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Hazlewood GS, Barnabe C, Tomlinson G, Marshall D, Devoe DJA, Bombardier C. Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis: A network meta-analysis. Cochrane Database Syst Rev 2016; 2016:CD010227. [PMID: 27571502 PMCID: PMC7087436 DOI: 10.1002/14651858.cd010227.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Methotrexate is considered the preferred disease-modifying anti-rheumatic drug (DMARD) for the treatment of rheumatoid arthritis, but controversy exists on the additional benefits and harms of combining methotrexate with other DMARDs. OBJECTIVES To compare methotrexate and methotrexate-based DMARD combinations for rheumatoid arthritis in patients naïve to or with an inadequate response (IR) to methotrexate. METHODS We systematically identified all randomised controlled trials with methotrexate monotherapy or in combination with any currently used conventional synthetic DMARD , biologic DMARDs, or tofacitinib. Three major outcomes (ACR50 response, radiographic progression and withdrawals due to adverse events) and multiple minor outcomes were evaluated. Treatment effects were summarized using Bayesian random-effects network meta-analyses, separately for methotrexate-naïve and methotrexate-IR trials. Heterogeneity was explored through meta-regression and subgroup analyses. The risk of bias of each trial was assessed using the Cochrane risk of bias tool, and trials at high risk of bias were excluded from the main analysis. The quality of evidence was evaluated using the GRADE approach. A comparison between two treatments was considered statistically significant if its credible interval excluded the null effect, indicating >97.5% probability that one treatment was superior. MAIN RESULTS 158 trials with over 37,000 patients were included. Methotrexate-naïve: Several treatment combinations with methotrexate were statistically superior to oral methotrexate for ACR50 response: methotrexate + sulfasalazine + hydroxychloroquine ("triple therapy"), methotrexate + several biologics (abatacept, adalimumab, etanercept, infliximab, rituximab, tocilizumab), and tofacitinib. The estimated probability of ACR50 response was similar between these treatments (range 56-67%, moderate to high quality evidence), compared with 41% for methotrexate. Methotrexate combined with adalimumab, etanercept, certolizumab, or infliximab was statistically superior to oral methotrexate for inhibiting radiographic progression (moderate to high quality evidence) but the estimated mean change over one year with all treatments was less than the minimal clinically important difference of five units on the Sharp-van der Heijde scale. Methotrexate + azathioprine had statistically more withdrawals due to adverse events than oral methotrexate, and triple therapy had statistically fewer withdrawals due to adverse events than methotrexate + infliximab (rate ratio 0.26, 95% credible interval: 0.06 to 0.91). Methotrexate-inadequate response: In patients with an inadequate response to methotrexate, several treatments were statistically significantly superior to oral methotrexate for ACR50 response: triple therapy (moderate quality evidence), methotrexate + hydroxychloroquine (low quality evidence), methotrexate + leflunomide (moderate quality evidence), methotrexate + intramuscular gold (very low quality evidence), methotrexate + most biologics (moderate to high quality evidence), and methotrexate + tofacitinib (high quality evidence). There was a 61% probability of an ACR50 response with triple therapy, compared to a range of 27% to 64% for the combinations of methotrexate + biologic DMARDs that were statistically significantly superior to oral methotrexate. No treatment was statistically significantly superior to oral methotrexate for inhibiting radiographic progression. Methotrexate + cyclosporine and methotrexate + tocilizumab (8 mg/kg) had a statistically higher rate of withdrawals due to adverse events than oral methotrexate and methotrexate + abatacept had a statistically lower rate of withdrawals due to adverse events than several treatments. AUTHORS' CONCLUSIONS We found moderate to high quality evidence that combination therapy with methotrexate + sulfasalazine+ hydroxychloroquine (triple therapy) or methotrexate + most biologic DMARDs or tofacitinib were similarly effective in controlling disease activity and generally well tolerated in methotrexate-naïve patients or after an inadequate response to methotrexate. Methotrexate + some biologic DMARDs were superior to methotrexate in preventing joint damage in methotrexate-naïve patients, but the magnitude of these effects was small over one year.
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Affiliation(s)
- Glen S Hazlewood
- University of CalgaryDepartment of Medicine and Department of Community Health Sciences3330 Hospital Drive NWCalgaryONCanadaT2N 1N1
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of TorontoInstitute of Health, Policy, Management and EvaluationTorontoONCanadaM5T 3M6
| | - Cheryl Barnabe
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of CalgaryDepartment of Medicine3330 Hospital Dr NWCalgaryABCanadaT2N 4N1
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - George Tomlinson
- University of TorontoDepartment of Medicine and Institute of Health Policy, Management and EvaluationEaton North, 6th Floor, Room 232B200 Elizabeth StreetTorontoONCanadaM5G 2C4
| | - Deborah Marshall
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Daniel JA Devoe
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Claire Bombardier
- University Health NetworkToronto General Research InstituteTorontoONCanadaM6J 3S3
- University of TorontoDepartment of Medicine and Institute of Health Policy, Management, and EvaluationTorontoONCanadaM5G 2C4
- Mount Sinai HospitalDivision of RheumatologyTorontoONCanadaM5T 3L9
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152
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Jansen JP, Vieira MC, Bradley JD, Cappelleri JC, Zwillich SH, Wallenstein GV. Meta-analysis of long-term joint structural deterioration in minimally treated patients with rheumatoid arthritis. BMC Musculoskelet Disord 2016; 17:348. [PMID: 27538585 PMCID: PMC4991055 DOI: 10.1186/s12891-016-1195-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 05/31/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and joint structural deterioration. Driven by recent expectations that patients in clinical trials randomized to placebo should be 'rescued' with active therapy within 6 months of starting treatment, the relative benefit of arresting joint damage with biologic agents beyond this period is unclear. With longer-term evidence of the rate of joint deterioration with minimal treatment, the efficacy of biologic agents and novel treatments might be projected beyond the placebo-controlled phase observed in clinical trials. The aim of this study was to estimate radiographic structural deterioration over time in patients with moderate-to-severe RA minimally treated with DMARDs. METHODS A literature review identified evidence of joint structural deterioration in patients with (DMARD-IR population) and without (non-DMARD-IR population) a history of inadequate response to DMARDs. Patients were minimally treated with one non-biologic DMARD or palliative care (non-DMARD-IR population only). Outcomes of interest were the (modified) Total Sharp Score (TSS) and subscales (Erosion Subscore [ES] and Joint Space Narrowing [JSN] Subscore), and Larsen score. Pooled joint-deterioration curves over time were obtained with meta-analysis models. RESULTS Mean change from baseline in TSS increased in the DMARD-IR population from 1.14 (95 % credible interval [CrI] 0.66, 1.67) to 9.84 (5.68, 14.46) at Weeks 12 and 104, respectively, and a non-linear increase of 1.56 (0.79, 2.34) and 5.13 (-1.35, 11.67) in the non-DMARD-IR population. At the same time points, mean changes (95 % CrI) were 0.51 (0.27, 0.83) and 4.43 (2.38, 7.21) for ES and 0.36 (0.09, 0.67) and 3.14 (0.80, 5.78) for JSN in the DMARD-IR population, whereas corresponding changes in the non-DMARD-IR population were 0.69 (0.31, 1.12) and 2.93 (0.92, 5.02), and 0.29 (0.17, 0.44) and 2.55 (1.45, 3.80), respectively. Larsen scores were only available for the non-DMARD-IR population, with mean changes (95 % CrI) of 0.08 (0.04, 0.11) and 0.65 (0.36, 0.96) at Weeks 12 and 104, respectively. CONCLUSION Minimal treatment of RA with one non-biologic DMARD results in deterioration of joint structure in patients with or without a history of inadequate response to non-biologic DMARDs.
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Affiliation(s)
- Jeroen P. Jansen
- Tufts University School of Medicine, Boston, MA USA
- 1714 Stockton Street, 3rd floor, San Francisco, CA 94133 USA
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153
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Haavardsholm EA, Aga AB, Olsen IC, Lillegraven S, Hammer HB, Uhlig T, Fremstad H, Madland TM, Lexberg ÅS, Haukeland H, Rødevand E, Høili C, Stray H, Noraas A, Hansen IJW, Bakland G, Nordberg LB, van der Heijde D, Kvien TK. Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial. BMJ 2016; 354:i4205. [PMID: 27530741 PMCID: PMC4986519 DOI: 10.1136/bmj.i4205] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine whether a treatment strategy based on structured ultrasound assessment would lead to improved outcomes in rheumatoid arthritis, compared with a conventional strategy. DESIGN Multicentre, open label, two arm, parallel group, randomised controlled strategy trial. SETTING Ten rheumatology departments and one specialist centre in Norway, from September 2010 to September 2015. PARTICIPANTS 238 patients were recruited between September 2010 and April 2013, of which 230 (141 (61%) female) received the allocated intervention and were analysed for the primary outcome. The main inclusion criteria were age 18-75 years, fulfilment of the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis, disease modifying anti-rheumatic drug naivety with indication for disease modifying drug therapy, and time from first patient reported swollen joint less than two years. Patients with abnormal kidney or liver function or major comorbidities were excluded. INTERVENTIONS 122 patients were randomised to an ultrasound tight control strategy targeting clinical and imaging remission, and 116 patients were randomised to a conventional tight control strategy targeting clinical remission. Patients in both arms were treated according to the same disease modifying anti-rheumatic drug escalation strategy, with 13 visits over two years. MAIN OUTCOME MEASURES The primary endpoint was the proportion of patients with a combination between 16 and 24 months of clinical remission, no swollen joints, and non-progression of radiographic joint damage. Secondary outcomes included measures of disease activity, radiographic progression, functioning, quality of life, and adverse events. All participants who attended at least one follow-up visit were included in the full analysis set. RESULTS 26 (22%) of the 118 analysed patients in the ultrasound tight control arm and 21 (19%) of the 112 analysed patients in the clinical tight control arm reached the primary endpoint (mean difference 3.3%, 95% confidence interval -7.1% to 13.7%). Secondary endpoints (disease activity, physical function, and joint damage) were similar between the two groups. Six (5%) patients in the ultrasound tight control arm and seven (6%) patients in the conventional arm had serious adverse events. CONCLUSIONS The systematic use of ultrasound in the follow-up of patients with early rheumatoid arthritis treated according to current recommendations is not justified on the basis of the ARCTIC results. The findings highlight the need for randomised trials assessing the clinical application of medical technology.Trial registration Clinical trials NCT01205854.
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Affiliation(s)
- Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway
| | - Anna-Birgitte Aga
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway
| | | | - Siri Lillegraven
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway
| | - Till Uhlig
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway
| | | | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | | | - Hilde Haukeland
- Department of Rheumatology, Martina Hansens Hospital AS, Sandvika, Norway
| | - Erik Rødevand
- Department of Rheumatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Christian Høili
- Department of Rheumatology, Hospital Østfold HF Moss, Grålum, Norway
| | - Hilde Stray
- Haugesund Rheumatism Hospital AS, Haugesund, Norway
| | - Anne Noraas
- The Rheumatology Clinic Dovland/Bendvold, Kristiansand, Norway
| | | | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, Tromsø, Norway Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Lena Bugge Nordberg
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway
| | - Désirée van der Heijde
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319 Oslo, Norway
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154
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Favalli EG, Pregnolato F, Biggioggero M, Becciolini A, Penatti AE, Marchesoni A, Meroni PL. Twelve-Year Retention Rate of First-Line Tumor Necrosis Factor Inhibitors in Rheumatoid Arthritis: Real-Life Data From a Local Registry. Arthritis Care Res (Hoboken) 2016; 68:432-9. [PMID: 26556048 DOI: 10.1002/acr.22788] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 10/13/2015] [Accepted: 11/03/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the 12-year survival of the first tumor necrosis factor inhibitor (TNFi) treatment in a cohort of rheumatoid arthritis (RA) patients, comparing the between-groups discontinuation rates for infliximab, etanercept, and adalimumab. METHODS RA patients treated with their first TNFi were investigated from a local registry. Before and after adjusting for propensity scores, overall and by individual TNFi 12-year drug retention was evaluated. Drug survival rates were calculated using the Kaplan-Meier method and compared by the Cox extended model. Subanalyses were performed according to concomitant methotrexate (MTX) and discontinuation reasons. RESULTS Of 583 patients, 222 were treated with infliximab, 179 with etanercept, and 182 with adalimumab; 33.7% and 26% discontinued the first TNFi because of inefficacy or adverse events, respectively. The overall 12-year drug survival rate for the unmatched population was 23.4%. In the propensity score-adjusted population, the hazard ratio (HR) for treatment discontinuation was significantly greater for adalimumab and infliximab versus etanercept (HR 2.89 [95% confidence interval (95% CI) 2.2-3.78] and HR 2.56 [95% CI 1.92-3.4], respectively), and no difference was found between and for adalimumab versus infliximab (HR 1.16 [95% CI 0.91-1.47]). The incidence of withdrawal due to secondary inefficacy was stable from 3 to 12 years for etanercept, but progressively increased for the monoclonal antibodies. Concomitant MTX significantly increased the survival of both adalimumab and etanercept (HR 1.48 [95% CI 1.18-1.86]). CONCLUSION The overall 12-year drug survival rate was 23.4%, being significantly higher for etanercept than adalimumab and infliximab. Etanercept discontinuations for inefficacy did not increase from 3 to 12 years. Concomitant MTX increased adalimumab and etanercept drug survival.
