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Huang Y, Agarwal SK, Chatterjee S, Chen H, Johnson ML, Aparasu RR. Risk of incident cardiovascular events with disease-modifying anti-rheumatic drugs among adults with rheumatoid arthritis: a nested case-control study. Clin Rheumatol 2024; 43:103-116. [PMID: 37540382 DOI: 10.1007/s10067-023-06709-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/22/2023] [Accepted: 07/16/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE This study examined the risk of cardiovascular disease (CVD) associated with the disease-modifying anti-rheumatic drugs (DMARDs) in rheumatoid arthritis (RA). METHOD This nested case-control study used the MarketScan database (2012-2014), involving adult RA patients (aged ≥18 years) initiating either a conventional synthetic (cs) DMARD, biologic DMARD, or targeted synthetic (ts) DMARD between January 1, 2013 and December 31, 2014 (cohort entry) and had no CVD history. Cases were individuals with incident CVD identified using diagnosis codes or procedure codes from medical claims. For each case, 10 age- and sex-matched controls were selected using the incident density sampling with replacement. Prescriptions of DMARDs were measured 90 days before the event date. Conditional logistic regression examined the association of risk of CVD with DMARDs in combination treatment or individual use, with reference to methotrexate (MTX) monotherapy, adjusting for baseline confounders. Subgroup analyses were performed separately in DMARD combination therapy users or individual DMARD users, respectively. RESULTS In total, 270 cases of incident CVD and 2700 controls were included (mean [standard deviation (SD)] age: 54 [1]; 75.6% women). The commonly prescribed DMARD therapies were csDMARD monotherapy (n = 795, 27.04%), followed by tumor necrosis factor inhibitors (TNFi) monotherapy (n = 367, 12.48%), and TNFi in combination with MTX (n = 314, 10.68%). Compared with MTX monotherapy, overall use of DMARD agents was not associated with the differential risk of CVD, including various types of DMARD combination regimens. The findings were similar across subgroup analyses. CONCLUSIONS The study found no differential risk of CVD with DMARDs in combination therapy or monotherapy compared to MTX monotherapy in patients with RA. Key Points • This study evaluated the risk of cardiovascular disease (CVD) associated with the disease-modifying anti-rheumatic drugs (DMARDs) in rheumatoid arthritis (RA). • Findings suggest no differential CVD risk with DMARDs in combination with MTX or used individually compared with MTX monotherapy in patients with early RA. • Further efforts should focus on a better understanding of the mechanism of DMARD combination treatments with MTX in modifying CV risk.
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Affiliation(s)
- Yinan Huang
- Department of Pharmacy Administration, College of Pharmacy, University of Mississippi, Oxford, MS, USA
| | - Sandeep K Agarwal
- Section of Immunology, Allergy & Rheumatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Satabdi Chatterjee
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, 4849 Calhoun Road, Health & Sciences Bldg. 2, Houston, TX, 77204, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, 4849 Calhoun Road, Health & Sciences Bldg. 2, Houston, TX, 77204, USA
| | - Michael L Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, 4849 Calhoun Road, Health & Sciences Bldg. 2, Houston, TX, 77204, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, 4849 Calhoun Road, Health & Sciences Bldg. 2, Houston, TX, 77204, USA.
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Merjanah S, Liew JW, Bihn J, Fillmore NR, Brophy MT, Do NV, Dubreuil M. Trends in Fracture Rates Over Two Decades Among Veterans With Ankylosing Spondylitis. Arthritis Care Res (Hoboken) 2023; 75:2481-2488. [PMID: 37308459 PMCID: PMC10704387 DOI: 10.1002/acr.25166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/09/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE There is an increased risk of fracture in individuals with ankylosing spondylitis (AS) compared to the general population, possibly due to systemic inflammatory effects. The use of tumor necrosis factor inhibitors (TNFi) may reduce fracture risk by inhibiting inflammation. We assessed fracture rates in AS versus non-AS comparators and whether these rates have changed since the introduction of TNFi. METHODS We used the national Veterans Affairs database to identify adults ≥18 years old with ≥1 International Classification of Diseases, Ninth Revision (ICD-9)/ICD-10 code for AS and at least 1 disease-modifying antirheumatic drug prescription. As comparators, we selected a random sample of adults without AS diagnosis codes. We calculated fracture incidence rates for AS and comparators, with direct standardization to the cohort structure in 2017. To compare fracture rates from 2000 to 2002 (pre-TNFi) versus 2004-2020 (TNFi era), we performed an interrupted time series analysis. RESULTS We included 3,794 individuals with AS (mean age 53 years, 92% male) and 1,152,805 comparators (mean age 60 years, 89% male). For AS, the incidence rate of fractures increased from 7.9/1,000 person-years in 2000 to 21.6/1,000 person-years in 2020. The rate also increased among comparators, although the ratio of fracture rates (AS/comparators) remained relatively stable. In the interrupted time series, the fracture rate for AS patients in the TNFi era was nonsignificantly increased compared to the pre-TNFi era. CONCLUSION Fracture rates have increased over time for both AS and non-AS comparators. The fracture rate in individuals with AS did not decrease after TNFi introduction in 2003.
