1
|
Brown P, Pratt AG, Hyrich KL. Therapeutic advances in rheumatoid arthritis. BMJ 2024; 384:e070856. [PMID: 38233032 DOI: 10.1136/bmj-2022-070856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Rheumatoid arthritis (RA) is one of the most common immune mediated inflammatory diseases. People with rheumatoid arthritis present with pain, swelling, and stiffness that typically affects symmetrically distributed small and large joints. Without effective treatment, significant joint damage, disability, and work loss develop, owing to chronic inflammation of the joint lining (synovium). Over the past 25 years, the management of this condition has been revolutionized, resulting in substantially higher levels of disease remission and better long term outcomes. This improvement reflects a paradigm shift towards early and aggressive pharmacological intervention coupled with a proliferation in treatment choice, in turn related to enhanced pathobiological understanding and the advent of new drugs for rheumatoid arthritis. Following an overview of these developments from a historical perspective, and with a general audience in mind, this review focuses on newer, targeted treatments in an ever evolving landscape. The review highlights ongoing areas of debate and unmet need, including the proportion of patients with persistent, difficult-to-treat disease, despite recent advances. Also discussed are personalized, strategic approaches to individual patients, the role for imaging in clinical decision making, and the goal of sustained, drug free remission and disease prevention in the future.
Collapse
Affiliation(s)
- Philip Brown
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- National Institute for Health and Care Research Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne Hospitals and Cumbria, Northumberland; and Tyne and Wear NHS Foundation Trusts, Newcastle upon Tyne, UK
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- National Institute for Health and Care Research Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne Hospitals and Cumbria, Northumberland; and Tyne and Wear NHS Foundation Trusts, Newcastle upon Tyne, UK
| | - Kimme L Hyrich
- Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
- National Institute for Health and Care Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| |
Collapse
|
2
|
Nowell WB, Curtis JR, Zhao H, Xie F, Stradford L, Curtis D, Gavigan K, Boles J, Clinton C, Lipkovich I, Venkatachalam S, Calvin A, Hayes VS. Participant Engagement and Adherence to Providing Smartwatch and Patient-Reported Outcome Data: Digital Tracking of Rheumatoid Arthritis Longitudinally (DIGITAL) Real-World Study. JMIR Hum Factors 2023; 10:e44034. [PMID: 37934559 PMCID: PMC10664008 DOI: 10.2196/44034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/27/2023] [Accepted: 08/20/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Digital health studies using electronic patient-reported outcomes (ePROs) and wearables bring new challenges, including the need for participants to consistently provide trial data. OBJECTIVE This study aims to characterize the engagement, protocol adherence, and data completeness among participants with rheumatoid arthritis enrolled in the Digital Tracking of Arthritis Longitudinally (DIGITAL) study. METHODS Participants were invited to participate in this app-based study, which included a 14-day run-in and an 84-day main study. In the run-in period, data were collected via the ArthritisPower mobile app to increase app familiarity and identify the individuals who were motivated to participate. Successful completers of the run-in period were mailed a wearable smartwatch, and automated and manual prompts were sent to participants, reminding them to complete app input or regularly wear and synchronize devices, respectively, during the main study. Study coordinators monitored participant data and contacted participants via email, SMS text messaging, and phone to resolve adherence issues per a priori rules, in which consecutive spans of missing data triggered participant contact. Adherence to data collection during the main study period was defined as providing requested data for >70% of 84 days (daily ePRO, ≥80% daily smartwatch data) or at least 9 of 12 weeks (weekly ePRO). RESULTS Of the 470 participants expressing initial interest, 278 (59.1%) completed the run-in period and qualified for the main study. Over the 12-week main study period, 87.4% (243/278) of participants met the definition of adherence to protocol-specified data collection for weekly ePRO, and 57.2% (159/278) did so for daily ePRO. For smartwatch data, 81.7% (227/278) of the participants adhered to the protocol-specified data collection. In total, 52.9% (147/278) of the participants met composite adherence. CONCLUSIONS Compared with other digital health rheumatoid arthritis studies, a short run-in period appears useful for identifying participants likely to engage in a study that collects data via a mobile app and wearables and gives participants time to acclimate to study requirements. Automated or manual prompts (ie, "It's time to sync your smartwatch") may be necessary to optimize adherence. Adherence varies by data collection type (eg, ePRO vs smartwatch data). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/14665.
Collapse
Affiliation(s)
- William B Nowell
- Global Healthy Living Foundation, Upper Nyack, NY, United States
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Hong Zhao
- Kirklin Solutions, Hoover, AL, United States
| | - Fenglong Xie
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Laura Stradford
- Global Healthy Living Foundation, Upper Nyack, NY, United States
| | - David Curtis
- Global Healthy Living Foundation, Upper Nyack, NY, United States
| | - Kelly Gavigan
- Global Healthy Living Foundation, Upper Nyack, NY, United States
| | | | - Cassie Clinton
- University of Alabama at Birmingham, Birmingham, AL, United States
| | | | | | - Amy Calvin
- Medidata Solutions, Inc, New York, NY, United States
| | | |
Collapse
|
3
|
Nkiruka Essien E, Revi N, Khatri V, Liu S, Van Thiel G, Bijukumar D. Methotrexate and Sulforaphane loaded PBA-G5-PAMAM dendrimers as a combination therapy for anti-inflammatory response in an intra-articular joint arthritic animal model. Int J Pharm 2023:123150. [PMID: 37336302 DOI: 10.1016/j.ijpharm.2023.123150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/21/2023]
Abstract
L-sulforaphane (LSF), a natural product developed from cruciferous vegetables, have shown potent anti-inflammatory effect in cancer as well as arthritis. However, the stable delivery of LSF remains a major challenge. Methotrexate (MTX) is currently the first line treatment for managing RA and is most effective in patients when used in combination with other anti-inflammatory or anti-rheumatic drugs. Here we developed phenylboronic acid-PAMAM dendrimer (PBA-G5D) nanoparticles conjugated MTX (MTX-PBA-G5D), and L-sulforaphane (LSF/PBA-G5D) loaded dendrimers. The MTX and LSF drug loading and release kinetics was analyzed using HPLC. The lipopolysaccharide (LPS) stimulated macrophages were treated with the formulations to study the inflammatory response in vitro. For in vivo studies, arthritis was induced in five-week-old female Wistar rats, and the MTX- and LSF/PBA-G5-D were injected via intra-articular injection for treatment and the arthritis reduction was scored by weight, knee diameter, and serum cytokine level measurement. The average size of the drug-nanoparticle conjugates ranged from 135-250 nm, with mostly cationic surface charges. The encapsulation efficiency of the drugs to the modified dendrimer was more than 60% with a slow release of drugs from the nanoparticles within 24 h at pH 7.4. Drugs in the nanoparticle formulation were biocompatible, with promising anti-inflammatory effects in vitro against LPS-activated murine macrophages. Further in vivo studies on arthritis induced female Wistar rats, revealed significant anti-arthritic effects based on the arthritic scoring from the knee diameter reading, and anti-inflammatory effects based on the serum cytokine levels. This study provides a promising strategy for utilizing PAMAM dendrimers as a nanocarrier for LSF delivery for RA therapy.