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Affiliation(s)
| | - Francesca Pregnolato
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | | | | | | | | | - Pier Luigi Meroni
- University of Milan and IRCCS Istituto Auxologico Italiano, Milan, Italy
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155
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Rau R. Methotrexat. Z Rheumatol 2016; 75:599-603. [DOI: 10.1007/s00393-016-0118-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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156
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Fleischmann RM, Huizinga TWJ, Kavanaugh AF, Wilkinson B, Kwok K, DeMasi R, van Vollenhoven RF. Efficacy of tofacitinib monotherapy in methotrexate-naive patients with early or established rheumatoid arthritis. RMD Open 2016; 2:e000262. [PMID: 27493790 PMCID: PMC4964179 DOI: 10.1136/rmdopen-2016-000262] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/20/2016] [Accepted: 06/06/2016] [Indexed: 12/11/2022] Open
Abstract
Introduction Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). Tofacitinib monotherapy was previously shown to inhibit structural damage, reduce clinical signs and symptoms of RA, and improve physical functioning over 24 months in methotrexate (MTX)-naive adult patients with RA. In this post hoc analysis, we compared efficacy and safety of tofacitinib in patients with early (disease duration <1 year) versus established (≥1 year) RA. Methods MTX-naive patients ≥18 years with active RA received tofacitinib monotherapy (5 or 10 mg two times a day, or MTX monotherapy, in a 24-month Phase 3 trial. Results Of 956 patients (tofacitinib 5 mg two times a day, n=373; tofacitinib 10 mg two times a day, n=397; MTX, n=186), 54% had early RA. Baseline disease activity and functional disability were similar in both groups; radiographic damage was greater in patients with established RA. At month 24, clinical response rates were significantly greater in patients with early versus established RA in the tofacitinib 5 mg two times a day group. Both tofacitinib doses had greater effects on clinical, functional and radiographic improvements at 1 and 2 years compared with MTX, independent of disease duration. No new safety signals were observed. Conclusions Treatment response was generally similar in early and established RA; significantly greater improvements were observed at month 24 with tofacitinib 5 mg two times a day in early versus established RA. Tofacitinib 5 and 10 mg two times a day demonstrated greater efficacy versus MTX irrespective of disease duration. No difference in safety profiles was observed between patients with early or established RA. Trial registration number NCT01039688; Results.
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Affiliation(s)
- Roy M Fleischmann
- University of Texas Southwestern Medical Center, Metroplex Research Center , Dallas, Texas , USA
| | | | - Arthur F Kavanaugh
- University of California San Diego School of Medicine , San Diego, California , USA
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157
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Wang Q, Wen Z, Cao Q. Risk of tuberculosis during infliximab therapy for inflammatory bowel disease, rheumatoid arthritis, and spondyloarthropathy: A meta-analysis. Exp Ther Med 2016; 12:1693-1704. [PMID: 27588089 PMCID: PMC4998002 DOI: 10.3892/etm.2016.3548] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/27/2016] [Indexed: 12/15/2022] Open
Abstract
Infliximab is a promising drug with good outcomes demonstrated for diseases such as inflammatory bowel disease (IBD), rheumatoid arthritis (RA) and spondyloarthropathy (SpA). However, treatment with this drug may increase the risk of tuberculosis infection. The aim of the present study was to investigate infliximab-associated tuberculosis infection. Literature searches in PubMed, MEDLINE and EMBASE databases were performed. Randomized controlled trials with >95% of the patients >18 years-old were included. Meta-analysis was performed to investigate the incidence of tuberculosis infection after infliximab infusion. A total of 24 RCTs were included in the present meta-analysis. In total, 21 (0.51%) tuberculosis infections were detected among 4,111 patients administered infliximab therapy, compared with 0 (0%) among 2,229 patients assigned to the placebo group. Pooled odds ratio (OR) of developing tuberculosis infection was significantly higher with infliximab therapy than with placebo [2.86; 95% confidence interval (CI), 1.09–7.52]. The OR of tuberculosis infection was 3.93 (95% CI, 0.91–16.91) in RA, 2.46 (95% CI, 0.38–15.92) in SpA and 1.66 (95% CI, 0.26–10.57) in IBD. Rates of tuberculosis infection with infliximab therapy in RA, SpA and IBD were 0.70, 0.22 and 0.52%, respectively. Compared with placebo, infliximab therapy may increase the risk of developing tuberculosis. However, the ORs for the risk of infliximab-associated tuberculosis were not demonstrated to be significant in IBD, RA and SpA; therefore, these findings should be interpreted with caution. The risk of developing tuberculosis demonstrates the importance of the prevention and management of tuberculosis infection with infliximab therapy.
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Affiliation(s)
- Qiang Wang
- Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, P.R. China
| | - Zhenzhen Wen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Qian Cao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
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158
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Delineation of Crohn's Disease Trajectories Using Change in Lémann Index: A Natural History Study. J Clin Gastroenterol 2016; 50:476-82. [PMID: 26646805 DOI: 10.1097/mcg.0000000000000463] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Crohn's disease (CD) causes lifelong, progressive bowel damage, which may be quantified using the Lémann Index (LI). We aimed to analyze patterns of LI and its association with 5-year clinical course, in an independent cohort of CD patients. METHODS CD patients with 5-year follow-up from a registry maintained at a tertiary center were included. LI was calculated using a computerized metric from the first (LI1) and last (LI2) clinical encounters during the 5 years. Groups were created based on change in score (LI2-LI1) or the delta Lémann Index (DLI) as showing improvement, no change, or deterioration and used for association analysis with patterns of health care utilization, disease activity, and quality-of-life scores. RESULTS A total of 363 CD patients with 5-year follow-up formed the study population [median age 43 y (interquartile range (IQR), 33.3 to 55 y); 57% female; median disease duration 12 y (IQR, 3 to 19 y), overall surgical exposure 69.7%]. Median (IQR) LI1, LI2, and DLI were 8 (0 to 54), 9 (0 to 75), and 0 (-22 to -47), respectively. Patients were stratified based on DLI into 3 groups: A: DLI<0; B: DLI=0; and C: DLI>0; which comprised 16.5%, 35.3%, and 48.2% of the cohort, respectively. Patients in group C had significantly higher CD-related surgical exposure, health care utilization, and annual use of steroids and biological agents. DLI showed independent significant positive correlation with perianal disease (P=0.044), steroid use (P=0.007), clinical visits (P<0.001), and new surgeries (P=0.001). CONCLUSIONS Change in LI over time could function as a marker of disease trajectory for risk substratification and prognostication in CD.
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159
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Álvaro-Gracia JM, Jover JA, García-Vicuña R, Carreño L, Alonso A, Marsal S, Blanco F, Martínez-Taboada VM, Taylor P, Martín-Martín C, DelaRosa O, Tagarro I, Díaz-González F. Intravenous administration of expanded allogeneic adipose-derived mesenchymal stem cells in refractory rheumatoid arthritis (Cx611): results of a multicentre, dose escalation, randomised, single-blind, placebo-controlled phase Ib/IIa clinical trial. Ann Rheum Dis 2016; 76:196-202. [PMID: 27269294 DOI: 10.1136/annrheumdis-2015-208918] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 05/17/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate the safety and tolerability of the intravenous administration of Cx611, a preparation of allogeneic expanded adipose-derived stem cells (eASCs), in patients with refractory rheumatoid arthritis (RA), as well as to obtain preliminary clinical efficacy data in this population. METHODS It is a multicentre, dose escalation, randomised, single-blind (double-blind for efficacy), placebo-controlled, phase Ib/IIa clinical trial. Patients with active refractory RA (failure to at least two biologicals) were randomised to receive three intravenous infusions of Cx611: 1 million/kg (cohort A), 2 million/kg (cohort B), 4 million/kg (cohort C) or placebo, on days 1, 8 and 15, and they were followed for therapy assessment for 24 weeks. RESULTS Fifty-three patients were treated (20 in cohort A, 20 in cohort B, 6 in cohort C and 7 in placebo group). A total of 141 adverse events (AEs) were reported. Seventeen patients from the group A (85%), 15 from the group B (75%), 6 from the group C (100%) and 4 from the placebo group (57%) experienced at least one AE.Eight AEs from 6 patients were grade 3 in intensity (severe), 5 in cohort A (lacunar infarction, diarrhoea, tendon rupture, rheumatoid nodule and arthritis), 2 in cohort B (sciatica and RA) and 1 in the placebo group (asthenia). Only one of the grade 3 AEs was serious (the lacunar infarction). American College of Rheumatology 20 responses for cohorts A, B, C and placebo were 45%, 20%, 33% and 29%, respectively, at month 1, and 25%, 15%, 17% and 0%, respectively, at month 3. CONCLUSIONS The intravenous infusion of Cx611 was in general well tolerated, without evidence of dose-related toxicity at the dose range and time period studied. In addition, a trend for clinical efficacy was observed. These data, in our opinion, justify further investigation of this innovative therapy in patients with RA. TRIAL REGISTRATION NUMBERS EudraCT: 2010-021602-37; NCT01663116; Results.
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Affiliation(s)
| | - Juan A Jover
- Hospital Universitario Clínico San Carlos de Madrid, Madrid, Spain
| | | | - Luis Carreño
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Francisco Blanco
- INIBIC-Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Victor M Martínez-Taboada
- Hospital Universitario Marqués de Valdecilla, Santander, Spain.,Facultad de Medicina, Universidad de Cantabria, Santander, Spain
| | - Peter Taylor
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | | | | | | | - Federico Díaz-González
- Department of Medicine, Universidad de La Laguna, La Laguna, Spain.,Complejo Hospitalario Universitario de Canarias, Tenerife, Spain
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160
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Almeida C, Choy EHS, Hewlett S, Kirwan JR, Cramp F, Chalder T, Pollock J, Christensen R. Biologic interventions for fatigue in rheumatoid arthritis. Cochrane Database Syst Rev 2016; 2016:CD008334. [PMID: 27271314 PMCID: PMC7175833 DOI: 10.1002/14651858.cd008334.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Fatigue is a common and potentially distressing symptom for patients with rheumatoid arthritis (RA), with no accepted evidence-based management guidelines. Evidence suggests that biologic interventions improve symptoms and signs in RA as well as reducing joint damage. OBJECTIVES To evaluate the effect of biologic interventions on fatigue in rheumatoid arthritis. SEARCH METHODS We searched the following electronic databases up to 1 April 2014: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Current Controlled Trials Register, the National Research Register Archive, The UKCRN Portfolio Database, AMED, CINAHL, PsycINFO, Social Science Citation Index, Web of Science, and Dissertation Abstracts International. In addition, we checked the reference lists of articles identified for inclusion for additional studies and contacted key authors. SELECTION CRITERIA We included randomised controlled trials if they evaluated a biologic intervention in people with rheumatoid arthritis and had self reported fatigue as an outcome measure. DATA COLLECTION AND ANALYSIS Two reviewers selected relevant trials, assessed methodological quality and extracted data. Where appropriate, we pooled data in meta-analyses using a random-effects model. MAIN RESULTS We identified 32 studies for inclusion in this current review. Twenty studies evaluated five anti-tumour necrosis factor (anti-TNF) biologic agents (adalimumab, certolizumab, etanercept, golimumab and infliximab), and 12 studies focused on five non-anti-TNF biologic agents (abatacept, canakinumab, rituximab, tocilizumab and an anti-interferon gamma monoclonal antibody). All but two of the studies were double-blind randomised placebo-controlled trials. In some trials, patients could receive concomitant disease-modifying anti-rheumatic drugs (DMARDs). These studies added either biologics or placebo to DMARDs. Investigators did not change the dose of the latter from baseline. In total, these studies included 9946 participants in the intervention groups and 4682 participants in the control groups. Overall, quality of randomised controlled trials was moderate with a low to unclear risk of bias in the reporting of the outcome of fatigue. We downgraded the quality of the studies from high to moderate because of potential reporting bias (studies included post hoc analyses favouring reporting of positive result and did not always include all randomised individuals). Some studies recruited only participants with early disease. The studies used five different instruments to assess fatigue in these studies: the Functional Assessment of Chronic Illness Therapy Fatigue Domain (FACIT-F), Short Form-36 Vitality Domain (SF-36 VT), Visual Analogue Scale (VAS) (0 to 100 or 0 to 10) and the Numerical Rating Scale (NRS). We calculated standard mean differences for pooled data in meta-analyses. Overall treatment by biologic agents led to statistically significant reduction in fatigue with a standardised mean difference of -0.43 (95% confidence interval (CI) -0.38 to -0.49). This equates to a difference of 6.45 units (95% CI 5.7 to 7.35) of FACIT-F score (range 0 to 52). Both types of biologic agents achieved a similar level of improvement: for anti-TNF agents, this stood at -0.42 (95% CI -0.35 to -0.49), equivalent to 6.3 units (95% CI 5.3 to 7.4) on the FACIT-F score; and for non-anti-TNF agents, it was -0.46 (95% CI -0.39 to -0.53), equivalent to 6.9 units (95% CI 5.85 to 7.95) on the FACIT-F score. In most studies, the double-blind period was 24 weeks or less. No study assessed long-term changes in fatigue. AUTHORS' CONCLUSIONS Treatment with biologic interventions in patients with active RA can lead to a small to moderate improvement in fatigue. The magnitude of improvement is similar for anti-TNF and non-anti-TNF biologics. However, it is unclear whether the improvement results from a direct action of the biologics on fatigue or indirectly through reduction in inflammation, disease activity or some other mechanism.