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Affiliation(s)
- Sali Merjanah
- Section of Rheumatology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Jean W. Liew
- Section of Rheumatology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - John Bihn
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, MA
| | - Nathanael R. Fillmore
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Mary T. Brophy
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, MA
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Nhan V. Do
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, MA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Maureen Dubreuil
- Section of Rheumatology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
- VA Boston Department of Medicine, VA Boston Healthcare System, Boston, MA
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Huang Y, Agarwal SK, Chen H, Chatterjee S, Johnson ML, Aparasu RR. Real-world Comparative Effectiveness of Methotrexate-based Combinations for Rheumatoid Arthritis: A Retrospective Cohort Study. Clin Ther 2023; 45:e177-e186. [PMID: 37573225 DOI: 10.1016/j.clinthera.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE Guidelines recommend using disease-modifying antirheumatic drugs (DMARDs) in combination with methotrexate (MTX) for patients with rheumatoid arthritis (RA) after monotherapy. Little is known about the real-world comparative effectiveness of these MTX-DMARD combinations. This study compared the effectiveness of various MTX-based DMARD combinations for patients with RA initiating MTX-DMARD combination therapy using administrative claims database. METHODS This retrospective cohort study included adults (aged ≥18 years) with RA who initiated MTX combination treatment with conventional synthetic DMARDs (csDMARDs), tumor necrosis factor inhibitor (TNFi) biologic DMARDs (bDMARDs), non-TNFi bDMARDs, or targeted synthetic DMARDs (tsDMARDs) between July 1, 2012, and December 31, 2013 (index date), from the MarketScan Commercial Claims Data. Patients had continuous enrollment from the 6 months of preindex period until the 12 months of postindex period. The MTX-based DMARD combination therapy cohort was defined as ≥1 MTX prescription in the first 30 days from the index date and ≥14 days overlapping use of the prescription fills of the MTX and the index DMARD. Effectiveness was measured by using the claims algorithm (dosing, switching, addition, oral glucocorticoid use, or multiple glucocorticoid injection). Propensity score analysis with the inverse probability of treatment weighting (PS-IPTW), estimated by using the generalized boosted machine learning method, was used to balance the distribution of baseline variables between the combination groups. Multivariable logistic regression using PS-IPTW was conducted to compare the effectiveness of the combination groups. Sensitivity analysis evaluated the modified effectiveness algorithms or the time to the first treatment failure. FINDINGS A total of 3174 adult patients with RA starting an MTX-DMARD combination therapy were identified (mean [SD] age, 50 [9] years), including 1568 (49%) initiating a csDMARD + MTX, 1343 (42%) initiating TNFi + MTX, and 240 (8%) initiating non-TNFi bDMARD + MTX, and 23 (1%) initiating tsDMARD + MTX. Owing to the small sample, the tsDMARD combination group was not included in the comparative analysis. Algorithm-based therapy effectiveness was found in 9.95% of the csDMARD + MTX, 20.48% of the TNFi + MTX, and 20.83% of the non-TNFi + MTX groups. PS-IPTW showed that the csDMARD combination is less effective (adjusted odds ratio, 0.422; 95% CI, 0.341-0.524) than the TNFi combination; however, the non-TNFi biologic combination had similar effectiveness (aOR, 1.063; 95% CI, 0.680-1.662) compared to the TNFi combination. Sensitivity analyses confirmed the main results. IMPLICATIONS Among RA patients initiating MTX-DMARD combinations, both non-TNFi biologics and TNFi-based combinations with MTX were equally effective, but csDMARD + MTX was less effective than the TNFi plus MTX.
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Affiliation(s)
- Yinan Huang
- Department of Pharmacy Administration, School of Pharmacy, University of Mississippi, Oxford. Mississippi, USA
| | - Sandeep K Agarwal
- Section of Immunology, Allergy & Rheumatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Satabdi Chatterjee
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Michael L Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA.
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Huang Y, Chatterjee S, Agarwal SK, Chen H, Johnson ML, Aparasu RR. Factors influencing prescribing the first add-on disease-modifying antirheumatic drugs in patients initiating methotrexate for rheumatoid arthritis. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 11:100296. [PMID: 37521021 PMCID: PMC10372178 DOI: 10.1016/j.rcsop.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 08/01/2023] Open
Abstract
Background Advances in Disease-Modifying Antirheumatic Drugs (DMARDs) have expanded the treatment landscape for Rheumatoid Arthritis (RA). Guidelines recommend adding either conventional synthetic (cs), biologic (b), or targeted synthetic (ts) DMARDs to methotrexate (MTX) for managing RA. Limited evidence exists regarding the factors that contribute to adding a DMARD agent to the MTX regimen. This study examined the factors associated with adding the first DMARD in RA patients initiating MTX. Methods This retrospective cohort study utilized the MarketScan data (2012-2014) involving adults (aged ≥18) with RA initiating an MTX (index date) between Jul 1, 2012 and Dec 30, 2013, and with continuous enrollment for the 6-month pre-index period. The combination therapy users received the first treatment addition of DMARD starting from day 30 after the index MTX over one year period. The study focused on the addition of csDMARDs, Tumor Necrosis Factor Inhibitors (TNFi) bDMARDs, non-TNFi bDMARDs, or tsDMARDs. Baseline covariates were measured in the 6-month pre-index and grouped into predisposing, enabling, and need factors, as per the Andersen Behavior Model. Multivariable logistic regression examined the factors associated with the addition of TNFi compared to adding a csDMARD. An additional regression model evaluated the factors associated with adding any biologic (combining TNFi and non-TNFi biologics). Results Among 8350 RA patients starting MTX, 31.92% (n = 2665) initiated any DMARD within the 1-year post-index period. Among RA patients initiating a DMARD prescription after starting MTX, 945 (11.32%) received combination therapy with treatment addition of a DMARD to MTX regimen; majority added TNFi (550, 58%), followed by csDMARD (352, 37%); non-TNF biologic (40, 4%), or tsDMARD (3, 0.3%). The tsDMARD group was limited and was not included for further analysis. The multivariable model found Preferred Provider Organization insurance coverage (odds ratio [OR], 1.43; 95% confidence interval (CI), 1.06-1.93), chronic pulmonary disease (OR, 1.98; 95% CI, 1.14-3.44), liver disease (OR, 5.24; 95% CI, 1.77-15.49), and Elixhauser score (OR, 0.91; 95% CI, 0.86-0.97) were significantly associated with the addition of TNF-α inhibitors. The separate multivariable model additionally found that patients from metropolitan areas (OR, 1.50; 95% CI, 1.04-2.16) were positively associated with adding any biological agent. Conclusions TNFi are often added to MTX for managing RA. Enabling and need factors contribute to the prescribing of a TNFi add-on therapy in RA. Future research should examine the impact of these combination therapies on RA management.
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Affiliation(s)
- Yinan Huang
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS, United States of America
| | - Satabdi Chatterjee
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
| | - Sandeep K. Agarwal
- Section of Immunology, Allergy & Rheumatology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
| | - Michael L. Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
| | - Rajender R. Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
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Moon DH, Kim A, Song BW, Kim YK, Kim GT, Ahn EY, So MW, Lee SG. High Baseline Neutrophil-to-Lymphocyte Ratio Could Serve as a Biomarker for Tumor Necrosis Factor-Alpha Blockers and Their Discontinuation in Patients with Ankylosing Spondylitis. Pharmaceuticals (Basel) 2023; 16:ph16030379. [PMID: 36986479 PMCID: PMC10055887 DOI: 10.3390/ph16030379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
Background: This study explores the association of neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), and platelet-to-lymphocyte (PLR) ratios with the 3-month treatment response and persistence of tumor necrosis factor-alpha (TNF-α) blockers in patients with ankylosing spondylitis (AS). Methods: This retrospective cohort study investigated 279 AS patients who were newly initiated on TNF-α blockers between April 2004 and October 2019 and 171 sex- and age-matched healthy controls. Response to TNF-α blockers was defined as a reduction in the Bath AS Disease Activity Index of ≥50% or 20 mm, and persistence referred to the time interval from the initiation to discontinuation of TNF-α blockers. Results: Patients with AS had significantly increased NLR, MLR, and PLR ratios as compared to controls. The frequency of non-response at 3 months was 3.7%, and TNF-α blockers’ discontinuation occurred in 113 (40.5%) patients during the follow-up period. A high baseline NLR but not high baseline MLR and PLR showed an independently significant association with a higher risk of non-response at 3 months (OR = 12.3, p = 0.025) and non-persistence with TNF-α blockers (HR = 1.66, p = 0.01). Conclusions: NLR may be a potential marker for predicting the clinical response and persistence of TNF-α blockers in AS patients.