Collapse
Affiliation(s)
- Edidiong Nkiruka Essien
- Nanomedicine Lab Department of Biomedical Sciences, University of Illinois College of Medicine, Rockford, IL
| | - Neeraja Revi
- Nanomedicine Lab Department of Biomedical Sciences, University of Illinois College of Medicine, Rockford, IL
| | - Vishal Khatri
- Nanomedicine Lab Department of Biomedical Sciences, University of Illinois College of Medicine, Rockford, IL
| | - Songyun Liu
- Rush University Medical Center, Chicago, Illinois, USA
| | | | - Divya Bijukumar
- Nanomedicine Lab Department of Biomedical Sciences, University of Illinois College of Medicine, Rockford, IL.
| |
Collapse
|
4
|
Gao Y, Gao YN, Wang MJ, Zhang Y, Zhang FQ, He ZX, Chen W, Li HC, Xie ZJ, Wen CP. Efficacy and safety of tofacitinib combined with methotrexate in the treatment of rheumatoid arthritis: A systematic review and meta-analysis. Heliyon 2023; 9:e15839. [PMID: 37215854 PMCID: PMC10196519 DOI: 10.1016/j.heliyon.2023.e15839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
Objective To evaluate the efficacy and safety of tofacitinib in combination with methotrexate (MTX) versus MTX monotherapy in patients with active rheumatoid arthritis (RA). Methods Trials were identified from four electronic databases: PubMed, Web of science, Cochrane Library and EMBASE from inception to April 2022. Two independent reviewers evaluated each database to scan the title, abstract and keywords of each record retrieved. Full articles were further assessed when the information suggested that the study was a randomized clinical trial (RCT) comparing tofacitinib combined with MTX vs. MTX monotherapy in patients with active RA. Data were extracted from the literature, and the methodological quality of the included literature were evaluated and screened by two reviewers independently. The results were analyzed using RevMan5.3 software. The full text of the studies and extracted data were reviewed independently according to PRISMA guidelines. The outcome indicators were ACR 20, ACR 50, ACR 70, Disease activity score 28 (DAS28), erythrocyte sedimentation Rate (ESR) and adverse events (AEs). Results Of 1152 studies yielded by the search, 4 were retained, totaling 1782 patients (1345 treated with tofacitinib combined with MTX vs 437 received MTX. In the trial of insufficient response to MTX treatment, tofacitinib combined with MTX had significant advantages compared with MTX monotherapy. Numerically higher ACR20, ACR50 and ACR70 response rates were observed in the tofacitinib combined with MTX groups versus MTX monotherapy. ACR20 (odds ratio (OR), 3.62; 95% CI, 2.84-4.61; P < 0.001), ACR50 (OR, 5.17; 95% CI, 3.62-7.38; P < 0.001), and ACR70 (OR, 8.44; 95% CI, 4.34-16.41; P < 0.001), DAS28 (ESR) < 2.6 (OR, 4.71, 95% CI, 2.06-10.77; P < 0.001). The probability of adverse events of tofacitinib combined with MTX was lower than that of MTX monotherapy (OR, 1.42; 95% CI, 1.08-1.88; P = 0.01). The number of cases discontinued due to lack of efficacy or adverse events was similar in both groups (OR, 0.93; 95% CI, 0.52-1.68). The probability of abnormal liver enzymes in the treatment of tofacitinib combined with MTX was significantly lower than that of MTX monotherapy (OR, 1.86; 95% CI, 1.35-2.56). However, there was no significant difference between the two groups in severe adverse reactions, neutropenia, anemia and cardiovascular disease. Conclusions In terms of ACR20/50/70 and DAS28 (ESR), tofacitinib combined with MTX demonstrated superiority to MTX monotherapy in the treatment of patients with refractory RA. Considering the hepatoprotective and observably therapeutic efficacy, tofacitinib combined with MTX could be effective in treating refractory RA. However, in terms of hepatoprotective, it requires further large-scale and high-quality clinical trials to confirm.
Collapse
|
5
|
A systematic comparison of different composite measures (DAS 28, CDAI, SDAI, and Boolean approach) for determining treatment effects on low disease activity and remission in rheumatoid arthritis. BMC Rheumatol 2022; 6:82. [PMID: 36482451 PMCID: PMC9732992 DOI: 10.1186/s41927-022-00314-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Some composite measures for determining the treatment effects of disease-modifying antirheumatic drugs on remission and low disease activity (LDA) in rheumatoid arthritis (RA) may produce misleading results if they include an acute phase reactant (APR). To inform the choice of appropriate measure, we performed a systematic comparison of treatment effects using different composite measures. METHODS We used data generated for a systematic review of biologics in RA conducted by the Institute for Quality and Efficiency in Health Care and data from systematic reviews of newer biologics and Janus kinase (JAK) inhibitors provided by sponsors. The studies included had been conducted up to 2020 and investigated comparisons of biologics with placebo and head-to-head comparisons of biologics. Treatment effects on LDA and remission in studies investigating biologics or JAK inhibitors in RA were compared among 4 composite measures: the disease activity score 28 (DAS 28), the simplified disease activity index (SDAI), the Boolean approach (remission only), and the clinical disease activity index (CDAI)-only the latter does not include an APR. RESULTS 49 placebo-controlled studies included 9 different biologics; 48 studies (16,233 patients) investigated LDA and 49 (16,338 patients) investigated remission. 11 active-controlled studies (5996 patients) investigated both LDA and remission and included 5 different head-to-head comparisons of biologics and 5 different comparisons (6 studies) of biologics with JAK inhibitors. Statistically significantly larger treatment effects were found for biologics or JAK inhibitors versus placebo or active control in 16% of pairwise comparisons of composite measures (27 of 168). Most of these larger effects were observed for composite measures with an APR, i.e. the DAS 28 (19 comparisons) followed by the SDAI (n = 7). Larger effects were most frequently detected in favour of interleukin (IL)-6 inhibitors and to a lesser extent for JAK inhibitors versus treatments with different modes of action. CONCLUSIONS The use of the DAS 28 and SDAI in clinical studies may generate results favouring certain treatments based on their mode of action (e.g. IL-6 inhibitors versus other biologics). To enable unbiased comparative effectiveness research, a composite measure without an APR (i.e. the CDAI) should thus be the measure of choice.
Collapse
|
6
|
Tan Y, Buch MH. 'Difficult to treat' rheumatoid arthritis: current position and considerations for next steps. RMD Open 2022; 8:e002387. [PMID: 35896282 PMCID: PMC9335059 DOI: 10.1136/rmdopen-2022-002387] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/14/2022] [Indexed: 11/15/2022] Open
Abstract
The European Alliance of Associations for Rheumatology recently defined difficult to treat (D2T) rheumatoid arthritis (RA) and provided points to consider in its management. This review summarises the key concepts of D2T-RA that underpinned this recent guidance. D2T-RA is primarily characterised by failure of at least two different mechanism of action biologic/targeted synthetic disease-modifying antirheumatic drug (DMARDs) with evidence of active/progressive disease. The basis for progressive disease, however, is not limited to clear inflammatory joint pathology, capturing wider contributors to treatment cycling such as comorbidity, obesity and fibromyalgia. This means D2T-RA comprises a heterogeneous population, with a proportion within this exhibiting bona fide treatment-refractory disease. The management points to consider, however, emphasise the importance of checking for the presence of inflammatory pathology before further treatment change. This review suggests additional considerations in the definition of D2T-RA, the potential value in identifying D2T traits and intervening before the development of D2T-RA state and the need for real world evidence of targeted synthetic DMARD in this population to compare to recent trial data. Finally, the review asks whether the presence of D2T-RA implies a failure to treat effectively from the outset, and the need for pharmacological and non-pharmacological management approaches to address the wider D2T-RA population effectively.
Collapse
Affiliation(s)
- Yvonne Tan
- Kellgren centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Maya H Buch
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
7
|
Kondo N, Kuroda T, Kobayashi D. Cytokine Networks in the Pathogenesis of Rheumatoid Arthritis. Int J Mol Sci 2021; 22:ijms222010922. [PMID: 34681582 PMCID: PMC8539723 DOI: 10.3390/ijms222010922] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 12/13/2022] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic systemic inflammation causing progressive joint damage that can lead to lifelong disability. The pathogenesis of RA involves a complex network of various cytokines and cells that trigger synovial cell proliferation and cause damage to both cartilage and bone. Involvement of the cytokines tumor necrosis factor (TNF)-α and interleukin (IL)-6 is central to the pathogenesis of RA, but recent research has revealed that other cytokines such as IL-7, IL-17, IL-21, IL-23, granulocyte macrophage colony-stimulating factor (GM-CSF), IL-1β, IL-18, IL-33, and IL-2 also play a role. Clarification of RA pathology has led to the development of therapeutic agents such as biological disease-modifying anti-rheumatic drugs (DMARDs) and Janus kinase (JAK) inhibitors, and further details of the immunological background to RA are emerging. This review covers existing knowledge regarding the roles of cytokines, related immune cells and the immune system in RA, manipulation of which may offer the potential for even safer and more effective treatments in the future.