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Affiliation(s)
- Celia Almeida
- University of the West of EnglandFaculty of Health & Life SciencesCourtyard Building, BRIBristolUKBS2 8HW
| | - Ernest HS Choy
- Cardiff University School of MedicineSection of Rheumatology, Division of Infection and ImmunityTenovus BuildingHeath ParkCardiffUKCF14 4XN
| | - Sarah Hewlett
- University of the West of EnglandFaculty of Health & Life SciencesCourtyard Building, BRIBristolUKBS2 8HW
| | - John R Kirwan
- University of Bristol, Bristol Royal InfirmaryRheumatology UnitThe CourtyardMarlborough StreetBristolUKBS2 8 HW
| | - Fiona Cramp
- University of the West of EnglandFaculty of Health & Life SciencesCourtyard Building, BRIBristolUKBS2 8HW
| | - Trudie Chalder
- Institute of Psychiatry, Psychology & Neuroscience, King's College LondonChronic Fatigue Service, Department of Psychological MedicineWeston Education CentreCutcombe RoadLondonUKSE5 9RH
| | - Jon Pollock
- University of the West of EnglandFaculty of Health & Life SciencesCourtyard Building, BRIBristolUKBS2 8HW
| | - Robin Christensen
- Copenhagen University Hospital, Bispebjerg og FrederiksbergMusculoskeletal Statistics Unit, The Parker InstituteNordre Fasanvej 57CopenhagenDenmarkDK‐2000
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Abstract
The treatment of rheumatoid arthritis (RA) has changed dramatically over the past two decades. The combination of better insights into the pathophysiological and immunological mechanisms of RA and the possibilities offered by biotechnology led to the development and introduction into clinical practice of a new class of antirheumatic biologic therapies, which along with earlier and more aggressive treatment contributed to dramatically better outcomes for patients with RA. To date, nine biologic agents have been approved for the treatment for RA, and a first Janus kinase (JAK) inhibitor has also been approved in the United States and various other countries in the world (but not by the European Medicines Agency [EMA]). Many additional molecules with distinct mechanisms of action are currently being tested in laboratories and in clinical trials. In addition, considerable improvements have been made in the optimal use of all these agents through treatment strategies such as treating-to-target, induction-maintenance, and dose individualization.
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Affiliation(s)
- Ronald F van Vollenhoven
- Department of Medicine, Karolinska Institute, Unit for Clinical Research Therapy, Inflammatory Diseases (ClinTrid), D1:00, Karolinska Universitetssjukhustet 171 76, Stockholm, Sweden.
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Granger B, Combe B, Le Loet X, Saraux A, Guillemin F, Fautrel B. Performance of matrices developed to identify patients with early rheumatoid arthritis with rapid radiographic progression despite methotrexate therapy: an external validation study based on the ESPOIR cohort data. RMD Open 2016; 2:e000245. [PMID: 27252898 PMCID: PMC4879338 DOI: 10.1136/rmdopen-2016-000245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/07/2016] [Accepted: 04/16/2016] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Use of prediction matrices of risk or rapid radiographic progression (RRP) for early rheumatoid arthritis (RA) in clinical practice could help to better rationalise the first line of treatment. Before use, they must be validated in populations that have not participated in their construction. The main objective is to use the ESPOIR cohort to validate the performance of 3 matrices (ASPIRE, BEST and SONORA) to predict patients at high risk of RRP at 1 year of disease despite initial treatment with methotrexate (MTX). METHODS We selected from the ESPOIR cohort 370 patients receiving MTX or leflunomide (LEF) for ≥3 months within the first year of follow-up. Patients were assessed clinically every 6 months, and structural damage progression seen on radiography was measured by the van der Heijde-modified Sharp score (vSHS) at 1 year. RRP was defined as an increase in the vSHS≥5 points during the first year. RESULTS At 1 year, the mean vSHS score was 1.7±5.0 and 46 patients had RRP. The ASPIRE matrix had only moderate validity in the ESPOIR population, with area under the receiver operating characteristic curve (AUC) <0.7. The AUC for the BEST and SONORA matrices were 0.73 and 0.76. Presence of rheumatoid factor (RF)-or anti-citrullinated protein antibodies (ACPAs) and initial structural damage were always predictive of RRP at 1 year. Disease Activity Score in 28 joints (DAS28) and C reactive protein (ASPIRE threshold) were not associated with RRP. CONCLUSIONS Matrices to identify patients at risk of RRP tested in the ESPOIR cohort seem to perform moderately. There is no matrix that shows clearly superior performance.
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Affiliation(s)
- Benjamin Granger
- Université Pierre et Marie Curie (UPMC)—Paris 6, GRC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
- Department of Biostatistics, Public Health and Medical Information, AP-HP Pitié Salpêtrière Hospital, Paris, France
| | - Bernard Combe
- Department of Rheumatology, Montpellier I University; Lapeyronie Hospital, Montpellier, France
| | - Xavier Le Loet
- Rheumatology Department, Rouen University Hospital & INSERM U905, Institute for Research and Innovation in Biomedicine, Rouen University, Rouen, France
| | - Alain Saraux
- Department of Rheumatology, Brest University, La Cavale Blanche University Hospital, Brest, France
- INSERM ESPRI, ERI29 Université Bretagne Occidentale, Brest, France
| | - Francis Guillemin
- EA 4360 APEMAC, Lorraine University, Paris-Descartes University, Nancy, France
- Faculty of Medicine, CS 50184, 54505 Vandoeuvre-lès-Nancy & Inserm, CIC-EC, CHU de Brabois, 54505 Vandoeuvre-lès-Nancy, Nancy, France
| | - Bruno Fautrel
- Université Pierre et Marie Curie (UPMC)—Paris 6, GRC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
- Department of Rheumatology, Pitié Salpêtrière Hospital, Paris, France
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Singh JA, Hossain A, Tanjong Ghogomu E, Kotb A, Christensen R, Mudano AS, Maxwell LJ, Shah NP, Tugwell P, Wells GA. Biologics or tofacitinib for rheumatoid arthritis in incomplete responders to methotrexate or other traditional disease-modifying anti-rheumatic drugs: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2016; 2016:CD012183. [PMID: 27175934 PMCID: PMC7068903 DOI: 10.1002/14651858.cd012183] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This is an update of the 2009 Cochrane overview and network meta-analysis (NMA) of biologics for rheumatoid arthritis (RA). OBJECTIVES To assess the benefits and harms of nine biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib, versus comparator (MTX, DMARD, placebo (PL), or a combination) in adults with rheumatoid arthritis who have failed to respond to methotrexate (MTX) or other disease-modifying anti-rheumatic drugs (DMARDs), i.e., MTX/DMARD incomplete responders (MTX/DMARD-IR). METHODS We searched for randomized controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (via The Cochrane Library Issue 6, June 2015), MEDLINE (via OVID 1946 to June 2015), and EMBASE (via OVID 1947 to June 2015). Data extraction, risk of bias and GRADE assessments were done in duplicate. We calculated both direct estimates using standard meta-analysis and used Bayesian mixed treatment comparisons approach for NMA estimates to calculate odds ratios (OR) and 95% credible intervals (CrI). We converted OR to risk ratios (RR) which are reported in the abstract for the ease of interpretation. MAIN RESULTS This update included 73 new RCTs for a total of 90 RCTs; 79 RCTs with 32,874 participants provided usable data. Few trials were at high risk of bias for blinding of assessors/participants (13% to 21%), selective reporting (4%) or major baseline imbalance (8%); a large number had unclear risk of bias for random sequence generation (68%) or allocation concealment (74%).Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a statistically significant and clinically meaningful improvement in ACR50 versus comparator (RR 2.71 (95% confidence interval (CI) 2.36 to 3.10); absolute benefit 24% more patients (95% CI 19% to 29%), number needed to treat for an additional beneficial outcome (NNTB) = 5 (4 to 6). NMA estimates for ACR50 in tumor necrosis factor (TNF) biologic+MTX/DMARD (RR 3.23 (95% credible interval (Crl) 2.75 to 3.79), non-TNF biologic+MTX/DMARD (RR 2.99; 95% Crl 2.36 to 3.74), and anakinra + MTX/DMARD (RR 2.37 (95% Crl 1.00 to 4.70) were similar to the direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a clinically and statistically important improvement in function measured by the Health Assessment Questionnaire (0 to 3 scale, higher = worse function) with a mean difference (MD) based on direct evidence of -0.25 (95% CI -0.28 to -0.22); absolute benefit of -8.3% (95% CI -9.3% to -7.3%), NNTB = 3 (95% CI 2 to 4). NMA estimates for TNF biologic+MTX/DMARD (absolute benefit, -10.3% (95% Crl -14% to -6.7%) and non-TNF biologic+MTX/DMARD (absolute benefit, -7.3% (95% Crl -13.6% to -0.67%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with clinically and statistically significantly greater proportion of participants achieving remission in RA (defined by disease activity score DAS < 1.6 or DAS28 < 2.6) versus comparator (RR 2.81 (95% CI, 2.23 to 3.53); absolute benefit 18% more patients (95% CI 12% to 25%), NNTB = 6 (4 to 9)). NMA estimates for TNF biologic+MTX/DMARD (absolute improvement 17% (95% Crl 11% to 23%)) and non-TNF biologic+MTX/DMARD (absolute improvement 19% (95% Crl 12% to 28%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), radiographic progression (scale 0 to 448) was statistically significantly reduced in those on biologics + MTX/DMARDs versus comparator, MD -2.61 (95% CI -4.08 to -1.14). The absolute reduction was small, -0.58% (95% CI -0.91% to -0.25%) and we are unsure of the clinical relevance of this reduction. NMA estimates of TNF biologic+MTX/DMARD (absolute reduction -0.67% (95% Crl -1.4% to -0.12%) and non-TNF biologic+MTX/DMARD (absolute reduction, -0.68% (95% Crl -2.36% to 0.92%)) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for imprecision), results for withdrawals due to adverse events were inconclusive, with wide confidence intervals encompassing the null effect and evidence of an important increase in withdrawals, RR 1.11 (95% CI 0.96 to 1.30). The NMA estimates of TNF biologic+MTX/DMARD (RR 1.24 (95% Crl 0.99 to 1.57)) and non-TNF biologic+MTX/DMARD (RR 1.20 (95% Crl 0.87 to 1.67)) were similarly inconclusive and downgraded to low for both imprecision and indirectness.Based on direct evidence of high quality, biologic+MTX/DMARD was associated with clinically significantly increased risk (statistically borderline significant) of serious adverse events on biologic+MTX/DMARD (Peto OR [can be interpreted as RR due to low event rate] 1.12 (95% CI 0.99 to 1.27); absolute risk 1% (0% to 2%), As well, the NMA estimate for TNF biologic+MTX/DMARD (Peto OR 1.20 (95% Crl 1.01 to 1.43)) showed moderate quality evidence of an increase in the risk of serious adverse events. The other two NMA estimates were downgraded to low quality due to imprecision and indirectness and had wide confidence intervals resulting in uncertainty around the estimates: non-TNF biologics + MTX/DMARD: 1.07 (95% Crl 0.89 to 1.29) and anakinra: RR 1.06 (95% Crl 0.65 to 1.75).Based on direct evidence of low quality (downgraded for serious imprecision), results were inconclusive for cancer (Peto OR 1.07 (95% CI 0.68 to 1.68) for all biologic+MTX/DMARD combinations. The NMA estimates of TNF biologic+MTX/DMARD (Peto OR 1.21 (95% Crl 0.63 to 2.38) and non-TNF biologic+MTX/DMARD (Peto OR 0.99 (95% Crl 0.58 to 1.78)) were similarly inconclusive and downgraded to low quality for both imprecision and indirectness.Main results text shows the results for tofacitinib and differences between medications. AUTHORS' CONCLUSIONS Based primarily on RCTs of 6 months' to 12 months' duration, there is moderate quality evidence that the use of biologic+MTX/DMARD in people with rheumatoid arthritis who have failed to respond to MTX or other DMARDs results in clinically important improvement in function and higher ACR50 and remission rates, and increased risk of serious adverse events than the comparator (MTX/DMARD/PL; high quality evidence). Radiographic progression is slowed but its clinical relevance is uncertain. Results were inconclusive for whether biologics + MTX/DMARDs are associated with an increased risk of cancer or withdrawals due to adverse events.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterDepartment of MedicineFaculty Office Tower 805B510 20th Street SouthBirminghamALUSA35294
| | - Alomgir Hossain
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | | | - Ahmed Kotb
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | - Robin Christensen
- Copenhagen University Hospital, Bispebjerg og FrederiksbergMusculoskeletal Statistics Unit, The Parker InstituteNordre Fasanvej 57CopenhagenDenmarkDK‐2000
| | - Amy S Mudano
- University of Alabama at BirminghamDepartment of Medicine ‐ RheumatologyBirminghamUSA
| | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Nipam P Shah
- University of Alabama at BirminghamDepartment of Clinical Immunology and RheumatologyFaculty Office Tower, Suite 805, 510 20th Street SouthBirminghamALUSA35294
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
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West J, Ogston S, Foerster J. Safety and Efficacy of Methotrexate in Psoriasis: A Meta-Analysis of Published Trials. PLoS One 2016; 11:e0153740. [PMID: 27168193 PMCID: PMC4864230 DOI: 10.1371/journal.pone.0153740] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/04/2016] [Indexed: 01/19/2023] Open
Abstract
Background Methotrexate (MTX) has been used to treat psoriasis for over half a century. Even so, clinical data characterising its efficacy and safety are sparse. Objective In order to enhance the available evidence, we conducted two meta-analyses, one for efficacy and one for safety outcomes, respectively, according to PRISMA checklist. (Data sources, study criteria, and study synthesis methods are detailed in Methods). Results In terms of efficacy, only eleven studies met criteria for study design and passed a Cochrane risk of bias analysis. Based on this limited dataset, 45.2% [95% confidence interval 34.1–60.0] of patients achieve PASI75 at primary endpoint (12 or 16 weeks, respectively, n = 705 patients across all studies), compared to a calculated PASI75 of 4.4 [3.5–5.6] for placebo, yielding a relative risk of 10.2 [95% C.I. 7.1–14.7]. For safety outcomes, we extended the meta-analysis to include studies employing the same dose range of MTX for other chronic inflammatory conditions, e.g. rheumatoid arthritis, in order not to maximise capture of relevant safety data. Based on 2763 patient safety years, adverse events (AEs) were found treatment limiting in 6.9 ± 1.4% (mean ± s.e.) of patients treated for six months, with an adverse effect profile largely in line with that encountered in clinical practice. Finally, in order to facilitate prospective clinical audit and to help generate long-term treatment outcomes under real world conditions, we also developed an easy to use documentation form to be completed by patients without requirement for additional staff time. Limitations Meta-analyses for efficacy and safety, respectively, employed non-identical selection criteria. Conclusions These meta-analyses summarise currently available evidence on MTX in psoriasis and should be of use to gauge whether local results broadly fall within outcomes.