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Affiliation(s)
- Dong-Hyuk Moon
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Republic of Korea; (D.-H.M.); (A.K.); (B.-W.S.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Aran Kim
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Republic of Korea; (D.-H.M.); (A.K.); (B.-W.S.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Byung-Wook Song
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Republic of Korea; (D.-H.M.); (A.K.); (B.-W.S.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Yun-Kyung Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Kosin University, Busan 49104, Republic of Korea; (Y.-K.K.); (G.-T.K.)
| | - Geun-Tae Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Kosin University, Busan 49104, Republic of Korea; (Y.-K.K.); (G.-T.K.)
| | - Eun-Young Ahn
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea; (E.-Y.A.); (M.-W.S.)
| | - Min-Wook So
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea; (E.-Y.A.); (M.-W.S.)
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Republic of Korea; (D.-H.M.); (A.K.); (B.-W.S.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
- Correspondence: ; Tel.: +82-51-240-7225
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A novel anti-TNF-α drug ozoralizumab rapidly distributes to inflamed joint tissues in a mouse model of collagen induced arthritis. Sci Rep 2022; 12:18102. [PMID: 36302840 PMCID: PMC9613905 DOI: 10.1038/s41598-022-23152-6] [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: 08/22/2022] [Accepted: 10/25/2022] [Indexed: 12/30/2022] Open
Abstract
In clinical studies, the next-generation anti-tumor necrosis factor-alpha (TNF-α) single domain antibody ozoralizumab showed high clinical efficacy shortly after the subcutaneous injection. To elucidate the mechanism underlying the rapid onset of the effects of ozoralizumab, we compared the biodistribution kinetics of ozoralizumab and adalimumab after subcutaneous injection in an animal model of arthritis. Alexa Fluor 680-labeled ozoralizumab and adalimumab were administered by subcutaneous injection once (2 mg/kg) at five weeks after induction of collagen-induced arthritis (CIA) in an animal arthritis model. The time-course of changes in the fluorescence intensities of the two compounds in the paws and serum were evaluated. The paws of the CIA mice were harvested at four and eight hours after the injection for fluorescence microscopy. Biofluorescence imaging revealed better distribution of ozoralizumab to the joint tissues than of adalimumab, as early as at four hours after the injection. Fluorescence microscopy revealed a greater fluorescence intensity of ozoralizumab in the joint tissues than that of adalimumab at eight hours after the injection. Ozoralizumab showed a significantly higher absorption rate constant as compared with adalimumab. These results indicate that ozoralizumab enters the systemic circulation more rapidly and is distributed to the target tissues earlier and at higher levels than conventional IgG antibodies. Our investigation provides new insight into the mechanism underlying the rapid onset of the effects of ozoralizumab in clinical practice.
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Curtis JR, Palmer JL, Reed GW, Greenberg J, Pappas DA, Harrold LR, Kremer JM. Real-World Outcomes Associated With Methotrexate, Sulfasalazine, and Hydroxychloroquine Triple Therapy Versus Tumor Necrosis Factor Inhibitor/Methotrexate Combination Therapy in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2021; 73:1114-1124. [PMID: 32374918 DOI: 10.1002/acr.24253] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 04/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Though randomized controlled trials have demonstrated relatively comparable clinical outcomes with triple therapy (methotrexate [MTX], sulfasalazine [SSZ], and hydroxychloroquine [HCQ]) compared to combination therapy (tumor necrosis factor inhibitor [TNFi] and MTX), real-world experiences comparing these strategies have not been well studied. METHODS We evaluated the clinical effectiveness and effects of medication discontinuation of triple therapy with MTX/SSZ/HCQ versus combination therapy with TNFi/MTX in rheumatoid arthritis (RA) patients enrolled in the Corrona RA Drug Safety & Effectiveness Registry. Propensity score matching was used to match patients up to a ratio of 1:3 to adjust for imbalances between treatment groups, with stratification performed according to biologics-naive or biologics-exposed status of study participants. RESULTS Patients eligible for analysis in this study included biologics-naive RA patients (3,926 who received combination therapy with TNFi/MTX and 262 who received triple therapy with MTX/SSZ/HCQ) and biologics-exposed RA patients (3,365 who received combination therapy with TNFi/MTX and 130 patients who received triple therapy with MTX/SSZ/HCQ). Before propensity score matching, numerous factors were imbalanced between the treatment groups, with triple therapy patients generally being older, having a longer disease duration of RA and lower RA disease activity, and more likely having a history of malignancy and other comorbidities. After matching, almost all (93-98%) triple therapy patients could be matched to TNFi/MTX therapy patients, and cohort characteristics were generally well balanced. Discontinuation of medication was greater in triple therapy patients referent to TNFi/MTX therapy patients (adjusted hazard ratio [HR] of 2.17 [95% confidence interval 1.63-2.88] in the biologics-naive group; adjusted HR of 1.51 [95% confidence interval 1.06-2.15] in the biologics-exposed group). At 6 months, the proportion of biologics-naive patients attaining low disease activity was significantly greater in the TNFi/MTX treatment group (49.2% in TNFi/MTX therapy patients versus 33.3% in triple therapy patients), as was the mean change in Clinical Disease Activity Index scores (-9.3 units versus -5.5 [95% confidence interval -1.5, -6.1]). Corresponding results in the biologics-exposed patients numerically favored TNFi/MTX therapy compared to triple therapy but did not reach statistical significance. CONCLUSION Few patients receive triple therapy with MTX/SSZ/HCQ in the US. In the present study, drug persistence and clinical effectiveness outcomes were less favorable in triple therapy patients compared to TNFi/MTX therapy patients.
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Affiliation(s)
| | | | - George W Reed
- University of Massachusetts Medical School, Worcester
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Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
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9
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Fraenkel L, Bathon JM, England BR, St.Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2021; 73:924-939. [PMID: 34101387 PMCID: PMC9273041 DOI: 10.1002/acr.24596] [Citation(s) in RCA: 374] [Impact Index Per Article: 124.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.
