exhibited leukocytopenia, neutropenia, or thrombocytopenia in routine blood monitoring taken within the past month. One-fourth developed myelosuppression within the first two months (an early-onset period). Myelosuppression was severe in approximately 40% of patients. Hypoalbuminemia and non-use of folic acid supplements were significantly associated with the severity of pancytopenia (p = 0.001 and 0.008, respectively). Besides these two factors, early onset and the use of lower doses of MTX were significantly associated with the severity of neutropenia (p = 0.003, 0.007, 0.003, and 0.002, respectively). Conclusions Myelosuppression can occur abruptly at any time during low-dose MTX therapy, but severe neutropenia is more likely to occur in the early-onset period of this therapy. Contrary to our expectations, disease severity was not dependent on MTX doses. Serum albumin levels and folic acid supplementation are the important factors affecting the severity of MTX-related pancytopenia and neutropenia.
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146
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Malaviya AN, Gogia SB. Treatment of rheumatoid arthritis (RA) in India-how and by whom: results from a speciality clinic-use of low-dose methotrexate (MTX) was inexplicably suboptimal. Clin Rheumatol 2016; 35:2163-73. [PMID: 27122121 DOI: 10.1007/s10067-016-3283-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 04/12/2016] [Accepted: 04/14/2016] [Indexed: 12/19/2022]
Abstract
This study was conducted in order to study (a) seropositive RA patients for their prior caregivers, diagnosis makers, drugs and doses taken and (b) the disease status at the first visit and the last visit, from the standpoint of whether they received optimum or suboptimum DMARD treatment. Prospectively entered data were extracted from a rheumatology-specific electronic health record for demography, diagnostic delay, prior caregivers, diagnosis makers, intake of DMARDs and glucocorticoids and disease activity state at first presentation and at the last visit using structured query language. Among 316 patients, prior caregivers were orthopaedicians (73.4 %), alternative systems of medicine practitioners (62 %), internists (38 %), rheumatologists (35.8 %), general practitioners (17 %) and others (12 %). The diagnosis of RA was made by rheumatologists (55.6 %), orthopaedicians (21 %), internists (12.6 %), physiotherapists (3.5 %), homeopaths (2.8 %), general practitioner (2.1 %), neurologists (1.4 %) and Ayurvedic physicians (0.7 %). The mean and the median diagnostic delay among 142 patients where information was available were 18 and 8.5 months, respectively (SD +23.2). Thirty-two percent of the patients had early disease, 48 % established disease and 20 % late disease at presentation. Sixty-six percent of the patients had taken DMARDs-methotrexate (56 %), hydroxychloroquine (46.2 %), leflunomide (18.7 %) and sulfasalazine (20.6 %)-and often in combinations. Different preparations, doses and schedules of glucocorticoids were taken orally or parentally by 51 %. Only one (0.3 %) patient had taken biological DMARDs prior to visiting this clinic. High or moderate disease activity was present in 84 % at the first clinic visit that fell to 14 % at the last clinic visit. The majority of patients with RA were treated by orthopaedicians and practitioners of alternative systems of medicine with only a third by rheumatologists. In 80 % of patients, the diagnosis was made 18 months at the onset, yet in 84 %, the disease control was poor. Non-use or suboptimal use of methotrexate appeared to be the main reason.
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Affiliation(s)
- Anand N Malaviya
- A&R Clinic for Arthritis & Rheumatism, Flat 2015, Sector B-2, Vasant Kunj, New Delhi, 110070, India. .,Department of Rheumatology, ISIC Superspeciality Hospital, Vasant Kunj, New Delhi, 110070, India.