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Affiliation(s)
- Jonathan West
- University of Dundee, College of Medicine, Dentistry, and Nursing, Dundee, Scotland
| | - Simon Ogston
- University of Dundee, College of Medicine, Dentistry, and Nursing, Dundee, Scotland
| | - John Foerster
- University of Dundee, College of Medicine, Dentistry, and Nursing, Dundee, Scotland
- Department of Dermatology and Photobiology, NHS Tayside, Dundee, Scotland
- * E-mail:
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165
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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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Naniwa T, Iwagaitsu S, Kajiura M. Efficacy of add-on tacrolimus on methotrexate to maintain clinical remission after rediscontinuation of a tumor necrosis factor inhibitor in rheumatoid arthritis patients who relapsed shortly after discontinuation of the same tumor necrosis factor inhibitor due to clinical remission. Mod Rheumatol 2016; 27:29-34. [PMID: 27143107 DOI: 10.3109/14397595.2016.1174394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To describe the efficacy of adding tacrolimus to maintain remission in patients with rheumatoid arthritis (RA) on methotrexate after discontinuation of tumor necrosis factor inhibitor (TNFi) therapy. METHODS Consecutive patients with RA, who resumed a TNFi to treat flares after initial TNFi-free remission and discontinued a TNFi again after achieving remission and adding tacrolimus were enrolled. The lengths of remission after discontinuation of TNFi without or with tacrolimus were analyzed. RESULTS Thirteen TNFi-free periods in six patients, in which seven were without and six were with tacrolimus were analyzed. All were seropositive females with a median age of 46 years and symptom duration of 1.2 years at the onset of TNFi therapy. Two were treated with infliximab and four were with etanercept. The median dose of tacrolimus was 2 mg/day with trough level of 4.5 ng/ml. The length of time to flare after discontinuation of TNFi therapy with tacrolimus was significantly longer than those without tacrolimus (median 107 weeks [range 4-207] versus 13 weeks [2-36]). After adding tacrolimus, only one patient resumed TNFi therapy and three had no flare until final observation. CONCLUSIONS Add-on tacrolimus was effective in maintaining TNFi-free remission in patients with RA who ever relapsed after TNFi-free remission.
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Affiliation(s)
- Taio Naniwa
- a Division of Rheumatology , Nagoya City University Hospital , Nagoya , Aichi , Japan.,b Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya , Aichi , Japan , and.,c Takeuchi Orthopedics and Internal Medicine , Chita , Aichi , Japan
| | - Shiho Iwagaitsu
- a Division of Rheumatology , Nagoya City University Hospital , Nagoya , Aichi , Japan.,b Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya , Aichi , Japan , and
| | - Mikiko Kajiura
- c Takeuchi Orthopedics and Internal Medicine , Chita , Aichi , Japan
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Yun H, Xie F, Delzell E, Levitan EB, Chen L, Lewis JD, Saag KG, Beukelman T, Winthrop KL, Baddley JW, Curtis JR. Comparative Risk of Hospitalized Infection Associated With Biologic Agents in Rheumatoid Arthritis Patients Enrolled in Medicare. Arthritis Rheumatol 2016; 68:56-66. [PMID: 26315675 DOI: 10.1002/art.39399] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/18/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The risks of hospitalized infection associated with biologic agents used to treat rheumatoid arthritis (RA) are unclear. The aim of this study was to determine whether the associated risk of hospitalized infections differed between specific biologic agents used to treat RA. METHODS In a retrospective cohort study using Medicare data from 2006-2011 for all enrolled patients with RA, new episodes of treatment with etanercept, adalimumab, certolizumab, golimumab, infliximab, abatacept, rituximab, and tocilizumab were identified. Patients were required to have received another biologic agent previously and to have been continuously enrolled in Medicare medical and pharmacy plans during the baseline period and throughout followup. Followup started on the date of initiation of treatment with the new biologic agent (after previous treatment with a different biologic agent) and ended on the date of the earliest hospitalized infection, at 12 months, after an exposure gap of >30 days, or at the time of death or loss of Medicare coverage. Cox regression analysis was used to calculate the adjusted hazard ratio (HR) for hospitalized infection, adjusting for an infection risk score and other confounders. RESULTS Of 31,801 new biologic treatment episodes in patients who had previously received another biologic agent, 12.0% were with etanercept, 15.2% with adalimumab, 5.9% with certolizumab, 4.4% with golimumab, 12.4% with infliximab, 28.9% with abatacept, 14.8% with rituximab, and 6.3% with tocilizumab. During followup, we identified 2,530 hospitalized infections; incidence rates ranged from 13.1 per 100 person-years (abatacept) to 18.7 per 100 person-years (rituximab). After adjustment, etanercept (HR 1.24, 95% confidence interval [95% CI] 1.07-1.45), infliximab (HR 1.39, 95% CI 1.21-1.60), and rituximab (HR 1.36, 95% CI 1.21-1.53) had significantly higher HRs for hospitalized infection compared with abatacept. CONCLUSION In RA patients with prior exposure to a biologic agent, exposure to etanercept, infliximab, or rituximab was associated with a greater 1-year risk of hospitalized infection compared with the risk associated with exposure to abatacept.
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Economic Burden of Switching to a Non-Tumor Necrosis Factor Inhibitor Versus a Tumor Necrosis Factor Inhibitor Biologic Therapy among Patients with Rheumatoid Arthritis. Adv Ther 2016; 33:807-23. [PMID: 27084724 DOI: 10.1007/s12325-016-0318-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The objective of this study was to examine healthcare resource utilization (HRU) and costs associated with switching to another tumor necrosis factor alpha inhibitor (TNFi) therapy versus a non-TNFi therapy among patients with rheumatoid arthritis (RA) discontinuing use of an initial TNFi biologic therapy. METHODS Patients with ≥2 RA diagnoses who used ≥1 TNFi on or after their initial RA diagnosis were identified in a US employer-based insurance claims database. Patients were selected based on ≥1 claim of another TNFi or a non-TNFi biologic therapy (occurring after 2010, and within 30 days before to 60 days after discontinuation of the initial TNFi), and continuous insurance ≥6 months before (baseline period) and ≥12 months after the switch date (study period). Patient demographic and clinical characteristics were measured during the baseline period. All-cause and RA-related HRU and costs were analyzed during the 12-month study period using multivariable regression analysis controlling for baseline characteristics and selected comorbidities. RESULTS Of the 1577 patients with RA that switched therapies, 1169 patients used another TNFi and 408 patients used a non-TNFi biologic. The most commonly used initial TNFi treatments were etanercept (50%) and adalimumab (34%) among the TNFi cohort, and infliximab (39%) and etanercept (28%) among the non-TNFi cohort. The TNFi cohort had significantly fewer outpatient visits [all-cause: 23.01 vs. 29.77 visits/patient/year; adjusted incidence rate ratio (IRR) = 0.78, P < 0.001; RA-related: 7.42 vs. 13.58; adjusted IRR = 0.58, P < 0.001] and rheumatologist visits (all-cause: 4.01 vs. 6.81; adjusted IRR = 0.66, P < 0.001; RA-related: 3.23 vs. 6.40; adjusted IRR = 0.58, P < 0.001) than the non-TNFi cohort. All-cause total costs were significantly lower for patients who switched to another TNFi instead of a non-TNFi therapy ($36,932 vs. $44,566; adjusted difference = $7045, P < 0.01), as were total RA-related costs ($26,973 vs. $31,735; adjusted difference = $4904, P < 0.01). CONCLUSION Adult patients with RA discontinuing TNFi therapy who switched to an alternative TNFi incurred lower healthcare costs than patients who switched to a non-TNFi biologic. FUNDING AbbVie, Inc.
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Yoo DH, Prodanovic N, Jaworski J, Miranda P, Ramiterre E, Lanzon A, Baranauskaite A, Wiland P, Abud-Mendoza C, Oparanov B, Smiyan S, Kim H, Lee SJ, Kim S, Park W. Efficacy and safety of CT-P13 (biosimilar infliximab) in patients with rheumatoid arthritis: comparison between switching from reference infliximab to CT-P13 and continuing CT-P13 in the PLANETRA extension study. Ann Rheum Dis 2016; 76:355-363. [PMID: 27130908 PMCID: PMC5284338 DOI: 10.1136/annrheumdis-2015-208786] [Citation(s) in RCA: 209] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 04/07/2016] [Accepted: 04/09/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess the efficacy and safety of switching from the infliximab reference product (RP; Remicade) to its biosimilar CT-P13 (Remsima, Inflectra) or continuing CT-P13 in patients with rheumatoid arthritis (RA) for an additional six infusions. METHODS This open-label extension study recruited patients with RA who had completed the 54-week, randomised, parallel-group study comparing CT-P13 with RP (PLANETRA; NCT01217086). CT-P13 (3 mg/kg) was administered intravenously every 8 weeks from weeks 62 to 102. All patients received concomitant methotrexate. Endpoints included American College of Rheumatology 20% (ACR20) response, ACR50, ACR70, immunogenicity and safety. Data were analysed for patients who received CT-P13 for 102 weeks (maintenance group) and for those who received RP for 54 weeks and then switched to CT-P13 (switch group). RESULTS Overall, 302 of 455 patients who completed the PLANETRA study enrolled into the extension. Of these, 158 had received CT-P13 (maintenance group) and 144 RP (switch group). Response rates at week 102 for maintenance versus switch groups, respectively, were 71.7% vs 71.8% for ACR20, 48.0% vs 51.4% for ACR50 and 24.3% vs 26.1% for ACR70. The proportion of patients with antidrug antibodies was comparable between groups (week 102: 40.3% vs 44.8%, respectively). Treatment-emergent adverse events occurred in similar proportions of patients in the two groups during the extension study (53.5% and 53.8%, respectively). CONCLUSIONS Comparable efficacy and tolerability were observed in patients who switched from RP to its biosimilar CT-P13 for an additional year and in those who had long-term CT-P13 treatment for 2 years. TRIAL REGISTRATION NUMBER NCT01571219; Results.
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Affiliation(s)
- Dae Hyun Yoo
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | | | | | - Pedro Miranda
- Universidad de Chile and Centro de Estudios Reumatologicos, Santiago de Chile, Chile
| | | | - Allan Lanzon
- Mary Mediatrix Medical Center, Batangas, Philippines
| | | | | | - Carlos Abud-Mendoza
- Hospital Central and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
| | | | - Svitlana Smiyan
- I.Ya. Horbachevsky Ternopil State Medical University, Municipal Institution of Ternopil Regional Council "Ternopil University Hospital", Ternopil, Ukraine
| | - HoUng Kim
- CELLTRION, Incheon, Republic of Korea
| | | | | | - Won Park
- IN-HA University, School of Medicine, Medicine/Rheumatology, Incheon, Republic of Korea
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Nawata M, Saito K, Fukuyo S, Hirata S, Tanaka Y. Clinically relevant radiographic progression in joint destruction in RA patients with abnormal MMP-3 or high levels of CRP despite 1-year treatment with infliximab. Mod Rheumatol 2016; 26:807-812. [PMID: 26915532 DOI: 10.3109/14397595.2016.1158386] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Identify the independently related factors of joint destruction progression in RA patients despite of infliximab treatment. METHODS The subjects were cases who underwent infliximab treatment for one year or longer in our department (n = 244). Patients in which modified total sharp score (mTSS), joint erosion (JE), and joint space narrowing (JSN) had advanced to the standard value (3.0) or more for one year were defined as mTSS- Clinically-Relevant-Rapid Progression (CRRP) (n = 20), JE-CRRP (n = 20), and JSN-CRRP (n = 23), and the respective related factors at baseline and week 54 were defined by multiple logistic regression. RESULTS The median disease duration was 24 months and median mTSS 9.0 at baseline. The median DAS28, CRP, and yearly progression of mTSS improved from 5.8 to 2.6, 1.2 to 0.1 mg/dL, and 4.4 to 0.0 point/year, respectively. The related factor in each of mTSS-CRRP, JE-CRRP, and JSN-CRRP was high CRP levels at baseline. At week 54, the related factor of mTSS-CRRP and JSN-CRRP was high MMP-3 titer; however, the related factor of JE-CRRP was high CRP levels. CONCLUSION High CRP levels at baseline were an independent predictive factor of joint destruction advancement during infliximab treatment. Moreover, it was believed that abnormal MMP-3 at week 54 was the index for mTSS and JSN advancement, while high CRP levels were the index for JE advancement.