Collapse
Affiliation(s)
- Naoki Kondo
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Japan;
| | - Takeshi Kuroda
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City 950-2181, Japan
- Correspondence: ; Tel.: +81-25-262-6244; Fax: +81-25-262-7517
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Japan;
| |
Collapse
|
8
|
Malm E, Nielsen SM, Berg J, Ioannidis JPA, Furst D, Smolen JS, Taylor PC, Kristensen LE, Tarp S, Ellingsen T, Christensen R. Risk of harm in synthetic and biological intervention trials in patients with inflammatory arthritis: protocol for a metaepidemiological study focusing on contextual factors. BMJ Open 2021; 11:e049850. [PMID: 34489286 PMCID: PMC8422485 DOI: 10.1136/bmjopen-2021-049850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Inflammatory arthritis (IA) conditions, including rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis, are characterised by inflammatory infiltration of the joints. Biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs), respectively, reduce the effects of proinflammatory cytokines and immune cells to ameliorate disease. However, immunosuppression can be associated with high rates of serious adverse events (SAEs), including serious infections, and maybe an increased risk of malignancies and cardiovascular events. Currently, there is no empirical evidence on the extent to which contextual factors and risk of bias (RoB) domains may modify these harm signals in randomised trials. METHODS AND ANALYSIS We will search MEDLINE (via PubMed) for systematic reviews published since April 2015 and all Cochrane reviews. From these reviews, randomised trials will be eligible if they include patients with an IA condition with at least one group randomly allocated to bDMARD and/or tsDMARD treatments. A predefined form will be used for extracting data on population characteristics (eg, baseline characteristics or eligibility criteria, such as medication background) and specific harm outcome measures, such as number of withdrawals, numbers of patients discontinuing due to adverse events and number of patients having SAEs. RoB in individual trials will be assessed using a modified Cochrane RoB tool. We will estimate the potentially causal harm effects related to the experimental intervention compared with control comparator as risk ratios, and heterogeneity across randomised comparisons will be assessed statistically and evaluated as inconsistency using the I2 Index. Our metaregression analyses will designate population and trial characteristics and each RoB domain as independent variables, whereas the three harm domains will serve as dependent variables. ETHICS AND DISSEMINATION Ethics approval is not required for this study. Results will be disseminated through publication in international peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42020171124.
Collapse
Affiliation(s)
- Esben Malm
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Sabrina Mai Nielsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Johannes Berg
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - John P A Ioannidis
- 3Department of Medicine, Department of Epidemiology and Population Health, Department of Biomedical Data Science, Department of Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Daniel Furst
- Division of Rheumatology, Department of Medicine, University of California at Los Angeles, LA, CA, USA
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lars Erik Kristensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Simon Tarp
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Torkell Ellingsen
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| |
Collapse
|
9
|
Nagy G, Roodenrijs NMT, Welsing PMJ, Kedves M, Hamar A, van der Goes MC, Kent A, Bakkers M, Pchelnikova P, Blaas E, Senolt L, Szekanecz Z, Choy EH, Dougados M, Jacobs JW, Geenen R, Bijlsma JW, Zink A, Aletaha D, Schoneveld L, van Riel P, Dumas S, Prior Y, Nikiphorou E, Ferraccioli G, Schett G, Hyrich KL, Mueller-Ladner U, Buch MH, McInnes IB, van der Heijde D, van Laar JM. EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis 2021; 81:20-33. [PMID: 34407926 PMCID: PMC8761998 DOI: 10.1136/annrheumdis-2021-220973] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/23/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA). METHODS An EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A-D: A typically consistent level 1 studies and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0-10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members. RESULTS Two overarching principles and 11 PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4-9.6). CONCLUSIONS These PtCs for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research.
Collapse
Affiliation(s)
- György Nagy
- Department of Rheumatology & Clinical Immunology, Semmelweis University, Budapest, Hungary .,Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Nadia M T Roodenrijs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Melinda Kedves
- Bács-Kiskun County Hospital, Rheumatology Department, Kecskemét, Hungary
| | - Attila Hamar
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Marlies C van der Goes
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Rheumatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Alison Kent
- Salisbury Foundation Trust NHS Hospital, Wiltshire, UK
| | - Margot Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Polina Pchelnikova
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Etienne Blaas
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ladislav Senolt
- Department of Rheumatology, 1st Faculty of Medicine, Charles University and Institute of Rheumatology, Prague, Czech Republic
| | - Zoltan Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ernest H Choy
- CREATE Centre, Section of Rheumatology, School of Medicine, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Maxime Dougados
- Université de Paris Department of Rheumatology - Hôpital Cochin. Assistance Publique - Hôpitaux de Paris INSERM (U1153) Clinical epidemiology and biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Johannes Wg Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rinie Geenen
- Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Johannes Wj Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Angela Zink
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Daniel Aletaha
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Leonard Schoneveld
- Department of Rheumatology, Bravis Hospital, Roosendaal, The Netherlands
| | - Piet van Riel
- Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sophie Dumas
- Department of Pharmacy, Marin Hospital, Asisstance Publique-Hopitaux de Paris, Hendaye, France
| | - Yeliz Prior
- School of Health and Society, Centre for Health Sciences Research, University of Salford, Salford, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK.,Rheumatology Department, King's College Hospital, London, UK
| | | | - Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University of Erlangen-Nuremberg and Universitatsklinikum Erlangen, Erlangen, Germany
| | - Kimme L Hyrich
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Ulf Mueller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Campus Kerckhoff, Bad Nauheim, Germany
| | - Maya H Buch
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.,Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | | - Jacob M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
10
|
Vasilev G, Manolova I, Ivanova M, Stanilov I, Miteva L, Stanilova S. The role of IL-18 in addition to Th17 cytokines in rheumatoid arthritis development and treatment in women. Sci Rep 2021; 11:15391. [PMID: 34321563 PMCID: PMC8319149 DOI: 10.1038/s41598-021-94841-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/16/2021] [Indexed: 12/31/2022] Open
Abstract
We aimed to analyze serum pro-inflammatory profiles of female rheumatoid arthritis (RA) patients and compare them with healthy women to establish the relative importance of pro-inflammatory cytokines in RA and their relation with different treatment regimens. Levels of six cytokines were determined by ELISA assays. A supervised dimensionality reducing approach (PLS-DA Analysis) was applied. All of the cytokines assayed were significantly elevated in the sera of RA female patients than healthy controls with fold change: 21-fold for IL-6; 6.1-fold for IL-17A; 2.5-fold for IL-23; 2.3-fold for IL-18; 1.94-fold for TNF-α; 1.7-fold for IL-12p40. According to the results of the PLS-DA analysis, IL-17A, IL-18, and TNF-α were of higher importance rank compared to IL-23 and IL-12p40. Women in the early stage of RA displayed significantly elevated IL-17A levels than those with longer disease duration: 8.04 pg/ml [8.04-175.3] vs 4.64 pg/ml [2.95-13.31], p = 0.007. IL-6 serum levels were related to higher disease activity. We have demonstrated altered cytokine production within female RA patients on different treatment regimens. Those on Tocilizumab therapy showed elevated IL-6 levels and decreased IL-17A versus the rest of the patients' subgroups. In conclusion, our data support the pivotal role of IL-18 in addition to IL-6, IL-17A, and TNF-α as the hierarchical cytokines in the pathogenesis of RA, particularly valid for women. Therapy with biological agents targeting IL-18 in addition to the Th17 axis may be an adequate approach in RA patients.