| | - S B Gogia
- Department of Rheumatology, ISIC Superspeciality Hospital, Vasant Kunj, New Delhi, 110070, India.,Healthcare Informatics Sanwari Bai Surgical Centre, 28/31, Old Rajinder Nagar, New Delhi, 110060, India
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147
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148
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Gallo G, Brock F, Kerkmann U, Kola B, Huizinga TWJ. Efficacy of etanercept in combination with methotrexate in moderate-to-severe rheumatoid arthritis is not dependent on methotrexate dosage. RMD Open 2016; 2:e000186. [PMID: 27175292 PMCID: PMC4860865 DOI: 10.1136/rmdopen-2015-000186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 02/02/2016] [Accepted: 02/11/2016] [Indexed: 12/29/2022] Open
Abstract
Objective To evaluate the impact of methotrexate (MTX) dosage on clinical, functional and quality of life outcomes in patients with rheumatoid arthritis (RA) from two previous etanercept (ETN) trials after 24 months of treatment. Methods Patients with active RA in the ETN+MTX combination treatment arms of the Trial of Etanercept and Methotrexate with Radiographic Patient Outcomes (TEMPO) and COmbination of Methotrexate and ETanercept in Active Early Rheumatoid Arthritis (COMET) studies were pooled in this post hoc analysis and stratified by MTX dosage at 24 months, having MTX monotherapy groups as control: low dose, <10.0 mg/week; medium dose, 10.0–17.5 mg/week; and high dose, >17.5 mg/week. Data from these patient subgroups were included in descriptive summaries of demographic and disease characteristics at baseline. The following outcomes at 24 months were also evaluated for each subgroup: Disease Activity Score in 28 joints (DAS28) low disease activity (LDA) and remission; American College of Rheumatology 20%, 50% and 70% improvement criteria (ACR20, 50 and 70) responses; and changes from baseline in DAS28, Health Assessment Questionnaire Disease Index (HAQ-DI) and EuroQol 5-dimensions visual analogue scale (EQ-5D VAS). Results Baseline demographics were similar between the low, medium and high MTX dose groups in the ETN+MTX combination and MTX monotherapy arms, with the exception of disease duration (ETN+MTX low 5.5; medium 5.1; high 0.8 years vs MTX low 8.3; medium 4.7; high 0.8 years). Responses to ETN+MTX combination therapy at 24 months were consistently high across MTX dosage groups, with very similar rates of DAS28 LDA/remission and ACR20/50/70. Improvements in DAS28, HAQ-DI and EQ-5D VAS were also not dependent on MTX dosage in the combination treatment arm. Conclusions Patients with RA in the TEMPO and COMET trials who received ETN+MTX showed similar efficacy outcomes at 24 months, regardless of MTX dosage. Trial registration numbers NCT00195494 (COMET) and NCT00393471 (TEMPO).
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Affiliation(s)
- G Gallo
- Pfizer Europe , Rome , Italy
| | - F Brock
- Statistical Consultancy, Quanticate Ltd. , Hitchin , UK
| | | | - B Kola
- Pfizer Europe , Rome , Italy
| | - T W J Huizinga
- Leiden University Medical Center , Leiden , The Netherlands
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149
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Joshi D. Rheumatic and connective tissue disorders. Clin Liver Dis (Hoboken) 2016; 7:64-67. [PMID: 31041032 PMCID: PMC6490257 DOI: 10.1002/cld.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/18/2016] [Accepted: 01/24/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Deepak Joshi
- Institute of Liver StudiesKing's College HospitalLondonUnited Kingdom
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150
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Nair SC, Jacobs JWG, Bakker MF, Jahangier ZN, Bijlsma JWJ, van Laar JM, Lafeber FPJG, Welsing PMJ. Determining the Lowest Optimally Effective Methotrexate Dose for Individual RA Patients Using Their Dose Response Relation in a Tight Control Treatment Approach. PLoS One 2016; 11:e0148791. [PMID: 26987073 PMCID: PMC4795693 DOI: 10.1371/journal.pone.0148791] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 01/22/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To determine the optimal methotrexate dose in individual patients and to explore whether this optimal dose and the level of disease activity at that dose could be predicted. METHODS Data from CAMERA II trial comparing MTX and MTX with 10 mg of prednisone both in a tight control treatment strategy in early RA was used. For each patient a curve for disease activity over time was fitted and the MTX dose after which further step-up did not result in relevant improvement in disease activity anymore was determined the 'lowest optimally effective MTX dose (LOED)'. The association of demographic and clinical characteristics at baseline with this LOED and with the level of disease activity reached at LOED was studied. RESULTS In 204 (100 MTX and 104 MTX with prednisone) out of 236 patients LOED could be defined. 10 mg/wk was the most prevalent LOED in patients treated with MTX and prednisone and 10 mg/wk, 20 mg/wk and 30 mg/wk in the MTX strategy. Although the specific LOED could not reliably be predicted, higher baseline disease activity, height and lower weight were associated with higher LOEDs (i.e at least 15 mg/wk). A score was presented to decide on a starting dose of 10 mg/wk or (at least) 15 mg/wk. The level of disease activity at LOED could not be reliably predicted. CONCLUSION A starting dose of 10 mg/wk might be a good choice for most patients and is frequently already the optimal dose. However, a subgroup of patient can be determined who would require higher MTX doses.
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Affiliation(s)
- Sandhya C. Nair
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
- * E-mail:
| | - Johannes W. G. Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Marije F. Bakker
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | | | - Johannes W. J. Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Jacobs M. van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Floris P. J. G. Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Paco M. J. Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
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