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Affiliation(s)
- Masao Nawata
- a The First Department of Internal Medicine , University of Occupational and Environmental Health , Kitakyushu , Japan
| | - Kazuyoshi Saito
- a The First Department of Internal Medicine , University of Occupational and Environmental Health , Kitakyushu , Japan
| | - Shunsuke Fukuyo
- a The First Department of Internal Medicine , University of Occupational and Environmental Health , Kitakyushu , Japan
| | - Shintaro Hirata
- a The First Department of Internal Medicine , University of Occupational and Environmental Health , Kitakyushu , Japan
| | - Yoshiya Tanaka
- a The First Department of Internal Medicine , University of Occupational and Environmental Health , Kitakyushu , Japan
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Quintana-Duque MA, Rondon-Herrera F, Mantilla RD, Calvo-Paramo E, Yunis JJ, Varela-Nariño A, Restrepo JF, Iglesias-Gamarra A. Predictors of remission, erosive disease and radiographic progression in a Colombian cohort of early onset rheumatoid arthritis: a 3-year follow-up study. Clin Rheumatol 2016; 35:1463-73. [PMID: 27041382 DOI: 10.1007/s10067-016-3246-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/14/2016] [Accepted: 03/22/2016] [Indexed: 12/22/2022]
Abstract
The objective of the study is to find predictors of remission, radiographic progression (RP), and erosive disease in a cohort of patients with early onset rheumatoid arthritis (EORA) that followed a therapeutic protocol aiming at remission, in a real world tight-control setting. EORA patients were enrolled in a 3-year follow-up study. Clinical, biological, immunogenetic, and radiographical data were analyzed. Radiographs were scored according to Sharp-van der Heijde (SvdH) method. RP was defined by an increase of 3 units in 36 months. Remission was defined as DAS28 <2.6. A stepwise multiple logistic regression model was used to identify independent predictors of the three target outcomes. One hundred twenty-nine patients were included. Baseline disease activity was high. Significant overall improvement was observed, but only 33.3 % achieved remission. At 36 month, 50.4 % (65) of patients showed erosions. RP was observed in 62.7 % (81) of cases. Statistical analysis showed that baseline SvdH score was the only predictive factor associated with the three outcomes evaluated. Lower HAQ-DI and absence of autoantibodies were predictive of remission. Higher levels of ESR and presence of erosions at entry were predictive of RP. Independent baseline predictors of incident erosive disease were anti-CCP and RF positivity, symptom duration at baseline >3 months, and presence of HLA-DRB1 shared epitope. Radiographic damage at baseline was the main predictor of outcomes. Autoantibodies, HAQ and ESR at baseline, symptom duration before diagnosis, and HLA-DRB1 status had influence on clinical course and development of structural joint damage in Colombian RA patients.
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Affiliation(s)
- M A Quintana-Duque
- Rheumatology Unit, Faculty of Medicine, National University of Colombia, Cra. 30 No. 45-03, Bldg 471, 5th Floor, Office 510, Bogota, Colombia.
| | - F Rondon-Herrera
- Rheumatology Unit, Faculty of Medicine, National University of Colombia, Cra. 30 No. 45-03, Bldg 471, 5th Floor, Office 510, Bogota, Colombia
| | - R D Mantilla
- Rheumatology Unit, Faculty of Medicine, National University of Colombia, Cra. 30 No. 45-03, Bldg 471, 5th Floor, Office 510, Bogota, Colombia
| | - E Calvo-Paramo
- Radiology Unit, Faculty of Medicine, National University of Colombia, Bogota, Colombia
| | - J J Yunis
- Pathology unit, Genetic Institute, Faculty of Medicine, National University of Colombia, Bogota, Colombia
| | - A Varela-Nariño
- Rheumatology Unit, Faculty of Medicine, National University of Colombia, Cra. 30 No. 45-03, Bldg 471, 5th Floor, Office 510, Bogota, Colombia
| | - J F Restrepo
- Rheumatology Unit, Faculty of Medicine, National University of Colombia, Cra. 30 No. 45-03, Bldg 471, 5th Floor, Office 510, Bogota, Colombia
| | - A Iglesias-Gamarra
- Rheumatology Unit, Faculty of Medicine, National University of Colombia, Cra. 30 No. 45-03, Bldg 471, 5th Floor, Office 510, Bogota, Colombia
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Boers M, Aletaha D, Mela CM, Baker DG, Smolen JS. Glucocorticoid Effect on Radiographic Progression in Placebo Arms of Rheumatoid Arthritis Biologics Trials. J Rheumatol 2016; 43:1024-6. [PMID: 27036379 DOI: 10.3899/jrheum.150932] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the effect of glucocorticoids (GC) on damage progression in placebo-biologic arms of rheumatoid arthritis (RA) biologics trials. METHODS Posthoc metaanalysis of 2 infliximab (IFX) trials (established and early RA) and 1 tocilizumab (TCZ) trial (established RA). RESULTS The proportion of patients receiving GC was 38%-64%, baseline damage was 11-82 Sharp/van der Heijde points, and progression in the placebo groups was 0.5-4.8 points in 6 months. In the pooled IFX studies, GC cotreatment reduced 6-month progression by 2.6 points (95% CI 0.6-4.5). In the TCZ study (progression rate 0.5 Genant points), no such difference was seen. CONCLUSION GC cotreatment may affect results in RA trials.
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Affiliation(s)
- Maarten Boers
- From the Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands; Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria; Roche Products Ltd., Welwyn Garden City, UK; Janssen Research and Development, Spring House, Pennsylvania, USA.M. Boers, MD, PhD, MSc, Professor of Clinical Epidemiology, Department of Epidemiology and Biostatistics, VU University Medical Center; D. Aletaha, MD, MSc, Associate Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna; C.M. Mela, PhD, MSc, BSc, Clinical Development Scientist, Roche Products Ltd.; D.G. Baker, MD, Vice President Immunology, Janssen Research and Development; J.S. Smolen, MD, Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna.
| | - Daniel Aletaha
- From the Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands; Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria; Roche Products Ltd., Welwyn Garden City, UK; Janssen Research and Development, Spring House, Pennsylvania, USA.M. Boers, MD, PhD, MSc, Professor of Clinical Epidemiology, Department of Epidemiology and Biostatistics, VU University Medical Center; D. Aletaha, MD, MSc, Associate Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna; C.M. Mela, PhD, MSc, BSc, Clinical Development Scientist, Roche Products Ltd.; D.G. Baker, MD, Vice President Immunology, Janssen Research and Development; J.S. Smolen, MD, Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna
| | - Christopher M Mela
- From the Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands; Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria; Roche Products Ltd., Welwyn Garden City, UK; Janssen Research and Development, Spring House, Pennsylvania, USA.M. Boers, MD, PhD, MSc, Professor of Clinical Epidemiology, Department of Epidemiology and Biostatistics, VU University Medical Center; D. Aletaha, MD, MSc, Associate Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna; C.M. Mela, PhD, MSc, BSc, Clinical Development Scientist, Roche Products Ltd.; D.G. Baker, MD, Vice President Immunology, Janssen Research and Development; J.S. Smolen, MD, Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna
| | - Daniel G Baker
- From the Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands; Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria; Roche Products Ltd., Welwyn Garden City, UK; Janssen Research and Development, Spring House, Pennsylvania, USA.M. Boers, MD, PhD, MSc, Professor of Clinical Epidemiology, Department of Epidemiology and Biostatistics, VU University Medical Center; D. Aletaha, MD, MSc, Associate Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna; C.M. Mela, PhD, MSc, BSc, Clinical Development Scientist, Roche Products Ltd.; D.G. Baker, MD, Vice President Immunology, Janssen Research and Development; J.S. Smolen, MD, Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna
| | - Josef S Smolen
- From the Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands; Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria; Roche Products Ltd., Welwyn Garden City, UK; Janssen Research and Development, Spring House, Pennsylvania, USA.M. Boers, MD, PhD, MSc, Professor of Clinical Epidemiology, Department of Epidemiology and Biostatistics, VU University Medical Center; D. Aletaha, MD, MSc, Associate Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna; C.M. Mela, PhD, MSc, BSc, Clinical Development Scientist, Roche Products Ltd.; D.G. Baker, MD, Vice President Immunology, Janssen Research and Development; J.S. Smolen, MD, Professor of Medicine, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna
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Yoo DH, Racewicz A, Brzezicki J, Yatsyshyn R, Arteaga ET, Baranauskaite A, Abud-Mendoza C, Navarra S, Kadinov V, Sariego IG, Hong SS, Lee SY, Park W. A phase III randomized study to evaluate the efficacy and safety of CT-P13 compared with reference infliximab in patients with active rheumatoid arthritis: 54-week results from the PLANETRA study. Arthritis Res Ther 2016; 18:82. [PMID: 27038608 PMCID: PMC4818886 DOI: 10.1186/s13075-016-0981-6] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/23/2016] [Indexed: 02/08/2023] Open
Abstract
Background CT-P13 (Remsima®, Inflectra®) is a biosimilar of the infliximab reference product (RP; Remicade®). The aim of this study was to compare the 54-week efficacy, immunogenicity, safety, pharmacokinetics (PK) and pharmacodynamics (PD) of CT-P13 and RP in patients with active rheumatoid arthritis (RA). Methods In this multinational phase III double-blind study, patients with active RA and an inadequate response to methotrexate (MTX) were randomized (1:1) to receive CT-P13 (3 mg/kg) or RP (3 mg/kg) at weeks 0, 2, 6 and then every 8 weeks to week 54 in combination with MTX (12.5–25 mg/week). Efficacy endpoints included American College of Rheumatology (ACR)20, ACR50 and ACR70 response rates, Disease Activity Score in 28 joints (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), European League Against Rheumatism (EULAR) response rates, patient-reported outcomes and joint damage progression. Immunogenicity, safety and PK/PD outcomes were also assessed. Results Of 606 randomized patients, 455 (CT-P13 233, RP 222) were treated up to week 54. At week 54, ACR20 response rate was highly similar between groups (CT-P13 74.7 %, RP 71.3 %). ACR50 and ACR70 response rates were also comparable between groups (CT-P13 43.6 % and 21.3 %, respectively; RP 43.1 % and 19.9 %, respectively). DAS28, SDAI and CDAI decreased from baseline to week 54 to a similar extent with CT-P13 and RP. Radiographic progression measured by Sharp scores as modified by van der Heijde was also comparable. With both treatments, patient assessments of pain, disease activity and physical ability, as well as mean scores on the Medical Outcomes Study Short Form Health Survey (SF-36), improved markedly at week 14 and remained stable thereafter up to week 54. The proportion of patients positive for antidrug antibodies at week 54 was similar between the two groups: 41.1 % and 36.0 % with CT-P13 and RP, respectively. CT-P13 was well tolerated and had a similar safety profile to RP. PK/PD results were also comparable between CT-P13 and RP. Conclusions CT-P13 and RP were comparable in terms of efficacy (including radiographic progression), immunogenicity and PK/PD up to week 54. The safety profile of CT-P13 was also similar to that of RP. Trial registration ClinicalTrials.gov identifier: NCT01217086. Registered 4 Oct 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-0981-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dae Hyun Yoo
- Hanyang University Hospital, Seoul, Republic of Korea
| | | | | | - Roman Yatsyshyn
- Ivano-Frankivsk Regional Clinical Hospital, Ivano-Frankivsk, Ukraine
| | | | | | | | | | | | | | | | | | - Won Park
- Inha University Hospital, Incheon, Republic of Korea.
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Hirata S, Li W, Kubo S, Fukuyo S, Mizuno Y, Hanami K, Sawamukai N, Yamaoka K, Saito K, Defranoux NA, Tanaka Y. Association of the multi-biomarker disease activity score with joint destruction in patients with rheumatoid arthritis receiving tumor necrosis factor-alpha inhibitor treatment in clinical practice. Mod Rheumatol 2016; 26:850-856. [DOI: 10.3109/14397595.2016.1153449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Shintaro Hirata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | - Wanying Li
- Crescendo Bioscience Inc., South San Francisco, CA, USA
| | - Satoshi Kubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | - Shunsuke Fukuyo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | - Yasushi Mizuno
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | - Kentaro Hanami
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | - Norifumi Sawamukai
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | - Kunihiro Yamaoka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | - Kazuyoshi Saito
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
| | | | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan and
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Utilization of nanoparticle technology in rheumatoid arthritis treatment. Biomed Pharmacother 2016; 80:30-41. [PMID: 27133037 DOI: 10.1016/j.biopha.2016.03.004] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is one of the common and severe autoimmune diseases related to joints. This chronic autoimmune inflammatory disease, leads to functional limitation and reduced quality of life, since as there is bone and cartilage destruction, joint swelling and pain. Current advances and new treatment approaches have considerably postponed disease progression and improved the quality of life for many patients. In spite of major advances in therapeutic options, restrictions on the routes of administration and the necessity for frequent and long-term dosing often result in systemic adverse effects and patient non-compliance. Unlike usual drugs, nanoparticle systems are planned to deliver therapeutic agents especially to inflamed synovium, so avoiding systemic and unpleasant effects. The present review discusses about some of the most successful drugs in RA therapy and their side effects and also focuses on key design parameters of RA-targeted nanotechnology-based strategies for improving RA therapies.