Collapse
Affiliation(s)
- Georgi Vasilev
- Laboratory of Clinical Immunology, University Hospital "St. Iv. Rilski", Medical University of Sofia, Sofia, Bulgaria
| | - Irena Manolova
- Department of Molecular Biology, Immunology and Medical Genetics, Medical Faculty, Trakia University, Armeiska 11 Str, Stara Zagora, 6000, Bulgaria
| | - Mariana Ivanova
- Clinic of Rheumatology, University Hospital "St. Iv. Rilski", Medical University of Sofia, Sofia, Bulgaria
| | - Iskren Stanilov
- Department of Molecular Biology, Immunology and Medical Genetics, Medical Faculty, Trakia University, Armeiska 11 Str, Stara Zagora, 6000, Bulgaria
| | - Lyuba Miteva
- Department of Molecular Biology, Immunology and Medical Genetics, Medical Faculty, Trakia University, Armeiska 11 Str, Stara Zagora, 6000, Bulgaria.
| | - Spaska Stanilova
- Department of Molecular Biology, Immunology and Medical Genetics, Medical Faculty, Trakia University, Armeiska 11 Str, Stara Zagora, 6000, Bulgaria
| |
Collapse
|
11
|
The characteristics and its contributing factors of refractory rheumatoid arthritis, view of the rheumatologists of China: results of a nationwide cross-sectional survey. Clin Rheumatol 2021; 40:4029-4038. [PMID: 33942201 DOI: 10.1007/s10067-021-05687-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/20/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To explore the characteristics of refractory RA and its contributory factors based on the understanding of the rheumatologists of China. METHODS A national cross-sectional survey was performed in 32 provinces across China, and 1381 rheumatologists were recruited. Information about the sociodemographic background, refractory RA characteristics, and contributory factors was collected using a pre-made questionnaire including fourteen single-choice and four multiple-choice questions, respectively. Each of the single-choice and multiple-choice question had several items. RESULTS In response to the single-choice questions regarding the definition of refractory RA, 52.28% responded that "the 28 joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR) > 5.1 with presence of signs suggestive of inflammatory disease" is characteristic of refractory RA, whereas 50.18% opined that "If target was not achieved with 2 conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) combined with 1 biological or 1 targeted synthetic DMARD (b/tsDMARD), over a total of 3~6 months" should be considered refractory RA. In addition, 39.32% rheumatologists were in favor of inability to taper glucocorticoids (GCs) ≤ 10mg prednisone or equivalent daily. Additional features considered characteristics of refractory RA were extra-articular manifestations (84.94%), interfering comorbidities (76.32%), and radiographic progression (71.83%). Among the contributory factors, 92.03% considered infection, and interstitial lung disease was chosen by 90.95%, vasculitis by 82.26%, osteoporosis by 70.67%, and fibromyalgia syndrome by 70.38%. CONCLUSIONS Our survey has demonstrated a variety of concepts of refractory RA among the rheumatologists of China. Disease activity assessment, treatment options, interfering comorbidities, and radiological progression all were associated with the characteristics of refractory RA. Key Points • This study demonstrated the definition, characteristics, and contributing factors of refractory RA from the rheumatologists' views in China. • The clarification of the insights and concepts on refractory RA will help to make comprehensive guidelines to treat this disease, further improving prognosis and reducing the societal burdens of RA.
Collapse
|
12
|
Weng C, Xue L, Wang Q, Lu W, Xu J, Liu Z. Comparative efficacy and safety of Janus kinase inhibitors and biological disease-modifying antirheumatic drugs in rheumatoid arthritis: a systematic review and network meta-analysis. Ther Adv Musculoskelet Dis 2021; 13:1759720X21999564. [PMID: 33815570 PMCID: PMC7989112 DOI: 10.1177/1759720x21999564] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/01/2021] [Indexed: 12/21/2022] Open
Abstract
Objective: To evaluate the comparative efficacy and safety of Janus kinase (JAK) inhibitors and biological disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) and an inadequate response to at least one disease-modifying antirheumatic drug (DMARD). Methods: PubMed, Embase, Cochrane library and ClinicalTrials.gov were searched for relevant randomized controlled trials (RCTs) from inception to April 2020. The active drugs included three JAK inhibitors and eight bDMARDs while the control drugs included placebo or conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Outcomes include American College of Rheumatology 20% response (ACR20), Disease Activity Score in 28 joints (DAS28), Health Assessment Questionnaire–Disability Index (HAQ-DI) and discontinuations for adverse events (AEs). We estimated summary odds ratios (ORs) and weighted mean differences (WMDs) using network meta-analysis with random effects. Results: Eighty-eight RCTs with 31,566 patients were included. All JAK inhibitors and bDMARDs were more effective than placebo in ACR20 (ORs ranging between 3.05 and 5.61), DAS28 (WMDs ranging between −1.91 and −0.80) and HAQ-DI (WMDs ranging between −0.34 and −0.21). Tocilizumab, certolizumab pegol and upadacitinib showed relatively good efficacy in these three outcomes according to their relative ranking. Notably, tocilizumab was more effective than other active drugs in DAS28 (WMDs ranging between −1.11 and −0.49). Compared with the lower recommended doses, increasing the doses of JAK inhibitors (baricitinib 4 mg versus 2 mg, tofacitinib 10 mg versus 5 mg and upadacitinib 30 mg versus 15 mg) cannot provide significant additional benefits. In terms of discontinuations for AEs, all active drugs showed no significant difference compared with placebo except certolizumab pegol [OR 1.65, 95% credible interval (CrI) 1.06–2.61] and rituximab (3.17, 1.11–10.80). Conclusions: Tocilizumab, certolizumab pegol and upadacitinib may have relatively good efficacy in patients with RA after treatment failure with csDMARDs. RA patients taking a JAK inhibitor may have a preference for a lower recommended dose.
Collapse
Affiliation(s)
- Chenghua Weng
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Leixi Xue
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qing Wang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wentian Lu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiajun Xu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhichun Liu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Sanxiang Road No.1055, Suzhou, Jiangsu, 215000, P.R. China
| |
Collapse
|
13
|
BİLGİN E, CEYLAN F, DURAN E, FARİSOĞULLARI B, BÖLEK EÇ, YARDIMCI GK, KILIÇ L, AKDOĞAN A, KARADAĞ Ö, BİLGEN ŞA, KİRAZ S, ERTENLİ Aİ, KALYONCU U. Efficacy, retention, and safety of tofacitinib in real-life: Hur-bio monocentric experience. Turk J Med Sci 2021; 51:297-308. [PMID: 32979899 PMCID: PMC7991862 DOI: 10.3906/sag-2007-123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background/aim To assess the real-life efficacy, retention rate, and safety data of tofacitinib in rheumatoid arthritis (RA) patients. Materials and methods We analyzed all patients registered in the HURBİO database who received at least 1 dose of tofacitinib. Patients who received at least one dose were included in retention analysis; patients with at least 1 control visit were included in efficacy and safety analysis. Factors predicting good response at the last follow-up visit were analyzed by logistic regression analysis. Drug retention rates were calculated using the Kaplan–Meier method and predictors of drug retention were determined by Cox proportional hazard model. Adverse events, reasons for switching, and discontinuation were also determined. Results Two hundred and forty-seven (210, 85.0% female) patients were included in the study. The median duration of tofacitinib treatment was 10.2 (20.2) [med, (IQR)] months. Two hundred and four (82.6%) patients were included in safety and efficacy analysis; 45.6% of patients were in low-disease activity (LDA) state (DAS28-CRP ≤ 3.2). Predictors of LDA were being biologic-naïve [aOR 2.53 (1.31–4.88); 95% CI] and RF negativity [aOR 2.14 (1.12–4.07); 95% CI]. At 1 year, the overall tofacitinib retention rate was 63.9% with no relevant predicting factor. Response and retention rates of tofacitinib were similar in patients with and without concomitant csDMARDs. Treatment failure was the most common cause of discontinuation. The most common infectious and laboratory adverse events were herpes zoster infection (3.9 per 100 patient-years) and elevation in ALT (x3UNL: 9.7 per 100 patient-years), respectively. Conclusion Tofacitinib is effective as monotherapy or in combination with csDMARDs. It is a well-tolerated treatment option in Turkish RA patients.