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Affiliation(s)
- Liana Fraenkel
- Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut
| | - Joan M. Bathon
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - Bryant R. England
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care System, Omaha, Nebraska
| | | | | | | | | | - Mark Genovese
- Stanford University Medical Center, Palo Alto, California
| | - Kent Kwas Huston
- The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri
| | - Gail Kerr
- Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC
| | - Joel Kremer
- Albany Medical College and The Center for Rheumatology, Albany, New York
| | | | | | - Jasvinder A. Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Benjamin J. Smith
- State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | - Jeffrey A. Sparks
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jennifer L. Barton
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | | | | | | | - Sindhu R. Johnson
- Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lara Kahale
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Reza Mirza
- University of Toronto, Toronto, Ontario, Canada
| | - Pascale Schwab
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | | | | | | | | | - Elie A. Akl
- American University of Beirut, Beirut, Lebanon
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10
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Fraenkel L, Bathon JM, England BR, St Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2021; 73:1108-1123. [PMID: 34101376 DOI: 10.1002/art.41752] [Citation(s) in RCA: 310] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/15/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.
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Affiliation(s)
- Liana Fraenkel
- Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut, United States
| | - Joan M Bathon
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, United States
| | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska, United States
| | | | | | | | | | - Mark Genovese
- Stanford University Medical Center, Palo Alto, California, United States
| | - Kent Kwas Huston
- The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri, United States
| | - Gail Kerr
- Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC, United States
| | - Joel Kremer
- Albany Medical College and The Center for Rheumatology, Albany, New York, United States
| | | | - Linda A Russell
- Hospital for Special Surgery, New York, New York, United States
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, United States
| | - Benjamin J Smith
- Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | - Michael E Weinblatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | - Joshua F Baker
- Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Jennifer L Barton
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon, United States
| | - Laura Cappelli
- Johns Hopkins Medicine, Baltimore, Maryland, United States
| | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lara Kahale
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Reza Mirza
- University of Toronto, Toronto, Ontario, Canada
| | - Pascale Schwab
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon, United States
| | | | - Marat Turgunbaev
- American College of Rheumatology, Atlanta, Georgia, United States
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia, United States
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
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11
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Affiliation(s)
| | - Alexis Ogdie
- University of Pennsylvania Medical Center, Philadelphia
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12
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Zhang Q, Liu Y, Su L, Chai W, Zhang H, Wang X, Liu D. Negative central venous to arterial lactate gradient in patients receiving vasopressors is associated with higher ICU 30-day mortality: a retrospective cohort study. BMC Anesthesiol 2021; 21:25. [PMID: 33482733 PMCID: PMC7821722 DOI: 10.1186/s12871-021-01237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 01/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background Serum lactate has long been used to evaluate hypoxia and predict prognosis in critically ill patients, however, discrepancy in lactate measurements between different sites have not been recognized as a useful tool for monitoring hypoxia and evaluating outcome. Methods Data were obtained from the clinical information system of the intensive care unit (ICU) in a tertiary academic hospital for 1582 ICU patients with vasoactive drug requirement and valid paired blood gas. The mortality rates were compared between patients with sustained negative venous to arterial lactate gradient (VALac) and the others using the Cox proportional hazard model. Predictive factors associated with negative VALac were searched. Results A sustained negative VALac was significantly associated with higher 30 day ICU mortality [Adjusted hazard ratio (HR) = 2.31, 95% confidence interval (CI), 1.07–4.99; p = 0.032. Propensity score- weighted HR: 2.57; 95% CI, 1.17–5.64; p = 0.010]. Arterial lactate in the first blood gas pair, 24-h arterial lactate clearance, use of epinephrine, mean positive end-expiratory pressure level, and extracorporeal membrane oxygenation initiation showed statistically significant association with sustained negative VALac during the first 24 h. Conclusion The sustained negative VALac in the early stage of treatment may suggest additional information about tissue hypoxia than arterial lactate alone. Critical care physicians should pay more attention to the lactate discrepancy between different sites in their clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01237-5.
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Affiliation(s)
- Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China
| | - Ye Liu
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL, 35294-0022, USA
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China
| | - Wenzhao Chai
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China.
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China
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13
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Predictive factors of treatment persistence in rheumatoid arthritis. Joint Bone Spine 2020; 87:531-534. [DOI: 10.1016/j.jbspin.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/06/2020] [Indexed: 01/23/2023]
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Carbone L, Vasan S, Elam R, Gupta S, Tolaymat O, Crandall C, Wactawski-Wende J, Johnson KC. The Association of Methotrexate, Sulfasalazine, and Hydroxychloroquine Use With Fracture in Postmenopausal Women With Rheumatoid Arthritis: Findings From the Women's Health Initiative. JBMR Plus 2020; 4:e10393. [PMID: 33103025 PMCID: PMC7574701 DOI: 10.1002/jbm4.10393] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/16/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023] Open
Abstract
This study was conducted to evaluate the extent to which disease‐modifying antirheumatic medications (DMARDs) used as part of a triple therapy for the treatment of rheumatoid arthritis (RA) including methotrexate, sulfasalazine, and hydroxychloroquine are associated with fractures in postmenopausal women with RA. Incident fractures following use of methotrexate, sulfasalazine, and/or hydroxychloroquine in postmenopausal women with RA in the Women's Health Initiative were estimated by Cox proportional hazards using hazard ratios (HRs) and 95% CIs after consideration of potential confounders. There were 1201 women with RA enrolled in the Women's Health Initiative included in these analyses, of which 74% were white, 17% were black, and 9% were of other or unknown race/ethnicity. Of the women with RA, 421 (35%) had not used methotrexate, sulfasalazine, or hydroxychloroquine, whereas 519 (43%) women had used methotrexate, 83 (7%) sulfasalazine, and 363 (30%) hydroxychloroquine alone or in combination at some time during study follow‐up. Over a median length of 6.46 years of follow‐up, in multivariable adjusted models, no statistically significant association was found between methotrexate (HR, 1.1; 95% CI, 0.8–1.6), sulfasalazine (HR, 0.6; 95% CI, 0.2–1.5), or hydroxychloroquine (HR, 1.0; 95% CI, 0.7–1.5) use and incident fractures or between combination therapy with methotrexate and sulfasalazine or methotrexate and hydroxychloroquine use (HR, 0.9; 95% CI, 0.5–1.6) and incident fractures. In conclusion, postmenopausal women with RA receiving any component of triple therapy should not be expected to have any substantial reduction in fracture risk from use of these DMARDs. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Laura Carbone