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Gossen N, Jacob L, Kostev K. Second-line therapy with biological drugs in rheumatoid arthritis patients in German rheumatologist practices: a retrospective database analysis. Rheumatol Int 2016; 36:1113-8. [DOI: 10.1007/s00296-016-3448-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 02/18/2016] [Indexed: 12/19/2022]
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Katayama K, Okubo T, Sato T, Kamiya K, Fukai R, Abe S, Ito H, Makino Y, Kamishima T. One-year maintenance with routine assessment of patient index data 3-based remission may inhibit radiographic progression in patients with rheumatoid arthritis treated with routine clinical therapy: A retrospective comparison of radiographic outcome and its prognostic factors between maintained remissions with patient-reported outcome index and physician-oriented disease activity indices. Mod Rheumatol 2016; 26:817-827. [PMID: 26915909 DOI: 10.3109/14397595.2016.1158766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We investigated whether the maintenance of routine assessment of patient index data 3 (RAPID3) remission for one year (RAPID3-MR) may predict good radiographic outcomes. We also compared radiographic progression to prognostic factors among patients with RAPID3-MR, with the maintenance of clinical disease activity index remission for one year (CDAI-MR) or with the maintenance of 28 joint count disease activity score remission for one year (DAS28-MR). METHODS Of 1220 patients with available clinical data, 92 with RAPID3-MR, 80 with RAPID3-NMR (not satisfying RAPID3-MR), 45 with CDAI-MR, and 75 with DAS28-MR were retrospectively investigated. CDAI and DAS28 for clinical outcomes and the modified total Sharp score (mTSS) for radiographic joint damage were investigated for at least one year. RESULTS RAPID3, CDAI, DAS28, and their categories remained unchanged or significantly improved in RAPID3-MR patients but significantly deteriorated in RAPID3-NMR patients. The mean annual ΔmTSS was significantly lower in RAPID3-MR patients (0.12 ± 0.55) than in RAPID3-NMR patients (0.54 ± 1.27) (p = 0.025). There was no significant difference among RAPID3-MR patients, CDAI-MR patients (0.06 ± 0.85), and DAS28-MR patients (0.11 ± 0.89). The baseline mTSS (p = 0.038) and monotherapy with nonbiological disease-modifying antirheumatic drugs (p = 0.033) were good prognostic factors in RAPID3-MR patients. CONCLUSIONS One-year RAPID3 remission maintenance may predict good radiographic outcomes.
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Affiliation(s)
- Kou Katayama
- a Katayama Orthopedic Rheumatology Clinic , Hokkaido , Japan
| | - Takanobu Okubo
- a Katayama Orthopedic Rheumatology Clinic , Hokkaido , Japan
| | - Toshikazu Sato
- a Katayama Orthopedic Rheumatology Clinic , Hokkaido , Japan
| | - Kiyomi Kamiya
- a Katayama Orthopedic Rheumatology Clinic , Hokkaido , Japan
| | | | - Satomi Abe
- c Department of Orthopedic Surgery , Asahikawa Medical University , Hokkaido , Japan
| | - Hiroshi Ito
- c Department of Orthopedic Surgery , Asahikawa Medical University , Hokkaido , Japan
| | - Yuichi Makino
- d Department of Medicine, Division of Metabolism and Biosystemic Science , Asahikawa Medical University , Hokkaido , Japan , and
| | - Tamotsu Kamishima
- e Faculty of Health Science , Hokkaido University , Hokkaido , Japan
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Tanaka Y, Yamanaka H, Ishiguro N, Miyasaka N, Kawana K, Hiramatsu K, Takeuchi T. Adalimumab discontinuation in patients with early rheumatoid arthritis who were initially treated with methotrexate alone or in combination with adalimumab: 1 year outcomes of the HOPEFUL-2 study. RMD Open 2016; 2:e000189. [PMID: 26925252 PMCID: PMC4762209 DOI: 10.1136/rmdopen-2015-000189] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/22/2015] [Accepted: 01/16/2016] [Indexed: 11/15/2022] Open
Abstract
Objectives To evaluate the impact of discontinuation of adalimumab (ADA) for 1 year in Japanese patients with early rheumatoid arthritis (RA). Methods This 52-week postmarketing study, HOPEFUL-2, enrolled patients who had completed HOPEFUL-1 for early RA, in which patients received either ADA + methotrexate (MTX) or MTX alone in a 26-week randomised phase, followed by ADA+MTX in a 26-week open-label phase. Results A total of 220 patients (ADA discontinuation: 114 patients vs ADA continuation: 106 patients) were enrolled in this study. The proportion of patients with sustained low disease activity (LDA) in the ADA discontinuation group was significantly lower than that in the continuation group (80% (64/80 patients) vs 97% (71/73 patients); p=0.001); however, most patients sustained LDA in both groups. In patients with 28-joint disease activity score (DAS28)-C reactive protein ≤2.0 at week 52, the proportion of patients who achieved sustained LDA at week 104 was 93%, suggesting that DAS28 remission may be a predictor to indicate biological-free disease control in patients with early RA. The incidence of adverse events (AE) was significantly lower in the ADA discontinuation group than in the continuation group (34.2% (39/114 patients) vs 48.1% (51/106 patients); p=0.04), most notably for infection (14.9% vs 27.4%, p=0.031). Conclusions Although ADA discontinuation was associated with an increase in disease activity, a large proportion of patients maintained LDA with MTX monotherapy after ADA discontinuation. Since ADA discontinuation was associated with a lower AE incidence, physicians should weigh the risks and benefits of ADA discontinuation. Trial registration number NCT01163292.
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine , School of Medicine, University of Occupational and Environmental Health, Japan , Kitakyushu , Japan
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery , Nagoya University Graduate School and School of Medicine , Nagoya , Japan
| | | | | | | | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine , School of Medicine, Keio University , Tokyo , Japan
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Park W, Yoo DH, Jaworski J, Brzezicki J, Gnylorybov A, Kadinov V, Sariego IG, Abud-Mendoza C, Escalante WJO, Kang SW, Andersone D, Blanco F, Hong SS, Lee SH, Braun J. Comparable long-term efficacy, as assessed by patient-reported outcomes, safety and pharmacokinetics, of CT-P13 and reference infliximab in patients with ankylosing spondylitis: 54-week results from the randomized, parallel-group PLANETAS study. Arthritis Res Ther 2016; 18:25. [PMID: 26795209 PMCID: PMC4721187 DOI: 10.1186/s13075-016-0930-4] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/08/2016] [Indexed: 12/30/2022] Open
Abstract
Background CT-P13 (Remsima®, Inflectra®) is a biosimilar of the infliximab reference product (RP; Remicade®) and is approved in Europe and elsewhere, mostly for the same indications as RP. The aim of this study was to compare the 54-week efficacy, immunogenicity, pharmacokinetics (PK) and safety of CT-P13 with RP in patients with ankylosing spondylitis (AS), with a focus on patient-reported outcomes (PROs). Methods This was a multinational, double-blind, parallel-group study in patients with active AS. Participants were randomized (1:1) to receive CT-P13 (5 mg/kg) or RP (5 mg/kg) at weeks 0, 2, 6 and then every 8 weeks up to week 54. To assess responses, standardized assessment tools were used with an intention-to-treat analysis of observed data. Anti-drug antibodies (ADAs), PK parameters, and safety outcomes were also assessed. Results Of 250 randomized patients (n = 125 per group), 210 (84.0 %) completed 54 weeks of treatment, with similar completion rates between groups. At week 54, Assessment of Spondylo Arthritis international Society (ASAS)20 response, ASAS40 response and ASAS partial remission were comparable between treatment groups. Changes from baseline in PROs such as mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; CT-P13 −3.1 versus RP −2.8), Bath Ankylosing Spondylitis Functional Index (BASFI; −2.9 versus –2.7), and Short Form Health Survey (SF-36) scores (9.26 versus 10.13 for physical component summary; 7.30 versus 6.54 for mental component summary) were similar between treatment groups. At 54 weeks, 19.5 % and 23.0 % of patients receiving CT-P13 and RP, respectively, had ADAs. All observed PK parameters of CT-P13 and RP, including maximum and minimum serum concentrations, were similar through 54 weeks. The influence of ADAs on PK was similar in the two treatment groups. Most adverse events were mild or moderate in severity. There was no notable difference between treatment groups in the incidence of adverse events, serious adverse events, infections and infusion-related reactions. Conclusions CT-P13 and RP have highly comparable efficacy (including PROs) and PK up to week 54. Over a 1-year period, CT-P13 was well tolerated and displayed a safety profile comparable to RP; no differences in immunogenicity were observed. Trial registration ClinicalTrials.gov identifier: NCT01220518. Registered 4 October 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-0930-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Won Park
- Inha University Hospital, Incheon, Republic of Korea.
| | - Dae Hyun Yoo
- Hanyang University Hospital, Seoul, Republic of Korea.
| | | | - Jan Brzezicki
- Wojewodzki Szpital Zespolony w Elblagu, Elblag, Poland.
| | | | | | | | | | | | - Seong Wook Kang
- Chungnam National University Hospital, Daejeon, Republic of Korea.
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Ultrasound7 versus ultrasound12 in monitoring the response to infliximab in patients with rheumatoid arthritis. Clin Rheumatol 2016; 35:587-94. [DOI: 10.1007/s10067-016-3176-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 11/28/2015] [Accepted: 01/10/2016] [Indexed: 11/25/2022]
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181
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Huo Y, De Hair MJH, Shaib YO, van der Heijde D, Kuchuk NO, Viergever MA, van Laar JM, Vincken KL, Lafeber FP. Computerised versus conventional methodology of radiographic joint destruction assessment in early rheumatoid arthritis. RMD Open 2015; 1:e000148. [PMID: 26688750 PMCID: PMC4680585 DOI: 10.1136/rmdopen-2015-000148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 10/03/2015] [Accepted: 11/01/2015] [Indexed: 11/18/2022] Open
Abstract
Objectives To compare computerised and conventional methodology of radiographic joint destruction assessment in early rheumatoid arthritis (RA). Methods We investigated the contribution of the 3rd-to-5th carpometacarpal joints (CMC3-5, which are excluded in computerised assessment so far owing to bone overlapping) to total joint space narrowing (JSN) scores in two cohorts of patients with early RA (n=392). Next, we investigated agreement between JSN scoring using single time point individual joint-based method (individual joint of a single time point (IJSTP), reflecting computerised reading) and conventional JSN scoring using the Sharp-van der Heijde (SvdH) method in a cohort of patients with early RA (n=59). We used intraclass correlation coefficients (ICCs), Bland and Altman plots, and linear mixed modelling to analyse differences in progression between two methods. Radiographs were available at baseline, and at 1 and 2 years of follow-up. Results Of all joints affected by JSN at baseline or JSN progression during 2 years of follow-up, 3.9% and 6.6% concerned CMC3-5. Exclusion of CMC3-5 resulted in a decrease of 1.9–4.6% in JSN progression scores during 2 years of follow-up. The ICCs for JSN progression scores using IJSTP with or without CMC3-5 compared with SvdH were 0.71–0.81 and 0.69–0.78 at 1 and 2 years of follow-up. Signal-to-noise ratios for IJSTP-based and SvdH scoring were 0.51 and 0.58, respectively. The progression rate for each year was not statistically significantly different between two scoring methods (p=0.59 and 0.89). Conclusions This study showed that excluding CMC3-5 has limited influence on JSN (progression) scores and showed the feasibility of using IJSTP-based reading for computerised scoring of JSN (progression) in RA.
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Affiliation(s)
- Yinghe Huo
- Department of Rheumatology & Clinical Immunology , UMC Utrecht , Utrecht , The Netherlands ; Image Sciences Institute, UMC Utrecht , Utrecht , The Netherlands
| | - Maria J H De Hair
- Department of Rheumatology & Clinical Immunology , UMC Utrecht , Utrecht , The Netherlands
| | - Yasmin O Shaib
- Department of Rheumatology & Clinical Immunology , UMC Utrecht , Utrecht , The Netherlands
| | | | - Natalia O Kuchuk
- Department of Rheumatology & Clinical Immunology , UMC Utrecht , Utrecht , The Netherlands
| | - Max A Viergever
- Image Sciences Institute, UMC Utrecht , Utrecht , The Netherlands
| | - Jacob M van Laar
- Department of Rheumatology & Clinical Immunology , UMC Utrecht , Utrecht , The Netherlands
| | - Koen L Vincken
- Image Sciences Institute, UMC Utrecht , Utrecht , The Netherlands
| | - Floris P Lafeber
- Department of Rheumatology & Clinical Immunology , UMC Utrecht , Utrecht , The Netherlands
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Llop-Guevara A, Porras M, Cendón C, Di Ceglie I, Siracusa F, Madarena F, Rinotas V, Gómez L, van Lent PL, Douni E, Chang HD, Kamradt T, Román J. Simultaneous inhibition of JAK and SYK kinases ameliorates chronic and destructive arthritis in mice. Arthritis Res Ther 2015; 17:356. [PMID: 26653844 PMCID: PMC4675041 DOI: 10.1186/s13075-015-0866-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/19/2015] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Despite the broad spectrum of antirheumatic drugs, RA is still not well controlled in up to 30-50 % of patients. Inhibition of JAK kinases by means of the pan-JAK inhibitor tofacitinib has demonstrated to be effective even in difficult-to-treat patients. Here, we discuss whether the efficacy of JAK inhibition can be improved by simultaneously inhibiting SYK kinase, since both kinases mediate complementary and non-redundant pathways in RA. METHODS Efficacy of dual JAK + SYK inhibition with selective small molecule inhibitors was evaluated in chronic G6PI-induced arthritis, a non-self-remitting and destructive arthritis model in mice. Clinical and histopathological scores, as well as cytokine and anti-G6PI antibody production were assessed in both preventive and curative protocols. Potential immunotoxicity was also evaluated in G6PI-induced arthritis and in a 28-day TDAR model, by analysing the effects of JAK + SYK inhibition on hematological parameters, lymphoid organs, leukocyte subsets and cell function. RESULTS Simultaneous JAK + SYK inhibition completely prevented mice from developing arthritis. This therapeutic strategy was also very effective in ameliorating already established arthritis. Dual kinase inhibition immediately resulted in greatly decreased clinical and histopathological scores and led to disease remission in over 70 % of the animals. In contrast, single JAK inhibition and anti-TNF therapy (etanercept) were able to stop disease progression but not to revert it. Dual kinase inhibition decreased Treg and NK cell counts to the same extent as single JAK inhibition but overall cytotoxicity remained intact. Interestingly, treatment discontinuation rapidly reversed such immune cell reduction without compromising clinical efficacy, suggesting long-lasting curative effects. Dual kinase inhibition reduced the Th1/Th17 cytokine cascade and the differentiation and function of joint cells, in particular osteoclasts and fibroblast-like synoviocytes. CONCLUSIONS Concurrent JAK + SYK inhibition resulted in higher efficacy than single kinase inhibition and TNF blockade in a chronic and severe arthritis model. Thus, blockade of multiple immune signals with dual JAK + SYK inhibition represents a reasonable therapeutic strategy for RA, in particular in patients with inadequate responses to current treatments. Our data supports the multiplicity of events underlying this heterogeneous and complex disease.