Collapse
Affiliation(s)
- Emre BİLGİN
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Furkan CEYLAN
- Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Emine DURAN
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Bayram FARİSOĞULLARI
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Ertuğrul Çağrı BÖLEK
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Gözde Kübra YARDIMCI
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Levent KILIÇ
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Ali AKDOĞAN
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Ömer KARADAĞ
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Şule Apraş BİLGEN
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Sedat KİRAZ
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Ali İhsan ERTENLİ
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| | - Umut KALYONCU
- Division of Rheumatology, Department of Internal Medicine, Medical School of Hacettepe University, AnkaraTurkey
| |
Collapse
|
14
|
Roodenrijs NMT, Hamar A, Kedves M, Nagy G, van Laar JM, van der Heijde D, Welsing PMJ. Pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of difficult-to-treat rheumatoid arthritis. RMD Open 2021; 7:e001512. [PMID: 33419871 PMCID: PMC7798678 DOI: 10.1136/rmdopen-2020-001512] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To summarise, by a systematic literature review (SLR), the evidence regarding pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis (D2T RA), informing the EULAR recommendations for the management of D2T RA. METHODS PubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised. RESULTS Two hundred seven (207) papers studied therapeutic strategies. Limited evidence was found on effective and safe disease-modifying antirheumatic drugs (DMARDs) in patients with comorbidities and other contraindications that limit DMARD options (patients with obesity, hepatitis B and C, risk of venous thromboembolisms, pregnancy and lactation). In patients who previously failed biological (b-)DMARDs, all currently used b/targeted synthetic (ts-)DMARDs were found to be more effective than placebo. In patients who previously failed a tumour necrosis factor inhibitor (TNFi), there was a tendency of non-TNFi bDMARDs to be more effective than TNFis. Generally, effectiveness decreased in patients who previously failed a higher number of bDMARDs. Additionally, exercise, psychological, educational and self-management interventions were found to improve non-inflammatory complaints (mainly functional disability, pain, fatigue), education to improve goal setting, and self-management programmes, educational and psychological interventions to improve self-management.The identified evidence had several limitations: (1) no studies were found in patients with D2T RA specifically, (2) heterogeneous outcome criteria were used and (3) most studies had a moderate or high risk of bias. CONCLUSIONS This SLR underscores the scarcity of high-quality evidence on the pharmacological and non-pharmacological treatment of patients with D2T RA. Effectiveness of b/tsDMARDs decreased in RA patients who had failed a higher number of bDMARDs and a subsequent b/tsDMARD of a previously not targeted mechanism of action was somewhat more effective. Additionally, a beneficial effect of non-pharmacological interventions was found for improvement of non-inflammatory complaints, goal setting and self-management.
Collapse
Affiliation(s)
- Nadia M T Roodenrijs
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Attila Hamar
- Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Melinda Kedves
- Rheumatology, Bacs-Kiskun Megyei Korhaz, Kecskemet, Hungary
| | - György Nagy
- Genetics, Cell- and Immunobiology & Rheumatology & Clinical Rheumatology, Semmelweis University, Budapest, Hungary
| | - Jacob M van Laar
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Paco M J Welsing
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
15
|
Chaudhari AJ, Raynor WY, Gholamrezanezhad A, Werner TJ, Rajapakse CS, Alavi A. Total-Body PET Imaging of Musculoskeletal Disorders. PET Clin 2021; 16:99-117. [PMID: 33218607 PMCID: PMC7684980 DOI: 10.1016/j.cpet.2020.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Imaging of musculoskeletal disorders, including arthritis, infection, osteoporosis, sarcopenia, and malignancies, is often limited when using conventional modalities such as radiography, computed tomography (CT), and MR imaging. As a result of recent advances in Positron Emission Tomography (PET) instrumentation, total-body PET/CT offers a longer axial field-of-view, higher geometric sensitivity, and higher spatial resolution compared with standard PET systems. This article discusses the potential applications of total-body PET/CT imaging in the assessment of musculoskeletal disorders.
Collapse
Affiliation(s)
- Abhijit J Chaudhari
- Department of Radiology, University of California Davis, 4860 Y Street, Sacramento, CA 95825, USA.
| | - William Y Raynor
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia, PA 19129, USA
| | - Ali Gholamrezanezhad
- Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Los Angeles, CA 90033, USA
| | - Thomas J Werner
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Abass Alavi
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| |
Collapse
|
16
|
Xie F, Chen L, Yun H, Levitan EB, Curtis JR. Benefits of Methotrexate Use on Cardiovascular Disease Risk Among Rheumatoid Arthritis Patients Initiating Biologic Disease-modifying Antirheumatic Drugs. J Rheumatol 2020; 48:804-812. [PMID: 33060309 DOI: 10.3899/jrheum.191326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Methotrexate (MTX) has been associated with reduced risk for cardiovascular disease (CVD) events among patients with rheumatoid arthritis (RA) not exposed to biologic disease-modifying antirheumatic drugs (bDMARDs). The effect of concomitant MTX on CVD risk among RA patients initiating bDMARDs remains unknown. METHODS A retrospective cohort study was conducted to assess the effect of MTX on CVD risk using 2006-2015 Medicare claims data for patients with RA initiating bDMARD. The main exposure was current use of MTX, updated in a time-varying fashion. The primary outcome was a composite of incident myocardial infarction (MI), stroke, and fatal CVD. Secondary outcomes were each event that comprised the primary outcome. Incidence rates (IR) and 95% CI were calculated using Poisson regression. Associations between MTX and risk of CVD were assessed using Cox regression. RESULTS A total of 88,255 bDMARD initiations and 1861 CVD events were included in this study. Mean age was 64.6 (12.3) years, 84.0% were female, and 68.2% were non-Hispanic White. The crude IRs (95% CI) for CVD were 17.9 (16.9-18.8) and 12.1 (11.1-13.2) per 1000 patient-years among MTX unexposed and exposed, respectively. The multivariable adjusted HR (95% CI) for CVD events associated with MTX was 0.76 (0.68-0.85). Multivariable adjusted HRs were 0.78 (0.66-0.91), 0.74 (0.62-0.88), 0.77 (0.68-0.86), and 0.82 (0.73-0.93) for MI, stroke, MI or stroke, and a composite CVD outcome, respectively. Results were robust in sensitivity and subgroup analyses. CONCLUSION Among patients with RA receiving biologics, concomitant MTX use was associated with a 24% lower risk for CVD events.
