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Coburn BW, Baker JF, Hsu JY, Wu Q, Xie F, Curtis JR, George MD. Association of Cardiovascular Outcomes With Low-Dose Glucocorticoid Prescription in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2024. [PMID: 38923870 DOI: 10.1002/art.42928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/13/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Many guidelines recommend limiting glucocorticoids in patients with rheumatoid arthritis (RA), but 40% of patients remain on glucocorticoids long term. We evaluated the cardiovascular risk of long-term glucocorticoid prescription by studying patients on stable disease-modifying antirheumatic drugs (DMARDs). METHODS Using two claims databases, we identified patients with RA on stable DMARD therapy for >180 days. Proportional hazards models with inverse-probability weights and clustering to account for multiple observations were used to estimate the effect of glucocorticoid dose on composite cardiovascular outcomes (stroke or myocardial infarction [MI]). RESULTS There were 135,583 patients in Medicare and 39,272 in Optum's de-identified Clinformatics Data Mart (CDM) database. Medicare and CDM patients had an incidence of 1.3 and 0.8 composite cardiovascular outcomes per 100 person-years, respectively. In the older, comorbid Medicare cohort, glucocorticoids were associated with a dose-dependent increase in composite cardiovascular outcomes in adjusted models with predicted one-year incidence of 1.4% (95% confidence interval [CI] 1.2%-1.6%) for ≤5 mg, 1.6% (95% CI 1.4%-1.9%) for >5 to 10 mg, and 1.8% (95% CI 1.2%-2.5%) for >10 mg versus 1.1% (95% CI 1.1%-1.2%) among patients not receiving glucocorticoids. There was no significant association among the CDM cohort. However, in the subgroup of younger patients with RA and higher cardiovascular risk, glucocorticoids were associated with a dose-dependent increase in composite cardiovascular outcomes. CONCLUSION Among older patients with more comorbidities and younger patients with higher cardiovascular risk with RA on stable DMARD therapy, glucocorticoids were associated with a dose-dependent increased risk of MI and stroke, even at doses ≤5 mg/day. By contrast, no association was noted among younger, healthier patients with RA.
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Affiliation(s)
| | - Joshua F Baker
- University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | | | - Qufei Wu
- University of Pennsylvania, Philadelphia
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2
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Huang Y, Bruera S, Agarwal SK, Suarez-Almazor ME, Bazzazzadehgan S, Ramachandran S, Bhattacharya K, Bentley JP, Yang Y. Opioid Treatment for Adults With and Without Systemic Autoimmune/Inflammatory Rheumatic Diseases: Analysis of 2006-2019 United States National Data. Arthritis Care Res (Hoboken) 2024. [PMID: 38766880 DOI: 10.1002/acr.25378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 04/29/2024] [Accepted: 05/10/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVES This study compared opioid prescribing among ambulatory visits with systemic autoimmune/inflammatory rheumatic diseases (SARDs) or without and assessed factors associated with opioid prescribing in SARDs. METHODS This cross-sectional study used the National Ambulatory Medical Care Survey between 2006 and 2019. Adult (≥18 years) visits with a primary diagnosis of SARDs, including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or systemic lupus erythematosus were included in the study. Opioid prescribing was compared between those with vs without SARDs using multivariable logistic regression accounting for the complex survey design and adjusting for predisposing, enabling, and need factors within Andersen's Behavioral Model of Health Services Use. Another multivariable logistic regression examined the predictors associated with opioid prescribing in SARDs. RESULTS Annually, an average of 5.20 million (95% confidence interval [CI] 3.58-6.82) visits were made for SARDs, whereas 780.14 million (95% CI 747.56-812.72) visits were made for non-SARDs. The SARDs group was more likely to be prescribed opioids (22.53%) than the non-SARDs group (9.83%) (adjusted odds ratio [aOR] 2.65; 95% CI 1.68-4.18). Among the SARDs visits, patient age from 50 to 64 (aOR 1.95; 95% CI 1.05-3.65 relative to ages 18-49) and prescribing of glucocorticoids (aOR 1.75; 95% CI 1.20-2.54) were associated with an increased odd of opioid prescribing, whereas private insurance relative to Medicare (aOR 0.50; 95% CI 0.31-0.82) was associated with a decreased odds of opioid prescribing. CONCLUSION Opioid prescribing in SARDs was higher compared to non-SARDs. Concerted efforts are needed to determine the appropriateness of opioid prescribing in SARDs.