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Affiliation(s)
| | - Mónica Porras
- Draconis Pharma S.L., Calle Pallars 179, Barcelona, Spain.
| | - Carla Cendón
- Draconis Pharma S.L., Calle Pallars 179, Barcelona, Spain.
- Deutsches Rheuma-Forschungszentrum, Berlin, Germany.
| | | | | | | | - Vagelis Rinotas
- Laboratory of Genetics, Department of Biotechnology, Agricultural University of Athens, Athens, Greece.
| | - Lluís Gómez
- Draconis Pharma S.L., Calle Pallars 179, Barcelona, Spain.
| | | | - Eleni Douni
- Laboratory of Genetics, Department of Biotechnology, Agricultural University of Athens, Athens, Greece.
- Biomedical Sciences Research Center "Alexander Fleming", Vari, Greece.
| | | | | | - Juan Román
- Draconis Pharma S.L., Calle Pallars 179, Barcelona, Spain.
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Are All Biologics the Same? Optimal Treatment Strategies for Patients With Early Rheumatoid Arthritis. J Clin Rheumatol 2015; 21:398-404. [DOI: 10.1097/rhu.0000000000000272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Poiroux L, Allanore Y, Kahan A, Avouac J. All-cause Mortality Associated with TNF-α Inhibitors in Rheumatoid Arthritis: A Meta-Analysis of Randomized Controlled Trials. Am J Med 2015; 128:1367-73.e1. [PMID: 26247564 DOI: 10.1016/j.amjmed.2015.07.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 06/29/2015] [Accepted: 07/06/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare mortality data obtained from randomized controlled trials for the 5 tumor necrosis factor-α (TNF-α) inhibitors used in the treatment of rheumatoid arthritis. METHODS A systematic review of articles published up to November 2014 was performed using electronic databases. We included randomized, controlled trials, with a follow-up period of at least 24 weeks, comparing TNF-α inhibitors to placebo or disease-modifying antirheumatic drugs. The primary outcome was the occurrence of all-cause mortality. RESULTS Twenty-three studies were selected. These articles included 6525 patients in the anti-TNF-α group and 3523 in the control group. The duration of patient follow-up ranged from 24 to 104 weeks. The risk of all-cause mortality in patients receiving TNF-α inhibitors was not significantly different from those receiving the comparator (odds ratio 1.32; 95% confidence interval, 0.76-2.29). Subgroup analyses with respect to the molecule used, the dose received, the use of TNF-α inhibitors as monotherapy or combination therapy, or the quality of the trial did not modify the findings. CONCLUSION This meta-analysis performed on a large number of patients and including the 5 TNF-α inhibitors currently available shows no increased risk of medium-term all-cause mortality in patients with rheumatoid arthritis.
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Affiliation(s)
- Lucile Poiroux
- Paris Descartes University, Sorbonne Paris Cité, Rheumatology A Department, Cochin Hospital, Paris, France
| | - Yannick Allanore
- Paris Descartes University, Sorbonne Paris Cité, Rheumatology A Department, Cochin Hospital, Paris, France
| | - André Kahan
- Paris Descartes University, Sorbonne Paris Cité, Rheumatology A Department, Cochin Hospital, Paris, France
| | - Jérôme Avouac
- Paris Descartes University, Sorbonne Paris Cité, Rheumatology A Department, Cochin Hospital, Paris, France.
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Braun J, Kudrin A. Progress in biosimilar monoclonal antibody development: the infliximab biosimilar CT-P13 in the treatment of rheumatic diseases. Immunotherapy 2015; 7:73-87. [PMID: 25713985 DOI: 10.2217/imt.14.109] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Biosimilars are biologic medical products whose active drug substance is made by a living organism or derived from it. The term is used to describe a subsequent version of an innovator biopharmaceutical product aiming at approval following patent expiry on the reference product. Biosimilars of monoclonal need to demonstrate similar but not identical quality of nonclinical and clinical attributes. Not all data of the originator product need to be recapitulated, as large numbers of patient-years of exposure data are already available. Thus, biosimilar development is largely based on the safety profiles of the originator product. The evaluation of biosimilarity includes immunogenicity attributed risks. CT-P13 (Remsima™/Inflectra™, Celltrion/Hospira), a biosimilar of the innovator drug infliximab (INF), was the first approved complex biosimilar monoclonal antibody in the EU, within the framework of WHO, EMA and US FDA biosimilar guidelines. CT-P13 has shown analytical and nonclinical features highly similar to INF including pharmacokinetics, efficacy, safety and immunogenicity profiles in ankylosing spondylitis and rheumatoid arthritis. The objective of this article is to highlight the recent biosimilar development and to review the results from the studies PLANETRA and PLANETAS, which have supported the approval of CT-P13 for several indications.
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Affiliation(s)
- Jürgen Braun
- Rheumazentrum Ruhrgebiet, Claudiusstr. 45, 44649 Herne, & Ruhr Universität Bochum, Germany
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186
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Priori R, Casadei L, Valerio M, Scrivo R, Valesini G, Manetti C. ¹H-NMR-Based Metabolomic Study for Identifying Serum Profiles Associated with the Response to Etanercept in Patients with Rheumatoid Arthritis. PLoS One 2015; 10:e0138537. [PMID: 26558759 PMCID: PMC4641599 DOI: 10.1371/journal.pone.0138537] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 09/01/2015] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE A considerable proportion of patients with rheumatoid arthritis (RA) do not have a satisfactory response to biological therapies. We investigated the use of metabolomics approach to identify biomarkers able to anticipate the response to biologics in RA patients. METHODS Due to gender differences in metabolomic profiling, the analysis was restricted to female patients starting etanercept as the first biological treatment and having a minimum of six months' follow-up. Each patient was evaluated by the same rheumatologist before and after six months of treatment. At this time, the clinical response (good, moderate, none) was determined according to the EUropean League Against Rheumatism (EULAR) criteria, based on both erythrocyte sedimentation rate (EULAR-ESR) and C-reactive protein (EULAR-CRP). Sera collected prior and after six months of etanercept were analyzed by 1H-nuclear magnetic resonance (NMR) spectroscopy in combination with multivariate data analysis. RESULTS Twenty-seven patients were enrolled: 18 had a good/moderate response and 9 were non responders according to both EULAR-ESR and EULAR-CRP after six months of etanercept. Metabolomic analysis at baseline was able to discriminate good, moderate, and non-responders with a very good predictivity (Q2 = 0.68) and an excellent sensitivity, specificity, and accuracy (100%). In good responders, we found an increase in isoleucine, leucine, valine, alanine, glutamine, tyrosine, and glucose levels and a decrease in 3-hydroxybutyrate levels after six months of treatment with etanercept with respect to baseline. CONCLUSION Our study confirms the potential of metabolomic analysis to predict the response to biological agents. Changes in metabolic profiles during treatment may help elucidate their mechanism of action.
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Affiliation(s)
- Roberta Priori
- Department of Internal Medicine and Medical Specialties—Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Luca Casadei
- Department of Chemistry—Sapienza University of Rome, Rome, Italy
| | | | - Rossana Scrivo
- Department of Internal Medicine and Medical Specialties—Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Guido Valesini
- Department of Internal Medicine and Medical Specialties—Rheumatology Unit, Sapienza University of Rome, Rome, Italy
- * E-mail:
| | - Cesare Manetti
- Department of Chemistry—Sapienza University of Rome, Rome, Italy
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Xu Z, Davis HM, Zhou H. Clinical impact of concomitant immunomodulators on biologic therapy: Pharmacokinetics, immunogenicity, efficacy and safety. J Clin Pharmacol 2015; 55 Suppl 3:S60-74. [PMID: 25707965 DOI: 10.1002/jcph.380] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 08/07/2014] [Indexed: 12/19/2022]
Abstract
Immune-mediated inflammatory diseases encompass a variety of different clinical syndromes, manifesting as either common diseases such as rheumatoid arthritis (RA), inflammatory bowel disease (IBD) and psoriasis, or rare diseases such as cryopyrin-associated periodic syndromes. The therapy for these diseases often involves the use of a wide range of drugs including nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, immunomodulators, and biologic therapies. Due to the abundance of relevant clinical data, this article provides a general overview on the clinical impact of the concomitant use of immunomodulators and biologic therapies, with a focus on anti-tumor necrosis factor-α agents (anti-TNFα), for the treatment of RA and Crohn's disease (CD). Compared to biologic monotherapy, concomitant use of immunomodulators (methotrexate, azathioprine, and 6-mercaptopurine) often increases the systemic exposure of the anti-TNFα agent and decreases the formation of antibodies to the anti-TNFα agent, consequently enhancing clinical efficacy. Nevertheless, long-term combination therapy with immunomodulators and anti-TNFα agents may be associated with increased risks of serious infections and malignancies. Therefore, the determination whether combination therapy is suitable for a patient should always be based on an individualized benefit-risk evaluation. More research should be undertaken to identify and validate prognostic markers for predicting patients who would benefit the most and those who are at greater risk from combination therapy with immunomodulators and anti-TNFα agents.
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Affiliation(s)
- Zhenhua Xu
- Janssen Research and Development, LLC., Spring House, PA, USA
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Burmester GR, Rigby WF, van Vollenhoven RF, Kay J, Rubbert-Roth A, Kelman A, Dimonaco S, Mitchell N. Tocilizumab in early progressive rheumatoid arthritis: FUNCTION, a randomised controlled trial. Ann Rheum Dis 2015; 75:1081-91. [PMID: 26511996 PMCID: PMC4893095 DOI: 10.1136/annrheumdis-2015-207628] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 10/03/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The efficacy of tocilizumab (TCZ), an anti-interleukin-6 receptor antibody, has not previously been evaluated in a population consisting exclusively of patients with early rheumatoid arthritis (RA). METHODS In a double-blind randomised controlled trial (FUNCTION), 1162 methotrexate (MTX)-naive patients with early progressive RA were randomly assigned (1:1:1:1) to one of four treatment groups: 4 mg/kg TCZ+MTX, 8 mg/kg TCZ+MTX, 8 mg/kg TCZ+placebo and placebo+MTX (comparator group). The primary outcome was remission according to Disease Activity Score using 28 joints (DAS28-erythrocyte sedimentation rate (ESR) <2.6) at week 24. Radiographic and physical function outcomes were also evaluated. We report results through week 52. RESULTS The intent-to-treat population included 1157 patients. Significantly more patients receiving 8 mg/kg TCZ+MTX and 8 mg/kg TCZ+placebo than receiving placebo+MTX achieved DAS28-ESR remission at week 24 (45% and 39% vs 15%; p<0.0001). The 8 mg/kg TCZ+MTX group also achieved significantly greater improvement in radiographic disease progression and physical function at week 52 than did patients treated with placebo+MTX (mean change from baseline in van der Heijde-modified total Sharp score, 0.08 vs 1.14 (p=0.0001); mean reduction in Health Assessment Disability Index, -0.81 vs -0.64 (p=0.0024)). In addition, the 8 mg/kg TCZ+placebo and 4 mg/kg TCZ+MTX groups demonstrated clinical efficacy that was at least as effective as MTX for these key secondary endpoints. Serious adverse events were similar among treatment groups. Adverse events resulting in premature withdrawal occurred in 20% of patients in the 8 mg/kg TCZ+MTX group. CONCLUSIONS TCZ is effective in combination with MTX and as monotherapy for the treatment of patients with early RA. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, number NCT01007435.
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Affiliation(s)
- Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Free University and Humboldt University of Berlin, Berlin, Germany
| | - William F Rigby
- Department of Medicine-Rheumatology, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | | | - Jonathan Kay
- Rheumatology Center, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, Massachusetts, USA
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Zampeli E, Vlachoyiannopoulos PG, Tzioufas AG. Treatment of rheumatoid arthritis: Unraveling the conundrum. J Autoimmun 2015; 65:1-18. [PMID: 26515757 DOI: 10.1016/j.jaut.2015.10.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 11/28/2022]
Abstract
Rheumatoid arthritis (RA) is a heterogeneous disease with a complex and yet not fully understood pathophysiology, where numerous different cell-types contribute to a destructive process of the joints. This complexity results into a considerable interpatient variability in clinical course and severity, which may additionally involve genetics and/or environmental factors. After three decades of focused efforts scientists have now achieved to apply in clinical practice, for patients with RA, the "treat to target" approach with initiation of aggressive therapy soon after diagnosis and escalation of the therapy in pursuit of clinical remission. In addition to the conventional synthetic disease modifying anti-rheumatic drugs, biologics have greatly improved the management of RA, demonstrating efficacy and safety in alleviating symptoms, inhibiting bone erosion, and preventing loss of function. Nonetheless, despite the plethora of therapeutic options and their combinations, unmet therapeutic needs in RA remain, as current therapies sometimes fail or produce only partial responses and/or develop unwanted side-effects. Unfortunately the mechanisms of 'nonresponse' remain unknown and most probable lie in the unrevealed heterogeneity of the RA pathophysiology. In this review, through the effort of unraveling the complex pathophysiological pathways, we will depict drugs used throughout the years for the treatment of RA, the current and future biological therapies and their molecular or cellular targets and finally will suggest therapeutic algorithms for RA management. With multiple biologic options, there is still a need for strong predictive biomarkers to determine which drug is most likely to be effective, safe, and durable in a given individual. The fact that available biologics are not effective in all patients attests to the heterogeneity of RA, yet over the long term, as research and treatment become more aggressive, efficacy, toxicity, and costs must be balanced within the therapeutic equation to enhance the quality of life in patients with RA.