Collapse
Affiliation(s)
- Fenglong Xie
- F. Xie, PhD, H. Yun, PhD, J.R. Curtis, MD, MS, MPH, Division of Clinical Immunology and Rheumatology, and Department of Epidemiology, University of Alabama at Birmingham
| | - Lang Chen
- L. Chen, PhD, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham
| | - Huifeng Yun
- F. Xie, PhD, H. Yun, PhD, J.R. Curtis, MD, MS, MPH, Division of Clinical Immunology and Rheumatology, and Department of Epidemiology, University of Alabama at Birmingham
| | - Emily B Levitan
- E.B. Levitan, ScD, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- F. Xie, PhD, H. Yun, PhD, J.R. Curtis, MD, MS, MPH, Division of Clinical Immunology and Rheumatology, and Department of Epidemiology, University of Alabama at Birmingham;
| |
Collapse
|
17
|
Affiliation(s)
| | - Amravi Shah
- Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Viswanath Kaushik
- Department of Rheumatology, Apollo Hospital, Chennai, Tamil Nadu, India
| |
Collapse
|
18
|
Janke K, Biester K, Krause D, Richter B, Schürmann C, Hirsch K, Hörn H, Kerekes MF, Kohlepp P, Wieseler B. Comparative effectiveness of biological medicines in rheumatoid arthritis: systematic review and network meta-analysis including aggregate results from reanalysed individual patient data. BMJ 2020; 370:m2288. [PMID: 32636183 PMCID: PMC7338922 DOI: 10.1136/bmj.m2288] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the comparative effectiveness of biological medicines in rheumatoid arthritis in sufficiently similar patient populations, based on the current definitions of key outcomes. DESIGN Systematic review and network meta-analysis including aggregate results from reanalysed individual patient data. DATA SOURCES Clinical study reports and aggregate results from reanalyses of individual patient data on key outcomes for rheumatoid arthritis provided by study sponsors for studies conducted up to 2017, and several databases and registries from inception up to February 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials investigating patient relevant outcomes in adults with rheumatoid arthritis treated with biological medicines in combination with methotrexate after methotrexate failure for at least 24 weeks. RESULTS 45 eligible trials were identified. Combining data from clinical study reports and aggregate results from reanalyses of individual patient data allowed extensive analyses yielding sufficiently similar populations and homogeneous study results for network meta-analyses, including up to 35 studies on eight biological medicines combined with methotrexate. These analyses showed few statistically significant differences between the combination treatments. For example, anakinra showed less benefit than almost all the other seven biological medicines regarding clinical remission or low disease activity (clinical disease activity index ≤2.8 or ≤10, respectively) and certolizumab pegol showed more harm than the other seven biological medicines regarding serious adverse events or infections. Some outcomes had very wide 95% confidence intervals, potentially implying unidentified differences between the eight biological medicines, but wide 95% confidence intervals were less prominent for low disease activity, serious adverse events, and infections. Owing to a lack of head-to-head trials, results were mainly based on indirect comparisons with a limited number of studies, and recently approved Janus kinase inhibitors could not be included. CONCLUSIONS For patients with rheumatoid arthritis after methotrexate failure, only minor differences in benefits and harms were seen between biological medicines in combination with methotrexate. However, the analysis was hampered by a lack of long term direct comparisons. The substantial information gain achieved by the reanalysis of individual patient data calls for the routine availability of individual patient data.
Collapse
Affiliation(s)
- Kirsten Janke
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Katharina Biester
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | | | - Bernd Richter
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christoph Schürmann
- Medical Biometry Department, Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Katharina Hirsch
- Medical Biometry Department, Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Helmut Hörn
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Michaela Florina Kerekes
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Petra Kohlepp
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Beate Wieseler
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| |
Collapse
|
19
|
Angelini J, Talotta R, Roncato R, Fornasier G, Barbiero G, Dal Cin L, Brancati S, Scaglione F. JAK-Inhibitors for the Treatment of Rheumatoid Arthritis: A Focus on the Present and an Outlook on the Future. Biomolecules 2020; 10:E1002. [PMID: 32635659 PMCID: PMC7408575 DOI: 10.3390/biom10071002] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023] Open
Abstract
Janus kinase inhibitors (JAKi) belong to a new class of oral targeted disease-modifying drugs which have recently revolutionized the therapeutic panorama of rheumatoid arthritis (RA) and other immune-mediated diseases, placing alongside or even replacing conventional and biological drugs. JAKi are characterized by a novel mechanism of action, consisting of the intracellular interruption of the JAK-STAT pathway crucially involved in the immune response. The aim of this narrative review is to globally report the most relevant pharmacological features and clinical outcomes of the developed and incoming JAKi for RA, based on the available preclinical and clinical evidence. A total of 219 papers, including narrative and systematic reviews, randomized controlled trials (RCTs), observational studies, case reports, guidelines, and drug factsheets, were selected. The efficacy and safety profile of both the first generation JAKi (baricitinib and tofacitinib) and the second generation JAKi (upadacitinib, filgotinib, peficitinib, decernotinib and itacitinib) were compared and discussed. Results from RCTs and real-life data are encouraging and outline a rapid onset of the pharmacologic effects, which are maintained during the time. Their efficacy and safety profile are comparable or superior to those of biologic agents and JAKi proved to be efficacious when given as monotherapy. Finally, the manufacturing of JAKi is relatively easier and cheaper than that of biologics, thus increasing the number of compounds being formulated and tested for clinical use.
Collapse
Affiliation(s)
- Jacopo Angelini
- Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, 20133 Milan, Italy; (J.A.); (G.F.); (G.B.); (L.D.C.); (S.B.)
| | - Rossella Talotta
- Department of Clinical and Experimental Medicine, Rheumatology Unit, AOU “Gaetano Martino”, University of Messina, 98100 Messina, Italy
| | - Rossana Roncato
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Pordenone, 33081 Aviano, Italy;
| | - Giulia Fornasier
- Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, 20133 Milan, Italy; (J.A.); (G.F.); (G.B.); (L.D.C.); (S.B.)
- Pharmacy Unit, IRCCS-Burlo Garofolo di Trieste, 34137 Trieste, Italy
| | - Giorgia Barbiero
- Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, 20133 Milan, Italy; (J.A.); (G.F.); (G.B.); (L.D.C.); (S.B.)
| | - Lisa Dal Cin
- Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, 20133 Milan, Italy; (J.A.); (G.F.); (G.B.); (L.D.C.); (S.B.)
| | - Serena Brancati
- Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, 20133 Milan, Italy; (J.A.); (G.F.); (G.B.); (L.D.C.); (S.B.)
| | - Francesco Scaglione
- Head of Clinical Pharmacology and Toxicology Unit, Grande Ospedale Metropolitano Niguarda, Department of Oncology and Onco-Hematology, Director of Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, 20162 Milan, Italy;
| |
Collapse
|
20
|
Nasonov EL, Avdeeva AS, Lila AM. Efficacy and safety of tofacitinib for immune-mediated inflammatory rheumatic diseases (Part I). RHEUMATOLOGY SCIENCE AND PRACTICE 2020. [DOI: 10.14412/1995-4484-2020-62-79] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | | | - A. M. Lila
- V.A. Nasonova Research Institute of Rheumatology; Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia
| |
Collapse
|
21
|
Ho CTK, Mok CC, Cheung TT, Kwok KY, Yip RML. Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology. Clin Rheumatol 2019; 38:3331-3350. [PMID: 31485846 DOI: 10.1007/s10067-019-04761-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022]
Abstract
The expanding range of treatment options for rheumatoid arthritis (RA), from conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to biological DMARDs (bDMARDs), biosimilar bDMARDs, and targeted synthetic DMARDs, has improved patient outcomes but increased the complexity of treatment decisions. These updated consensus recommendations from the Hong Kong Society of Rheumatology provide guidance on the management of RA, with a focus on how to integrate newly available DMARDs into clinical practice. The recommendations were developed based on evidence from the literature along with local expert opinion. Early diagnosis of RA and prompt initiation of effective therapy remain crucial and we suggest a treat-to-target approach to guide optimal sequencing of DMARDs in RA patients to achieve tight disease control. Newly available DMARDs are incorporated in the treatment algorithm, resulting in a greater range of second-line treatment options. In the event of treatment failure or intolerance, switching to another DMARD with a similar or different mode of action may be considered. Given the variety of available treatments and the heterogeneity of patients with RA, treatment decisions should be tailored to the individual patient taking into consideration prognostic factors, medical comorbidities, drug safety, cost of treatment, and patient preference.