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Affiliation(s)
- Yinan Huang
- The University of Mississippi School of Pharmacy, University, Mississippi
| | | | | | | | | | | | | | - John P Bentley
- The University of Mississippi School of Pharmacy, University, Mississippi
| | - Yi Yang
- The University of Mississippi School of Pharmacy, University, Mississippi
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3
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Shan S, Mian M. Diagnostic Value of Short Course Low-dose Prednisolone in Patients with Clinically Suspected Seronegative Inflammatory Arthritis - A Retrospective Study. Curr Rheumatol Rev 2024; 20:296-303. [PMID: 38173068 DOI: 10.2174/0115733971273652231213092458] [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: 09/07/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE We aim to establish the utility of a trial of low-dose systemic glucocorticoid therapy in the assessment of new clinically suspected inflammatory arthritis patients. METHODS We retrospectively identified patients from a private rheumatology practice in Melbourne, Australia between January 1st, 2019, and December 31st, 2021, who presented with clinically suspected inflammatory arthritis and subsequently underwent a trial of low-dose prednisolone (15 mg daily weaned over three weeks in 5 mg increments). We excluded patients with known autoimmune/ inflammatory disorders or concurrent immunosuppression at presentation. We collected basic participant demographic details and clinical details of their presentation, glucocorticoid response, investigations, and treatment. RESULTS We recruited 177 participants with a median age of 52, and 69.5% were female gender. The median symptom time to presentation was 12 months. Hands were the most affected joint in 63.3% and 85% had bilateral disease. Among the participants, 29.4% had synovitis on clinical review and 75.7% had imaging performed as part of the initial assessment. At presentation, the median CRP was 11 and the median ESR was 16. 79.7% of the cohort experienced significant improvement in their arthritis symptoms from low-dose glucocorticoids and 83.6% of the cohort required long-term immunosuppression for an underlying inflammatory condition. Of those who responded to glucocorticoids, 92.1% were diagnosed with an inflammatory condition. Rheumatoid arthritis was the most common overall diagnosis in 28%. CONCLUSION An initial trial of low-dose glucocorticoids in undifferentiated arthritis patients is useful in predicting the diagnosis of inflammatory arthritis. It is also a predictor of further long-term steroid-sparing therapy.
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Affiliation(s)
- Sam Shan
- Department of General Medicine, Northern Health, Victoria, 3076, Australia
| | - Mueed Mian
- Department of Rheumatology, Northern Health, Victoria, 3076, Australia
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Barbulescu A, Sjölander A, Delcoigne B, Askling J, Frisell T. Glucocorticoid exposure and the risk of serious infections in rheumatoid arthritis: a marginal structural model application. Rheumatology (Oxford) 2023; 62:3391-3399. [PMID: 36821426 PMCID: PMC10547528 DOI: 10.1093/rheumatology/kead083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE Observational studies have reported an increased risk of infections associated with glucocorticoids in RA, not supported by evidence from randomized controlled trials. Inappropriately accommodating time-varying exposure and confounding in observational studies might explain the conflicting results. Therefore, we compared the incidence of serious infections between different oral glucocorticoid dose patterns over three years in a prospective inception cohort, adjusting for time-varying confounders in marginal structural models. METHODS We included 9654 newly diagnosed RA patients from the Swedish Rheumatology Quality Register between 2007-2018 and followed them for three years after the first rheumatology visit. Follow-up was divided into 90-day periods. A mean oral prednisone daily dose was calculated for each period and categorized into 'no use', 'low' (≤10 mg/day) and 'high' (>10 mg/day) doses. The incidence of serious infections (hospitalization for infection) over follow-up periods was modelled by pooled logistic regression allowing separate effects for recent and past exposure. RESULTS An increased incidence of serious infections was associated with higher compared with lower doses and with more recent compared with past glucocorticoid exposure. Over 3 years of follow-up, the marginal structural models predicted one additional serious infection for every 83 individuals treated with low GC doses for the first 6 months, and for every 125 individuals treated with high GC doses for the first 3 months, compared with no GC use. CONCLUSION Our results broadly agree with previous observational studies showing a dose dependent increased risk of infection associated with (recent) use of oral glucocorticoids.