- Department of Medicine, Division of Rheumatology, J. Harold Harrison MD, Distinguished University Chair in Rheumatology Medical College of Georgia at Augusta University Augusta GA USA.,Department of Rheumatology Charlie Norwood Veterans Affairs Medical Center Augusta GA USA
| | - Sowmya Vasan
- Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Rachel Elam
- Department of Rheumatology Charlie Norwood Veterans Affairs Medical Center Augusta GA USA.,Department of Medicine, Division of Rheumatology Medical College of Georgia at Augusta University Augusta GA USA
| | - Sandeepkumar Gupta
- Department of Medicine, Division of Rheumatology Medical College of Georgia at Augusta University Augusta GA USA
| | - Omar Tolaymat
- Department of Medicine, Division of Rheumatology Medical College of Georgia at Augusta University Augusta GA USA
| | - Carolyn Crandall
- Department of Medicine, Division of General Internal Medicine and Health Services Research David Geffen School of Medicine at University of California, Los Angeles Los Angeles CA USA
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions University at Buffalo Buffalo NY USA
| | - Karen C Johnson
- Department of Preventive Medicine University of Tennessee Health Science Center Memphis TN USA
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15
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Garcia BN, Lu CC, Stephens AR, Kazmers NH, Chen W, Leng J, Li L, Sauer BC, Tyser AR. Risk of Total Wrist Arthrodesis or Reoperation Following 4-Corner Arthrodesis or Proximal Row Carpectomy for Stage-II SLAC/SNAC Arthritis: A Propensity Score Analysis of 502 Wrists. J Bone Joint Surg Am 2020; 102:1050-1058. [PMID: 32187124 DOI: 10.2106/jbjs.19.00965] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND For stage-II scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) patterns of wrist arthritis, the optimal method of surgical treatment remains unclear. Previous literature has demonstrated similar clinical outcomes between proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA), making the risk of reoperation a focus of particular interest. In the present study, the primary null hypothesis was that there would be no difference in the rate of conversion to total wrist arthrodesis between PRC and FCA. Additionally, we hypothesized that the rate of secondary surgical procedures would be similar between the 2 procedures. METHODS The national Veterans Health Administration Corporate Data Warehouse was utilized to identify 2,449 patients who underwent either PRC or FCA between 1992 and 2016. With use of operative reports to identify the arthritis pattern, only cases of stage-II SLAC/SNAC were included. All complications and subsequent surgical procedures were confirmed by manual chart review. Propensity score analyses with matching weights were utilized to balance the PRC and FCA cohorts. The rates of conversion to wrist arthrodesis and secondary surgical procedures were calculated. RESULTS Of the 1,168 patients with stage-II SLAC/SNAC arthritis, 933 wrists underwent PRC and 257 wrists underwent FCA. Ten-year survival free of total wrist arthrodesis in the matching PRC (251 procedures) and FCA (251 procedures) cohorts was 94.3% (95% confidence interval [CI], 92.3% to 96.3%) and 94.1% (95% CI, 90.8% to 97.4%), respectively. Survival free of a secondary surgical procedure other than wrist arthrodesis was 99.7% (95% CI, 99.3% to 100.0%) for PRC and 83.5% (95% CI, 78.2% to 88.8%) for FCA. CONCLUSIONS PRC and FCA demonstrated similarly low rates of conversion to total wrist arthrodesis. In contrast, the rate of secondary surgical procedures following FCA was significantly higher compared with PRC. Given the historically similar clinical outcomes between PRC and FCA, the results of the present study show that PRC may be a preferable treatment for stage-II SLAC/SNAC wrist arthritis. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brittany N Garcia
- Department of Orthopaedic Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Chao-Chin Lu
- HSR&D IDEAS Center, Salt Lake City George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.,Team VERITAS, Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Andrew R Stephens
- Department of Orthopaedic Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Nikolas H Kazmers
- Department of Orthopaedic Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Wei Chen
- HSR&D IDEAS Center, Salt Lake City George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.,Team VERITAS, Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jianwei Leng
- HSR&D IDEAS Center, Salt Lake City George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.,Team VERITAS, Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Liang Li
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian C Sauer
- HSR&D IDEAS Center, Salt Lake City George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.,Team VERITAS, Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Andrew R Tyser
- Department of Orthopaedic Surgery, University of Utah Hospital, Salt Lake City, Utah
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16
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Li CKH, Baker K, Jones T, Coulson E, Roberts A, Birrell F. Safety and Tolerability of Subcutaneous Methotrexate in Routine Clinical Practice. Arthritis Care Res (Hoboken) 2020; 73:1306-1311. [PMID: 32475009 DOI: 10.1002/acr.24334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/19/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To show the safety and efficacy of subcutaneous (SC) methotrexate (MTX) compared to oral MTX, alternative disease-modifying antirheumatic drugs (DMARDs) monotherapy, biologic monotherapy, and combinations (conventional and biologic combination groups) in routine clinical practice. METHODS Clinical and laboratory data were retrospectively analyzed for rheumatology clinic attendances at a large Northeast England hospital trust between January 2014 and January 2018. Rates of adverse events and stop events (transaminitis [serum alanine aminotransferase level of >80 units/liter] or neutropenia [neutrophil count of <2.0 × 109 /liter]) were calculated, with adjustment for duration of DMARD exposure. RESULTS In the present study, 8,394 patients received DMARDs, with 2,093 patients receiving oral MTX and 949 patients receiving SC MTX. The median dose was 15 mg (interquartile range [IQR] 10-20 mg) for oral MTX, and 20 mg (IQR 15-25 mg) for SC MTX (P < 0.0001). Continuation rates were higher for SC MTX therapy when adjusted for follow-up duration, with a rate ratio (RR) of 1.54 (95% confidence interval [95% CI] 1.40-1.70) (P < 0.0001). For the time period assessed, 2,382 patients experienced 4,358 adverse events, with 1,711 incidents of transaminitis and 2,647 incidents of neutropenia recorded. Significantly fewer adverse events were observed in patients who received SC MTX monotherapy versus those who received biologic and combination DMARD therapies (P < 0.01). Compared to oral MTX, SC MTX was associated with a nonsignificant trend toward lower rates of neutropenia, but only a slightly higher rate of transaminitis (RR 1.26 [95% CI 1.07-1.48]) (P = 0.006), despite significantly higher doses of MTX. CONCLUSION Subcutaneous MTX is safe in routine clinical practice. This is the largest study yet reported on SC MTX and provides observational data that SC MTX is continued longer and better tolerated in patients compared to other therapy groups, especially oral MTX.