Collapse
Affiliation(s)
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Tuen Mun, Hong Kong, China.
| | | | | | | |
Collapse
|
22
|
Santos-Moreno P, Valencia O. Experiencia de unidades de terapias biológicas en artritis reumatoide y otras enfermedades autoinmunes. ACTA ACUST UNITED AC 2019; 15:61-62. [DOI: 10.1016/j.reuma.2018.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 12/12/2018] [Indexed: 12/13/2022]
|
23
|
A Bayesian mixed treatment comparison of efficacy of biologics and small molecules in early rheumatoid arthritis. Clin Rheumatol 2019; 38:1309-1317. [PMID: 30628014 DOI: 10.1007/s10067-018-04406-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/18/2018] [Indexed: 01/05/2023]
Abstract
The current paradigm in the management of rheumatoid arthritis (RA) is to treat patients in the early stage of the disease (ERA). Previous meta-analysis-based mixed treatment comparisons (MTCs), aimed to identify the most effective drugs in ERA, are biased by the wide "window" of early definition, ranging from 6 months to 2 years. The aim of this study was to estimate through a Bayesian Network Meta-Analysis which biologics or small molecules are more likely to achieve a 1-year good clinical response in ERA patients with disease duration < 1 year. According to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, randomized controlled trials (RCTs) of biologic agents and small molecules in combination with MTX to treat patients affected with ERA lasting < 1 year were searched through MEDLINE, EMBASE, Cochrane Library, and Clinicaltrials.gov between 1990 and September 2017. The outcome of interest was the achievement of American College of Rheumatology (ACR) 50 and ACR 70 response at 1 year. WinBUGS 1.4 software (MRC Biostatistics Unit, Cambridge, UK) was used to perform the analyses, using a fixed effect model. Fourteen studies were included in the analysis. Tofacitinib (64.83%) followed by Etanercept (23.26%) were the drugs with the highest probability of achieving ACR50 response. Rituximab showed the highest probability of inducing ACR70 response (52.81%) followed by Etanercept (26.85%). This is the first MTC involving only RCTs on ERA patients with disease duration < 1 year. Tofacitinib and rituximab were the drugs ranked first in inducing 1-year ACR50 and ACR70 response, respectively.
Collapse
|
24
|
Li SJ, Perez-Chada LM, Merola JF. TNF Inhibitor-Induced Psoriasis: Proposed Algorithm for Treatment and Management. ACTA ACUST UNITED AC 2018; 4:70-80. [PMID: 31093599 PMCID: PMC6513344 DOI: 10.1177/2475530318810851] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tumor necrosis factor a (TNF-α)-targeted therapies have expanded the therapeutic options for patients with inflammatory bowel disease (IBD), rheumatoid arthritis (RA), psoriasis, and psoriatic arthritis (PsA) and have significantly improved patients' quality of life. Paradoxically, anti-TNF-α agents may induce psoriatic eruptions or worsen preexisting psoriatic skin disease. Currently, there is no standard approach for the management of TNF inhibitor-induced psoriasis. Here, we conduct a literature review on TNF inhibitor-induced psoriasis and introduce a novel treatment algorithm for maintaining otherwise effective anti-TNF therapy versus switching to a different class as appropriate in the management of patients with IBD, RA, psoriasis, or PsA.
Collapse
Affiliation(s)
- Sara Jiayang Li
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lourdes M Perez-Chada
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph F Merola
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW Etanercept was the first tumour necrosis factor inhibitor approved to treat rheumatoid arthritis (RA) in the United States (US) and Europe. The recent patent expiration of the etanercept originator ENBREL in Europe has facilitated the development of biosimilar products, creating the prospect of reduced treatment costs. In this article, we review the original trials for etanercept in RA to facilitate critical appraisal of biosimilar trial data. RECENT FINDINGS Two etanercept biosimilars are currently approved in Europe and/or the US, SB4 (Benepali) and GP2015 (Erelzi), having met the pre-specified equivalence criteria for biosimilarity. Trial data demonstrates subtle differences in clinical outcomes and adverse events between the biosimilars and the reference product (RP). The development of etanercept biosimilars may reduce the financial burden of treating RA, but real-world data regarding efficacy and safety in comparison to the RP will be vital to assess for meaningful differences.
Collapse
Affiliation(s)
- Laura Chadwick
- Institute of Ageing and Chronic Disease, University of Liverpool, Aintree University Hospital, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Sizheng Zhao
- Institute of Ageing and Chronic Disease, University of Liverpool, Aintree University Hospital, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Eduardo Mysler
- Organización Medica de Investigación, Buenos Aires, Argentina
| | - Robert J Moots
- Institute of Ageing and Chronic Disease, University of Liverpool, Aintree University Hospital, Longmoor Lane, Liverpool, L9 7AL, UK.
- Department of Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, Aintree University Hospital, Clinical Sciences Centre, Longmoor Lane, Liverpool, L9 7AL, UK.
| |
Collapse
|
26
|
|
27
|
Chuang SY, Lin CH, Huang TH, Fang JY. Lipid-Based Nanoparticles as a Potential Delivery Approach in the Treatment of Rheumatoid Arthritis. NANOMATERIALS 2018; 8:nano8010042. [PMID: 29342965 PMCID: PMC5791129 DOI: 10.3390/nano8010042] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 12/23/2022]
Abstract
Rheumatoid arthritis (RA), a chronic and joint-related autoimmune disease, results in immune dysfunction and destruction of joints and cartilages. Small molecules and biological therapies have been applied in a wide variety of inflammatory disorders, but their utility as a therapeutic agent is limited by poor absorption, rapid metabolism, and serious side effects. To improve these limitations, nanoparticles, which are capable of encapsulating and protecting drugs from degradation before they reach the target site in vivo, may serve as drug delivery systems. The present research proposes a platform for different lipid nanoparticle approaches for RA therapy, taking advantage of the newly emerging field of lipid nanoparticles to develop a targeted theranostic system for application in the treatment of RA. This review aims to present the recent major application of lipid nanoparticles that provide a biocompatible and biodegradable delivery system to effectively improve RA targeting over free drugs via the presentation of tissue-specific targeting of ligand-controlled drug release by modulating nanoparticle composition.
Collapse
Affiliation(s)
- Shih-Yi Chuang
- Research Center for Food and Cosmetic Safety and Research Center for Chinese Herbal Medicine, Chang Gung University of Science and Technology, Kweishan, Taoyuan 333, Taiwan.
| | - Chih-Hung Lin
- Center for General Education, Chang Gung University of Science and Technology, Kweishan, Taoyuan 333, Taiwan.
| | - Tse-Hung Huang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Keelung 204, Taiwan.
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan 333, Taiwan.
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan.
| | - Jia-You Fang
- Research Center for Food and Cosmetic Safety and Research Center for Chinese Herbal Medicine, Chang Gung University of Science and Technology, Kweishan, Taoyuan 333, Taiwan.
- Pharmaceutics Laboratory, Graduate Institute of Natural Products, Chang Gung University, Kweishan, Taoyuan 333, Taiwan.
- Chinese Herbal Medicine Research Team, Healthy Aging Research Center, Chang Gung University, Kweishan, Taoyuan 333, Taiwan.
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan.
| |
Collapse
|
28
|
The Role of High-Mobility Group Box-1 and Its Crosstalk with Microbiome in Rheumatoid Arthritis. Mediators Inflamm 2017; 2017:5230374. [PMID: 29200665 PMCID: PMC5672636 DOI: 10.1155/2017/5230374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/16/2017] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, definitely disabling, and potentially severe autoimmune disease. Although an increasing number of patients are affected, a key treatment for all patients has not been discovered. High-mobility group box-1 (HMGB1) is a nuclear protein passively and actively released by almost all cell types after several stimuli. HMGB1 is involved in RA pathogenesis, but a convincing explanation about its role and possible modulation in RA is still lacking. Microbiome and its homeostasis are altered in patients with RA, and the microbiota restoration has been proposed to patients with RA. The purpose of the present review is to analyze the available evidences regarding HMGB1 and microbiome roles in RA and the possible implications of the crosstalk between the nuclear protein and microbiome in understanding and possibly treating patients affected by this harmful condition.