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Affiliation(s)
- Evangelia Zampeli
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
| | | | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece.
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190
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Aletaha D, Alasti F, Smolen JS. Optimisation of a treat-to-target approach in rheumatoid arthritis: strategies for the 3-month time point. Ann Rheum Dis 2015; 75:1479-85. [DOI: 10.1136/annrheumdis-2015-208324] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/06/2015] [Indexed: 01/29/2023]
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191
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Yoo DH, Oh C, Hong S, Park W. Analysis of clinical trials of biosimilar infliximab (CT-P13) and comparison against historical clinical studies with the infliximab reference medicinal product. Expert Rev Clin Immunol 2015; 11 Suppl 1:S15-24. [DOI: 10.1586/1744666x.2015.1090314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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192
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Gulácsi L, Brodszky V, Baji P, Kim H, Kim SY, Cho YY, Péntek M. Biosimilars for the management of rheumatoid arthritis: economic considerations. Expert Rev Clin Immunol 2015; 11 Suppl 1:S43-52. [DOI: 10.1586/1744666x.2015.1090313] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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193
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Kim JS, Kim SH, Kwon B, Hong S. Comparison of immunogenicity test methods used in clinical studies of infliximab and its biosimilar (CT-P13). Expert Rev Clin Immunol 2015; 11 Suppl 1:S33-41. [DOI: 10.1586/1744666x.2015.1090312] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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194
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Schellekens H, Lietzan E, Faccin F, Venema J. Biosimilar monoclonal antibodies: the scientific basis for extrapolation. Expert Opin Biol Ther 2015; 15:1633-46. [PMID: 26365396 DOI: 10.1517/14712598.2015.1083552] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Biosimilars are biologic products that receive authorization based on an abbreviated regulatory application containing comparative quality and nonclinical and clinical data that demonstrate similarity to a licensed biologic product. Extrapolation of safety and efficacy has emerged as an important way to simplify biosimilar development. Regulatory authorities have generally reached the consensus that extrapolation of similarity from one indication to other approved indications of the reference product can be permitted if it is scientifically justified. AREAS COVERED Recently, the first biosimilar, biosimilar infliximab (Remsima/Inflectra) to the innovator monoclonal antibody infliximab (Remicade), was approved in the European Union, Canada and South Korea; the USA subsequently approved its first biosimilar, a less complex molecule (filgrastim-sndz). Based on two clinical trials of biosimilar infliximab in patients with rheumatoid arthritis and ankylosing spondylitis, the European Medicines Agency allowed extrapolation to all eight approved indications for innovator infliximab, whereas Health Canada did not permit extrapolation to the indications for ulcerative colitis and Crohn's disease. These differing decisions on extrapolation of indications for biosimilar infliximab highlight important unanswered regulatory and scientific questions. Here, we propose substantive scientific considerations for indication extrapolation. EXPERT OPINION The preclinical and clinical criteria that are currently required to merit indication extrapolation have not been rigorously evaluated.
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Affiliation(s)
- Huub Schellekens
- a 1 Utrecht University, Departments of Pharmaceutical Sciences and Innovation Studies , Utrecht, The Netherlands
| | - Erika Lietzan
- b 2 University of Missouri School of Law , Columbia, MO, USA
| | - Freddy Faccin
- c 3 AbbVie Inc., Biotherapeutics, Global Medical Affairs , 9615 Los Romeros Avenue, Suite 700, San Juan, PR, USA +1 787 622 5454 ; +1 787 276 3016 ;
| | - Jaap Venema
- d 4 AbbVie Inc., Biotherapeutics, Global Medical Affairs, Biologics Strategic Development , North Chicago, IL, USA
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195
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Tvete IF, Natvig B, Gåsemyr J, Meland N, Røine M, Klemp M. Comparing Effects of Biologic Agents in Treating Patients with Rheumatoid Arthritis: A Multiple Treatment Comparison Regression Analysis. PLoS One 2015; 10:e0137258. [PMID: 26356639 PMCID: PMC4565694 DOI: 10.1371/journal.pone.0137258] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/13/2015] [Indexed: 12/18/2022] Open
Abstract
Rheumatoid arthritis patients have been treated with disease modifying anti-rheumatic drugs (DMARDs) and the newer biologic drugs. We sought to compare and rank the biologics with respect to efficacy. We performed a literature search identifying 54 publications encompassing 9 biologics. We conducted a multiple treatment comparison regression analysis letting the number experiencing a 50% improvement on the ACR score be dependent upon dose level and disease duration for assessing the comparable relative effect between biologics and placebo or DMARD. The analysis embraced all treatment and comparator arms over all publications. Hence, all measured effects of any biologic agent contributed to the comparison of all biologic agents relative to each other either given alone or combined with DMARD. We found the drug effect to be dependent on dose level, but not on disease duration, and the impact of a high versus low dose level was the same for all drugs (higher doses indicated a higher frequency of ACR50 scores). The ranking of the drugs when given without DMARD was certolizumab (ranked highest), etanercept, tocilizumab/ abatacept and adalimumab. The ranking of the drugs when given with DMARD was certolizumab (ranked highest), tocilizumab, anakinra, rituximab, golimumab/ infliximab/ abatacept, adalimumab/ etanercept. Still, all drugs were effective. All biologic agents were effective compared to placebo, with certolizumab the most effective and adalimumab (without DMARD treatment) and adalimumab/ etanercept (combined with DMARD treatment) the least effective. The drugs were in general more effective, except for etanercept, when given together with DMARDs.
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Affiliation(s)
| | - Bent Natvig
- Department of Mathematics, University of Oslo, Oslo, Norway
| | - Jørund Gåsemyr
- Department of Mathematics, University of Oslo, Oslo, Norway
| | - Nils Meland
- Smerud Medical Research International AS, Oslo, Norway
| | | | - Marianne Klemp
- Department of Pharmacology, University of Oslo, Oslo, Norway
- The Norwegian Knowledge Centre for the Health Services, Oslo, Norway
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196
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Oliveira Junior HAD, Almeida AM, Acurcio FA, Santos JBD, Kakehasi AM, Alvares J, Dabés CGES, Cherchiglia ML. Profile of patients with rheumatic diseases undergoing treatment with anti-TNF agents in the Brazilian Public Health System (SUS), Belo Horizonte - MG. BRAZ J PHARM SCI 2015. [DOI: 10.1590/s1984-82502015000300023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of this study was to describe the baseline demographic and clinical characteristics as well as the functional status of a prospective cohort of patients with rheumatic diseases assisted by the Brazilian Public Health System (SUS). Data for 302 patients receiving tumor necrosis factor α inhibitors (anti-TNF agents) was collected through a standard form. Among patients, 229 (75.8%) were female and 155 (51.3%) were Caucasian; the mean age was 50.3 ± 12.8 years, and the mean disease duration was 9.9 ± 8.7 years. Among them 214 patients (70.9%) received adalimumab, 72 (23.8%) etanercept, and 16 (5.3%) infliximab. Mean Health Assessment Questionnaire-Disability Index (HAQ-DI) was 1.37 ± 0.67 for all participants. Poor functional response was associated with female gender, married patients and with a score of < 0.6 on the EuroQoL-5 dimensions (EQ-5D). Significant correlation was found between the HAQ-DI values, disease activity and quality of life (QOL). The results obtained in this study contribute to a better understanding of the clinical and demographic characteristics of patients with rheumatic diseases at the beginning of anti-TNF-agent treatment by SUS. Furthermore, our findings are consistent with another Brazilian and foreign cross-sectional investigations. This knowledge can be of great importance for further studies evaluating the effectiveness of biological agents, as well as, to contribute to improve the well-being of the patients with rheumatic diseases.
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197
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Chighizola CB, Favalli EG, Meroni PL. Novel mechanisms of action of the biologicals in rheumatic diseases. Clin Rev Allergy Immunol 2015; 47:6-16. [PMID: 23345026 DOI: 10.1007/s12016-013-8359-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Biological drugs targeting pro-inflammatory or co-stimulatory molecules or depleting lymphocyte subsets made a revolution in rheumatoid arthritis (RA) treatment. Their comparable efficacy in clinical trials raised the point of the heterogeneity of RA pathogenesis, suggesting that we are dealing with a syndrome rather than with a single disease. Several tumor necrosis factor-alpha (TNF-α) blockers are available, and a burning question is whether they are biosimilar or not. The evidence of diverse biological effects in vitro is in line with the fact that a lack of efficacy to one TNF-α agent does not imply a non-response to another one. As proteins, biologicals are potentially immunogenic. It has been recently raised that anti-drug antibodies (ADA) may affect their bioavailability and eventually the clinical efficacy through local formation of immune complexes and directly by preventing the interaction between the drug and TNF-α. Regular monitoring of drug and ADA levels appears the best way to tailor anti-TNF-α therapies. Owing to the pleiotropic characteristics of the target, anti-TNF-α blockers may affect several mechanisms beyond rheumatoid synovitis. As TNF-α plays a pivotal role in the induction of early atherosclerosis, treatment with TNF-inhibitors may modulate cholesterol handling, in particular, cholesterol efflux from macrophages. Side effects are a major issue because of the systemic TNF-α blocking action. The efficacy of an anti-C5 monoclonal antibody fused to a peptide targeting inflamed synovia in experimental arthritis opened the way for new strategies: Homing to the synovium of molecules neutralizing TNF would allow to maximize the therapeutic action avoiding the side effects.
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198
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Manara M, Sinigaglia L. Bone and TNF in rheumatoid arthritis: clinical implications. RMD Open 2015; 1:e000065. [PMID: 26557382 PMCID: PMC4632149 DOI: 10.1136/rmdopen-2015-000065] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 07/13/2015] [Indexed: 12/30/2022] Open
Abstract
Experimental data have demonstrated that tumour necrosis factor (TNF) plays a significant role in systemic and local bone loss related to rheumatoid arthritis (RA). In clinical studies on patients with RA, treatment with TNF inhibitors was able to arrest systemic bone loss assessed by bone mineral density and bone turnover markers, but there is scarce evidence of a clinically meaningful effect of TNF inhibition in preventing fractures. TNF inhibitors showed a higher efficacy in reducing radiographic progression related to the disease compared to methotrexate in randomised clinical trials. Data from observational studies seem to confirm the effectiveness of anti-TNF therapy in reducing joint damage evolution.
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Affiliation(s)
- Maria Manara
- Department of Rheumatology , Gaetano Pini Institute , Milan , Italy
| | - Luigi Sinigaglia
- Department of Rheumatology , Gaetano Pini Institute , Milan , Italy
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199
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Downey C. Serious infection during etanercept, infliximab and adalimumab therapy for rheumatoid arthritis: A literature review. Int J Rheum Dis 2015. [DOI: 10.1111/1756-185x.12659] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Colum Downey
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
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200
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Tokunaga T, Miwa Y, Nishimi A, Nishimi S, Saito M, Oguro N, Miura Y, Ishii S, Takahashi R, Kasama T, Sanada K. Sex Differences in the Effects of a Biological Drug for Rheumatoid Arthritis on Depressive State. Open Rheumatol J 2015; 9:51-6. [PMID: 26312106 PMCID: PMC4541463 DOI: 10.2174/1874312901409010051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/11/2015] [Accepted: 05/18/2015] [Indexed: 11/22/2022] Open
Abstract
Objective : Sex-specific medicine has attracted attention in recent years, but no report on rheumatoid arthritis (RA) has examined sex differences in the effectiveness of biologics on activities of daily living (ADL), quality of life (QOL), or depressive state. Methods : The study subjects were 161 RA patients (female: 138; male: 23) attending regular doctor visits at our hospital. We compared the changes in disease activity, which was evaluated using the simplified disease activity index (SDAI), ADL (using the modified health assessment questionnaire; mHAQ), QOL (using short form-36; SF-36), and the Hamilton Depression Rating Scale (HAM-D) for RA patients between each sex over a six-month observation period while administering biologic treatment. Results : The female patients reported significant improvements in the following metrics: SDAI: from 22.1 ± 11.9 to 8.9 ± 7.8 (p < 0.001); mHAQ: from 0.46 ± 0.50 to 0.32 ± 0.45 (p < 0.001); and HAM-D: from 6.2 ± 4.8 to 3.8 ± 4.1 (p < 0.001). Moreover, all eight items of the SF-36 were significantly improved (p < 0.01). In contrast, the male patients improved on the SDAI (from 27.9 ± 11.7 to 12.7 ± 8.6 (p < 0.001)), but we did not observe significant improvements in the mHAQ or HAM-D scores or in any items on the SF-36. Conclusion : Both male and female patients with RA improved when using a biological drug. Sex differences in the improvement of depressive state were observed.
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Affiliation(s)
- Takahiro Tokunaga
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Yusuke Miwa
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Airi Nishimi
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Shinichiro Nishimi
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Mayu Saito
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Nao Oguro
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Yoko Miura
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Sho Ishii
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Ryo Takahashi
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Tsuyoshi Kasama
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Kenji Sanada
- Department of Psychiatry, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
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