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Affiliation(s)
- Christien K H Li
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Kenneth Baker
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Tania Jones
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Elizabeth Coulson
- Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Fraser Birrell
- Translational and Clinical Research Institute, Newcastle University and Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
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17
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Pokharel G, Deardon R, Barnabe C, Bykerk V, Bartlett SJ, Bessette L, Boire G, Hitchon CA, Keystone E, Pope J, Schieir O, Tin D, Thorne C, Hazlewood GS. Joint Estimation of Remission and Response for Methotrexate-Based DMARD Options in Rheumatoid Arthritis: A Bivariate Network Meta-Analysis. ACR Open Rheumatol 2019; 1:471-479. [PMID: 31777827 PMCID: PMC6858043 DOI: 10.1002/acr2.11052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 06/04/2019] [Indexed: 12/21/2022] Open
Abstract
Objective To jointly estimate American College of Rheumatology (ACR50) response (a more commonly reported outcome) and remission (a more clinically relevant outcome) for methotrexate (MTX)‐based treatment options in rheumatoid arthritis (RA). Methods We conducted a bivariate network meta‐analysis (NMA) to compare MTX monotherapy and MTX‐based conventional and biologic disease‐modifying antirheumatic drug (DMARD) combinations for RA. The correlation between the outcomes was derived from an incident RA cohort study, whereas the treatment effects were derived from randomized trials in the network of evidence. The analyses were conducted separately for MTX‐naïve and MTX–inadequate response (IR) populations in a Bayesian framework with uninformative priors. Results From the cohort study, the correlation between ACR50 response and Disease Activity Score 28 remission at 6 months was moderate (Pearson correlation coefficient = 0.58). In the bivariate NMA for MTX‐naïve populations, most combinations of MTX with either biologic or tofacitinib were statistically superior to MTX alone for both ACR50 response and remission. Triple therapy (MTX + sulfasalazine + hydroxychloroquine) was the only nonbiologic DMARD statistically superior to MTX for either ACR50 response (odds ratio [OR] 95% credible interval: 2.1 [1.0, 4.3]) or remission (OR: 2.5 [1.0, 5.8]). In the MTX‐IR analysis, all treatments except MTX + sulfasalazine were statistically superior to MTX alone. Compared to analyzing the outcomes separately, the bivariate model often resulted in more precise estimates and allowed remission to be estimated for all treatments. Conclusion Borrowing the strength of correlation between outcomes allowed us to demonstrate a statistically significant benefit for remission across most MTX‐based DMARD combinations, including triple therapy.
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Affiliation(s)
| | - Rob Deardon
- University of Calgary, Calgary, Alberta, Canada
| | | | - Vivian Bykerk
- Cornell University, New York, New York and Hospital for Special Surgery, New York, New York
| | - Susan J Bartlett
- McGill University, Montreal, Quebec, Canada, and Johns Hopkins University, Baltimore, Maryland
| | | | - Gilles Boire
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | | | - Janet Pope
- Western University, London, Ontario, Canada
| | | | - Diane Tin
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | - Carter Thorne
- Southlake Regional Health Center, Newmarket, Ontario, Canada
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18
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Erhardt DP, Cannon GW, Teng C, Mikuls TR, Curtis JR, Sauer BC. Low Persistence Rates in Patients With Rheumatoid Arthritis Treated With Triple Therapy and Adverse Drug Events Associated With Sulfasalazine. Arthritis Care Res (Hoboken) 2019; 71:1326-1335. [DOI: 10.1002/acr.23759] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 09/11/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Daniel P. Erhardt
- George E. Wahlen Veterans Administration Medical Center, Salt Lake CityUtah and University of Colorado Aurora
| | - Grant W. Cannon
- George E. Wahlen Veterans Administration Medical Center and University of Utah Salt Lake City
| | - Chia‐Chen Teng
- George E. Wahlen Veterans Administration Medical Center and University of Utah Salt Lake City
| | - Ted R. Mikuls
- Veterans Administration Nebraska–Iowa Health Care System and University of Nebraska Medical Center Omaha
| | | | - Brian C. Sauer
- George E. Wahlen Veterans Administration Medical Center and University of Utah Salt Lake City
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Lee HN, Kim YK, Kim GT, Ahn E, So MW, Sohn DH, Lee SG. Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio as predictors of 12-week treatment response and drug persistence of anti-tumor necrosis factor-α agents in patients with rheumatoid arthritis: a retrospective chart review analysis. Rheumatol Int 2019; 39:859-868. [DOI: 10.1007/s00296-019-04276-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022]
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Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. Arch Rheumatol 2019; 33:251-271. [PMID: 30632540 DOI: 10.5606/archrheumatol.2018.6911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/08/2018] [Indexed: 01/15/2023] Open
Abstract
Objectives This study aims to report the assessment of the Turkish League Against Rheumatism (TLAR) expert panel on the compliance and adaptation of the European League Against Rheumatism (EULAR) 2016 recommendations for the management of rheumatoid arthritis (RA) in Turkey. Patients and methods The EULAR 2016 recommendations for the treatment of RA were voted by 27 specialists experienced in this field with regard to participation rate for each recommendation and significance of items. Afterwards, each recommendation was brought forward for discussion and any alteration gaining ≥70% approval was accepted. Also, Turkish version of each item was rearranged. Last version of the recommendations was then revoted to determine the level of agreement. Levels of agreement of the two voting rounds were compared with Wilcoxon signed-rank test. In case of significant difference, the item with higher level of agreement was accepted. In case of no difference, the changed item was selected. Results Four overarching principles and 12 recommendations were assessed among which three overarching principles and one recommendation were changed. The changed overarching principles emphasized the importance of physical medicine and rehabilitation specialists as well as rheumatologists for the care of RA patients in Turkey. An alteration was made in the eighth recommendation on treatment of active RA patients with unfavorable prognostic indicators after failure of three conventional disease modifying anti-rheumatic drugs. Remaining principles were accepted as the same although some alterations were suggested but could not find adequate support to reach significance. Conclusion Expert opinion of the TLAR for the treatment of RA was composed for practices in Turkish rheumatology and/or physical medicine and rehabilitation clinics.
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George MD, Sauer BC, Teng CC, Cannon GW, England BR, Kerr GS, Mikuls TR, Baker JF. Biologic and Glucocorticoid Use after Methotrexate Initiation in Patients with Rheumatoid Arthritis. J Rheumatol 2018; 46:343-350. [PMID: 30275262 DOI: 10.3899/jrheum.180178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Biologic therapies can improve disease control for patients with rheumatoid arthritis (RA) but may be both overused and underused. We aimed to identify predictors of greater use of biologic therapies and to identify factors associated with persistent glucocorticoid use. METHODS Using national US Veteran's Affairs databases 2005-2016, we identified patients with RA receiving a first-ever prescription of methotrexate (MTX), requiring ≥ 6 months of baseline data. We evaluated predictors of biologic therapy initiation within 2 years of starting MTX and factors associated with baseline and persistent glucocorticoid use at 6-12 months using multivariable models. RESULTS Among 17,415 patients starting MTX, 3263 patients received biologic therapy within 2 years (20.6% 2-yr incidence). In adjusted analyses, biologic use was substantially lower in older patients [e.g., aHR 0.20 (95% CI 0.16, 0.26) for patients ≥ 80 vs < 50] and patients with more comorbidities [aHR 0.79 (95% CI 0.72, 0.87) for Charlson score ≥ 3 vs < 3]. Patients with heart failure [aHR 0.68 (95% CI 0.54, 0.84)], cancer [aHR 0.78 (95% CI 0.66, 0.92)], or who were nonwhite [aHR 0.79 (95% CI 0.72, 0.87)] were also less likely to receive a biologic. In contrast, baseline and persistent glucocorticoid use was similar across age groups and more common in patients with greater comorbidity. CONCLUSION Biologic therapy is initiated less frequently in patients with RA who are older, have more comorbidities, and who are nonwhite. While biologics may be avoided in older and sicker patients because of safety concerns, glucocorticoid use is similar regardless of age and is more frequent in patients with comorbidities, with implications for patient outcomes.