Collapse
|
29
|
Gadina M, Gazaniga N, Vian L, Furumoto Y. Small molecules to the rescue: Inhibition of cytokine signaling in immune-mediated diseases. J Autoimmun 2017; 85:20-31. [PMID: 28676205 DOI: 10.1016/j.jaut.2017.06.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/15/2017] [Indexed: 12/14/2022]
Abstract
Cytokines are small, secreted proteins associated with the maintenance of immune homeostasis but also implicated with the pathogenesis of several autoimmune and inflammatory diseases. Biologic agents blocking cytokines or their receptors have revolutionized the treatment of such pathologies. Nonetheless, some patients fail to respond to these drugs or do not achieve complete remission. The signal transduction originating from membrane-bound cytokine receptors is an intricate network of events that lead to gene expression and ultimately regulate cellular functionality. Our understanding of the intracellular actions that molecules such as interleukins, interferons (IFNs) and tumor necrosis factor (TNF) set into motion has greatly increased in the past few years, making it possible to interfere with cytokines' signaling cascades. The Janus kinase (JAK)/signal transducer and activator of transcription (STAT), the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB), the mitogen activated protein kinase (MAPK) and the Phosphatidylinositol-3'-kinases (PI3K) pathways have all been intensively studied and key steps as well as molecules have been identified. These research efforts have led to the development of a new generation of small molecule inhibitors. Drugs capable of blocking JAK enzymatic activity or interfering with the proteasome-mediated degradation of intermediates in the NF-kB pathway have already entered the clinical arena confirming the validity of this approach. In this review, we have recapitulated the biochemical events downstream of cytokine receptors and discussed some of the drugs which have already been successfully utilized in the clinic. Moreover, we have highlighted some of the new molecules that are currently being developed for the treatment of immune-mediated pathologies and malignancies.
Collapse
Affiliation(s)
- Massimo Gadina
- Translational Immunology Section, Office of Science and Technology, National Institute of Arthritis Musculoskeletal and Skin Diseases, USA.
| | - Nathalia Gazaniga
- Translational Immunology Section, Office of Science and Technology, National Institute of Arthritis Musculoskeletal and Skin Diseases, USA
| | - Laura Vian
- Translational Immunology Section, Office of Science and Technology, National Institute of Arthritis Musculoskeletal and Skin Diseases, USA
| | - Yasuko Furumoto
- Translational Immunology Section, Office of Science and Technology, National Institute of Arthritis Musculoskeletal and Skin Diseases, USA
| |
Collapse
|
30
|
Singh JA, Hossain A, Mudano AS, Tanjong Ghogomu E, Suarez‐Almazor ME, Buchbinder R, Maxwell LJ, Tugwell P, Wells GA. Biologics or tofacitinib for people with rheumatoid arthritis naive to methotrexate: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2017; 5:CD012657. [PMID: 28481462 PMCID: PMC6481641 DOI: 10.1002/14651858.cd012657] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Biologic disease-modifying anti-rheumatic drugs (biologics) are highly effective in treating rheumatoid arthritis (RA), however there are few head-to-head biologic comparison studies. We performed a systematic review, a standard meta-analysis and a network meta-analysis (NMA) to update the 2009 Cochrane Overview. This review is focused on the adults with RA who are naive to methotrexate (MTX) that is, receiving their first disease-modifying agent. OBJECTIVES To compare the benefits and harms of biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib versus comparator (methotrexate (MTX)/other DMARDs) in people with RA who are naive to methotrexate. METHODS In June 2015 we searched for randomized controlled trials (RCTs) in CENTRAL, MEDLINE and Embase; and trials registers. We used standard Cochrane methods. We calculated odds ratios (OR) and mean differences (MD) along with 95% confidence intervals (CI) for traditional meta-analyses and 95% credible intervals (CrI) using a Bayesian mixed treatment comparisons approach for network meta-analysis (NMA). We converted OR to risk ratios (RR) for ease of interpretation. We also present results in absolute measures as risk difference (RD) and number needed to treat for an additional beneficial or harmful outcome (NNTB/H). MAIN RESULTS Nineteen RCTs with 6485 participants met inclusion criteria (including five studies from the original 2009 review), and data were available for four TNF biologics (adalimumab (six studies; 1851 participants), etanercept (three studies; 678 participants), golimumab (one study; 637 participants) and infliximab (seven studies; 1363 participants)) and two non-TNF biologics (abatacept (one study; 509 participants) and rituximab (one study; 748 participants)).Less than 50% of the studies were judged to be at low risk of bias for allocation sequence generation, allocation concealment and blinding, 21% were at low risk for selective reporting, 53% had low risk of bias for attrition and 89% had low risk of bias for major baseline imbalance. Three trials used biologic monotherapy, that is, without MTX. There were no trials with placebo-only comparators and no trials of tofacitinib. Trial duration ranged from 6 to 24 months. Half of the trials contained participants with early RA (less than two years' duration) and the other half included participants with established RA (2 to 10 years). Biologic + MTX versus active comparator (MTX (17 trials (6344 participants)/MTX + methylprednisolone 2 trials (141 participants))In traditional meta-analyses, there was moderate-quality evidence downgraded for inconsistency that biologics with MTX were associated with statistically significant and clinically meaningful benefit versus comparator as demonstrated by ACR50 (American College of Rheumatology scale) and RA remission rates. For ACR50, biologics with MTX showed a risk ratio (RR) of 1.40 (95% CI 1.30 to 1.49), absolute difference of 16% (95% CI 13% to 20%) and NNTB = 7 (95% CI 6 to 8). For RA remission rates, biologics with MTX showed a RR of 1.62 (95% CI 1.33 to 1.98), absolute difference of 15% (95% CI 11% to 19%) and NNTB = 5 (95% CI 6 to 7). Biologics with MTX were also associated with a statistically significant, but not clinically meaningful, benefit in physical function (moderate-quality evidence downgraded for inconsistency), with an improvement of HAQ scores of -0.10 (95% CI -0.16 to -0.04 on a 0 to 3 scale), absolute difference -3.3% (95% CI -5.3% to -1.3%) and NNTB = 4 (95% CI 2 to 15).We did not observe evidence of differences between biologics with MTX compared to MTX for radiographic progression (low-quality evidence, downgraded for imprecision and inconsistency) or serious adverse events (moderate-quality evidence, downgraded for imprecision). Based on low-quality evidence, results were inconclusive for withdrawals due to adverse events (RR of 1.32, but 95% confidence interval included possibility of important harm, 0.89 to 1.97). Results for cancer were also inconclusive (Peto OR 0.71, 95% CI 0.38 to 1.33) and downgraded to low-quality evidence for serious imprecision. Biologic without MTX versus active comparator (MTX 3 trials (866 participants)There was no evidence of statistically significant or clinically important differences for ACR50, HAQ, remission, (moderate-quality evidence for these benefits, downgraded for imprecision), withdrawals due to adverse events,and serious adverse events (low-quality evidence for these harms, downgraded for serious imprecision). All studies were for TNF biologic monotherapy and none for non-TNF biologic monotherapy. Radiographic progression was not measured. AUTHORS' CONCLUSIONS In MTX-naive RA participants, there was moderate-quality evidence that, compared with MTX alone, biologics with MTX was associated with absolute and relative clinically meaningful benefits in three of the efficacy outcomes (ACR50, HAQ scores, and RA remission rates). A benefit regarding less radiographic progression with biologics with MTX was not evident (low-quality evidence). We found moderate- to low-quality evidence that biologic therapy with MTX was not associated with any higher risk of serious adverse events compared with MTX, but results were inconclusive for withdrawals due to adverse events and cancer to 24 months.TNF biologic monotherapy did not differ statistically significantly or clinically meaningfully from MTX for any of the outcomes (moderate-quality evidence), and no data were available for non-TNF biologic monotherapy.We conclude that biologic with MTX use in MTX-naive populations is beneficial and that there is little/inconclusive evidence of harms. More data are needed for tofacitinib, radiographic progression and harms in this patient population to fully assess comparative efficacy and safety.
Collapse
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
| | - Amy S Mudano
- University of Alabama at BirminghamDepartment of Medicine ‐ RheumatologyBirminghamUSA
| | | | - Maria E Suarez‐Almazor
- The University of Texas, MD Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - 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
| | | |
Collapse
|