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Affiliation(s)
- Andrei Barbulescu
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Bénédicte Delcoigne
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Rheumatology, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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5
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Frew AJ, Corry DB. Glucocorticoids. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00083-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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6
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George MD, Hsu JY, Hennessy S, Chen L, Xie F, Curtis JR, Baker JF. Risk of Serious Infection With Low-dose Glucocorticoids in Patients With Rheumatoid Arthritis: An Instrumental Variable Analysis. Epidemiology 2022; 33:65-74. [PMID: 34561348 PMCID: PMC8633063 DOI: 10.1097/ede.0000000000001422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Low-dose glucocorticoids are commonly used in the treatment of rheumatoid arthritis (RA). Observational studies have found an increased risk of serious infection associated with low-dose glucocorticoids, but concerns about residual confounding remain. METHODS We identified adults with RA on stable immunomodulatory therapy for >6 months receiving no glucocorticoids or ≤5 mg/day using Medicare data from 2006 to 2015. We used provider preference for glucocorticoids as an instrumental variable (IV) to assess associations between low-dose glucocorticoid use and the risk of infection requiring hospitalization using a cause-specific proportional hazards model. RESULTS We identified 163,603 qualifying treatment episodes among 120,656 patients. Glucocorticoids ≤5 mg/day were used by 25,373/81,802 (31.0%) of patients seen by a rheumatologist with low provider preference for glucocorticoids and by 36,087/81,801 (44.1%) of patients seen by a rheumatologist with high provider preference for glucocorticoids (adjusted odds ratio 1.81, 95% confidence interval 1.77, 1.84 for association between provider preference and glucocorticoids). Chronic obstructive pulmonary disease, opioids, antibiotics, previous emergency department visits, hospitalizations, and infections requiring hospitalization infections were unbalanced with regard to exposure but not to the IV. The incidence of infection requiring hospitalization was 8.0/100 person-years among patients unexposed to glucocorticoids versus 11.7/100 person-years among those exposed. The association between glucocorticoids and infection requiring hospitalization from IV analysis (hazard ratio 1.26 [1.02-1.56]) was similar to results from a standard multivariable model (hazard ratio 1.24 [1.21-1.28]). CONCLUSIONS Among patients with RA on stable immunomodulatory therapy, IV analysis based on provider preference demonstrated an increased risk of infection requiring hospitalization associated with low-dose glucocorticoids, similar to a traditional analysis.
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Affiliation(s)
- Michael D. George
- University of Pennsylvania, Division of Rheumatology, Philadelphia, Pennsylvania, UA
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
| | - Jesse Y. Hsu
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
| | - Sean Hennessy
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
| | - Lang Chen
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, Alabama, UA
| | - Fenglong Xie
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, Alabama, UA
| | - Jeffrey R. Curtis
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, Alabama, UA
| | - Joshua F. Baker
- University of Pennsylvania, Division of Rheumatology, Philadelphia, Pennsylvania, UA
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
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Ba X, Huang Y, Shen P, Huang Y, Wang H, Han L, Lin WJ, Yan HJ, Xu LJ, Qin K, Chen Z, Tu SH. WTD Attenuating Rheumatoid Arthritis via Suppressing Angiogenesis and Modulating the PI3K/AKT/mTOR/HIF-1α Pathway. Front Pharmacol 2021; 12:696802. [PMID: 34646130 PMCID: PMC8502817 DOI: 10.3389/fphar.2021.696802] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Wutou Decoction (WTD), as a classic prescription, has been generally used to treat rheumatoid arthritis (RA) for two thousand years in China. However, the potential protective effects of WTD on rheumatoid arthritis and its possible mechanism have rarely been reported. Purpose: The aim of this study was to explore the possible mechanism of WTD against RA and a promising alternative candidate for RA therapy. Methods: A model of collagen-induced arthritis (CIA) was constructed in rats to assess the therapeutic effects of WTD. Histopathological staining, immunofluorescence, and western blotting of synovial sections were conducted to detect the antiangiogenic effects of WTD. Then, cell viability assays, flow cytometry, scratch healing assays, and invasion assays were conducted to explore the effects of WTD on MH7A human fibroblast-like synoviocyte (FLS) cell proliferation, apoptosis, migration, and invasion in vitro. The ability of WTD to induce blood vessel formation after MH7A cell and human umbilical vein endothelial cell line (HUVEC) coculture with WTD intervention was detected by a tube formation assay. The mechanisms of WTD were screened by network pharmacology and confirmed by in vivo and in vitro experiments. Results: WTD ameliorated the symptoms and synovial pannus hyperplasia of CIA rats. Treatment with WTD inhibited MH7A cell proliferation, migration, and invasion and promoted MH7A apoptosis. WTD could inhibit MH7A cell expression of proangiogenic factors, including VEGF and ANGI, to induce HUVEC tube formation. Furthermore, the PI3K-AKT-mTOR-HIF-1α pathway was enriched as a potential target of WTD for the treatment of RA through network pharmacology enrichment analysis. Finally, it was confirmed in vitro and in vivo that WTD inhibits angiogenesis in RA by interrupting the PI3K-AKT-mTOR-HIF-1α pathway. Conclusion: WTD can inhibit synovial hyperplasia and angiogenesis, presumably by inhibiting the migration and invasion of MH7A cells and blocking the production of proangiogenic effectors in MH7A cells. The possible underlying mechanism by which WTD ameliorates angiogenesis in RA is the PI3K-AKT-mTOR-HIF-1α pathway.