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Affiliation(s)
- Michael D George
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA. .,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania.
| | - Brian C Sauer
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA.,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania
| | - Chia-Chen Teng
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA.,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania
| | - Grant W Cannon
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA.,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania
| | - Bryant R England
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA.,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania
| | - Gail S Kerr
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA.,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania
| | - Ted R Mikuls
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA.,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania
| | - Joshua F Baker
- From the Philadelphia Veterans Affairs (VA) Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Salt Lake City VA Medical Center and University of Utah, Salt Lake City, Utah; VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center (UNMC), Omaha, Nebraska; DC VA Medical Center, Georgetown and Howard University, Washington, D.C., USA.,M.D. George, MD, MSCE, University of Pennsylvania, VA Medical Center; B.C. Sauer, PhD, VA Medical Center, University of Utah; C.C. Teng, MS, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; G.W. Cannon, MD, VA Medical Center, University of Utah; B.R. England, MD, VA Medical Center, University of Nebraska Medical Center; G.S. Kerr, MD, VA Medical Center, Georgetown and Howard Universities; T.R. Mikuls, MD, MSPH, VA Medical Center, University of Nebraska Medical Center; J.F. Baker, MD, MSCE, VA Medical Center, University of Pennsylvania
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Inui K, Koike T, Tada M, Sugioka Y, Okano T, Mamoto K, Sakawa A, Fukushima K, Nakamura H. Clinical and radiologic analysis of on-demand use of etanercept for disease flares in patients with rheumatoid arthritis for 2 years: The RESUME study: A case-control study. Medicine (Baltimore) 2018; 97:e12462. [PMID: 30235736 PMCID: PMC6160256 DOI: 10.1097/md.0000000000012462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To reduce costs of biological disease-modifying antirheumatic drugs (bDMARDs), we evaluated the efficacy of repeated etanercept (ETN) discontinuation and restarting in rheumatoid arthritis (RA) patients in a case-control study.Thirty-one bDMARD-naive RA patients with moderate to high disease activity received ETN until low disease activity (LDA) was achieved, after which ETN was discontinued. Upon flaring, ETN was readministered with observation every 2 months for 2 years, and radiographically evaluated in comparison with a historical control group treated continuously with ETN. Statistical methods including Fisher exact test, analysis of variance (ANOVA), Kruskal-Wallis test, multiple regression analysis, and Student t test were conducted as appropriate.Thirteen patients with inadequate response to ETN were withdrawn from the study, and 5 had no flare-up after ETN discontinuation. In the remaining 13 patients, ETN was used on-demand to maintain LDA. Multivariate analysis revealed that MTX was significantly correlated with ETN. All 13 patients achieved LDA at final follow-up. Although joint damage progressed in patients using ETN on-demand, structural damage progression in the on-demand group was not significantly different from that in controls.On-demand use of ETN for flaring reduced disease activity but not structural damage in 50% of patients (though not significantly). However, inhibition of joint damage was achieved in 50% of patients after 2 years, supporting on-demand use of ETN as a treatment option for patients with RA who cannot afford bDMARD or targeted synthetic DMARD therapy.
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Affiliation(s)
- Kentaro Inui
- Department of Rheumatosurgery
- Department of Orthopaedic Surgery
| | - Tatsuya Koike
- Center for Senile Degenerative Disorders, Osaka City University Medical School, Abeno-ku, Osaka
- Search Institute for Bone and Arthritis Disease (SINBAD), Shirahama Foundation for Health and Welfare, Shirahama-cho, Wakayama
| | - Masahiro Tada
- Department of Orthopaedic Surgery, Osaka City General Hospital, Miyakojima-ku
| | - Yuko Sugioka
- Center for Senile Degenerative Disorders, Osaka City University Medical School, Abeno-ku, Osaka
| | | | | | - Akira Sakawa
- Department of Orthopaedic Surgery, Osaka City Juso Hospital, Yodogawa-ku
| | - Kenzo Fukushima
- Orthopaedic Surgery, Fujiidera Municipal Hospital, Fujiidera City, Osaka, Japan
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Kan HJ, Dyagilev K, Schulam P, Saria S, Kharrazi H, Bodycombe D, Molta CT, Curtis JR. Factors associated with physicians' prescriptions for rheumatoid arthritis drugs not filled by patients. Arthritis Res Ther 2018; 20:79. [PMID: 29720237 PMCID: PMC5932861 DOI: 10.1186/s13075-018-1580-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 03/27/2018] [Indexed: 12/22/2022] Open
Abstract
Background This study estimated the extent and predictors of primary nonadherence (i.e., prescriptions made by physicians but not initiated by patients) to methotrexate and to biologics or tofacitinib in rheumatoid arthritis (RA) patients who were newly prescribed these medications. Methods Using administrative claims linked with electronic health records (EHRs) from multiple healthcare provider organizations in the USA, RA patients who received a new prescription for methotrexate or biologics/tofacitinib were identified from EHRs. Claims data were used to ascertain filling or administration status. A logistic regression model for predicting primary nonadherence was developed and tested in training and test samples. Predictors were selected based on clinical judgment and LASSO logistic regression. Results A total of 36.8% of patients newly prescribed methotrexate failed to initiate methotrexate within 2 months; 40.6% of patients newly prescribed biologics/tofacitinib failed to initiate within 3 months. Factors associated with methotrexate primary nonadherence included age, race, region, body mass index, count of active drug ingredients, and certain previously diagnosed and treated conditions at baseline. Factors associated with biologics/tofacitinib primary nonadherence included age, insurance, and certain previously treated conditions at baseline. The area under the receiver operating characteristic curve of the logistic regression model estimated in the training sample and applied to the independent test sample was 0.86 and 0.78 for predicting primary nonadherence to methotrexate and to biologics/tofacitinib, respectively. Conclusions This study confirmed that failure to initiate new prescriptions for methotrexate and biologics/tofacitinib was common in RA patients. It is feasible to predict patients at high risk of primary nonadherence to methotrexate and to biologics/tofacitinib and to target such patients for early interventions to promote adherence.
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Affiliation(s)
- Hong J Kan
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Hampton House HH502, 624 N. Broadway, Baltimore, MD, 21205, USA.
| | | | - Peter Schulam
- Computer Science Department, Johns Hopkins University, 3400 N Charles Sreett, Baltimore, MD, 21218, USA
| | - Suchi Saria
- Computer Science Department, Johns Hopkins University, 3400 N Charles Sreett, Baltimore, MD, 21218, USA
| | - Hadi Kharrazi
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Hampton House HH502, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - David Bodycombe
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Hampton House HH502, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Charles T Molta
- Main Line Rheumatology, Lankenau Medical Center, 100 Lancaster Avenue, Wynnewood, PA, 19096, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Birmingham, AL, 35294, USA
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Peper SM, Lew R, Mikuls T, Brophy M, Rybin D, Wu H, O'Dell J. Rheumatoid Arthritis Treatment After Methotrexate: The Durability of Triple Therapy Versus Etanercept. Arthritis Care Res (Hoboken) 2017; 69:1467-1472. [DOI: 10.1002/acr.23255] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/24/2017] [Accepted: 04/04/2017] [Indexed: 11/08/2022]
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Affiliation(s)
- David L Scott
- Department of Clinical Rheumatology, King's College London, Weston Education Centre, London SE5 9RJ, UK.
| | - Matt D Stevenson
- Department of Health Technology Assessment, Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
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Mena-Vazquez N, Manrique-Arija S, Yunquera-Romero L, Ureña-Garnica I, Rojas-Gimenez M, Domic C, Jimenez-Nuñez FG, Fernandez-Nebro A. Adherence of rheumatoid arthritis patients to biologic disease-modifying antirheumatic drugs: a cross-sectional study. Rheumatol Int 2017. [PMID: 28631046 DOI: 10.1007/s00296-017-3758-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aims of this study were to evaluate adherence of rheumatoid arthritis (RA) patients to biological disease-modifying antirheumatic drugs (bDMARDs), identify potential risk factors, and analyze the discriminative ability of the Morisky-Green test (MGT) to detect bDMARD nonadherence. One hundred and seventy-eight adult RA patients treated with bDMARDs were included. Adherence was measured using the medication possession ratio (MPR) of the previous 6 months. An MPR >80% was considered good adherence. Patient demographics, clinical characteristics, and MGT scores were assessed through a standardized clinical interview at the cross-sectional date. One-hundred and twelve patients (63%) were taking subcutaneous bDMARDs, while 66 (37%) were taking intravenous drugs. One-hundred fifty-eight (88.8%) showed good adherence to bDMARDs, while 79 (61.2%) also correctly took concomitant conventional synthetic DMARDs (csDMARDs). In logistic regression models, nonadherence to bDMARDs was associated with higher disease activity [odds ratio (OR) 1.45; 95% CI, 1.03-2.03; p = 0.032] and subcutaneous route (OR 3.70; 95% CI 1.02-13.48; p = 0.040). MGT accurately identified an MPR >80% of bDMARDs in 76.9% of the patients. A sensitivity of 78%, specificity of 70%, positive predictive value of 95.3%, negative predictive value of 28.5%, positive likelihood ratio (LR) of 2.6, and negative LR of 0.3% were obtained. Adherence may be good for bDMARDs but is low for csDMARDs. Low adherence for bDMARDs is associated with poorer disease control during the past 6 months and use of subcutaneous route. These findings should alert doctors to consider possible low adherence before declaring treatment failure.
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Affiliation(s)
- Natalia Mena-Vazquez
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Pabellón C: "Hospital Civil", Plaza del Hospital Civil s/n, 29009, Málaga, Spain
| | - Sara Manrique-Arija
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Pabellón C: "Hospital Civil", Plaza del Hospital Civil s/n, 29009, Málaga, Spain
| | | | - Inmaculada Ureña-Garnica
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Pabellón C: "Hospital Civil", Plaza del Hospital Civil s/n, 29009, Málaga, Spain
| | - Marta Rojas-Gimenez
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Pabellón C: "Hospital Civil", Plaza del Hospital Civil s/n, 29009, Málaga, Spain
| | - Carla Domic
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Pabellón C: "Hospital Civil", Plaza del Hospital Civil s/n, 29009, Málaga, Spain
| | - Francisco Gabriel Jimenez-Nuñez
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Pabellón C: "Hospital Civil", Plaza del Hospital Civil s/n, 29009, Málaga, Spain
| | - Antonio Fernandez-Nebro
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Pabellón C: "Hospital Civil", Plaza del Hospital Civil s/n, 29009, Málaga, Spain.
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Yusuf IH, Sharma S, Luqmani R, Downes SM. Hydroxychloroquine retinopathy. Eye (Lond) 2017; 31:828-845. [PMID: 28282061 DOI: 10.1038/eye.2016.298] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/24/2016] [Indexed: 12/16/2022] Open
Abstract
Hydroxychloroquine (HCQ; Plaquenil) is used increasingly in the management of a variety of autoimmune disorders, with well established roles in dermatology and rheumatology and emerging roles in oncology. Hydroxychloroquine has demonstrated a survival benefit in patients with systemic lupus erythematosus; some clinicians advocate its use in all such patients. However, Hydroxychloroquine and chloroquine (CQ) have been associated with irreversible visual loss due to retinal toxicity. Hydroxychloroquine retinal toxicity is far more common than previously considered; an overall prevalence of 7.5% was identified in patients taking HCQ for greater than 5 years, rising to almost 20% after 20 years of treatment. This review aims to provide an update on HCQ/CQ retinopathy. We summarise emerging treatment indications and evidence of efficacy in systemic disease, risk factors for retinopathy, prevalence among HCQ users, diagnostic tests, and management of HCQ retinopathy. We highlight emerging risk factors such as tamoxifen use, and new guidance on safe dosing, reversing the previous recommendation to use ideal body weight, rather than actual body weight. We summarise uncertainties and the recommendations made by existing HCQ screening programmes. Asian patients with HCQ retinopathy may demonstrate an extramacular or pericentral pattern of disease; visual field testing and retinal imaging should include a wider field for screening in this group. HCQ is generally safe and effective for the treatment of systemic disease but because of the risk of HCQ retinal toxicity, modern screening methods and ideal dosing should be implemented. Guidelines regarding optimal dosing and screening regarding HCQ need to be more widely disseminated.
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Affiliation(s)
- I H Yusuf
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
| | - S Sharma
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
| | - R Luqmani
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford, UK
| | - S M Downes
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
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