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Affiliation(s)
- Xin Ba
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Huang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pan Shen
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yao Huang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Wang
- Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Liang Han
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Ji Lin
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Jia Yan
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Jun Xu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kai Qin
- Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhe Chen
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Hao Tu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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8
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Huang Y, Rege S, Chatterjee S, Aparasu RR. Opioid Prescribing Among Outpatients with Rheumatoid Arthritis. PAIN MEDICINE 2021; 22:2224-2234. [PMID: 33565582 DOI: 10.1093/pm/pnab054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To examine the outpatient opioid prescribing practices and the factors associated with opioid prescriptions in patient visits with rheumatoid arthritis (RA). DESIGN This cross-sectional study used the 2011-2016 National Ambulatory Medical Care Survey. Descriptive weighted analyses were used to examine the trends in opioid prescribing practices for RA. Multivariable logistic regression was used to examine the factors associated with opioid prescriptions among RA visits. SUBJECTS Adult patients (>18 years of age) with a primary diagnosis of RA based on the International Classification of Diseases. RESULTS According to the national surveys, an average of 4.45 (95% confidence interval [CI], 2.30-6.60) million office visits were made annually for RA. Approximately 24.28% of these visits involved opioid prescriptions. The RA visits involving opioid prescriptions increased from 1.43 million in 2011-2012 to 3.69 million in 2015-2016 (P < .0001). Being in the age group of 50-64 years (odds ratio [OR] = 3.40; 95% CI, 1.29-9.00), being Hispanic or Latino (OR = 2.92, 95% CI, 1.10-7.74), visiting primary physician (OR = 4.67; 95% CI, 1.86-11.75), prescribing of muscle relaxants (OR = 64.32; 95% CI, 9.71-426.09), acetaminophen (OR = 93.40; 95% CI, 26.19-333.04), antidepressants (OR = 6.10; 95% CI, 2.63-14.14), and glucocorticoids (OR = 3.20; 95% CI, 1.61-6.38), were associated with an increased likelihood of receiving opioid prescriptions in RA. CONCLUSIONS One in four adult RA visits resulted in opioid prescriptions, and the opioid visits more than doubled during the study period. Several patient and provider factors were associated with the opioid prescribing among RA visits. Understanding these prescribing practices can help to devise strategies for safe opioid prescribing practices in RA.
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Affiliation(s)
- Yinan Huang
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Sanika Rege
- 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
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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9
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Stacy JM, Greenmyer JR, Beal JR, Sahmoun AE, Diri E. The efficacy of low dose short-term prednisone therapy for remission induction in newly diagnosed rheumatoid arthritis patients. Adv Rheumatol 2021; 61:50. [PMID: 34372936 DOI: 10.1186/s42358-021-00205-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ACR/EULAR recommendations endorse the use of glucocorticoids (GCs) for rheumatoid arthritis (RA) patients' flares and as a bridge to a DMARD. However, the recommendation of low dose short-term monotherapy with (GCs) remains open to the discretion of the clinician. The aim of this study was to assess whether a short-term use of low dose prednisone monotherapy was effective in inducing remission in newly diagnosed RA patients. METHODS A retrospective analysis of patients newly diagnosed with RA at a Community Health Center in North Dakota was performed based on the ACR/EULAR RA classification criteria. Demographic and clinical data were abstracted from patients' medical charts. Patients treated with (< 10 mg/day) of prednisone up to 6 months were included. Response to prednisone was analyzed according to pre- and post-treatment DAS28-ESR score and EULAR response criteria. RESULTS Data on 201 patients were analyzed. The mean prednisone dose was 8 mg/day (range: 5-10; SD = 1.2) and the mean treatment duration was 42.2 days (12-177; 16.9). Disease severity significantly improved from baseline to follow-up for: tender joint count (8.6 ± 4.8 vs. 1.5 ± 3.3; P < 0.001), swollen joint count (6.2 ± 5.0 vs. 1.4 ± 3.0; P < 0.001), and visual analog pain score (4.8 ± 2.6 vs. 2.1 ± 2.5; P < 0.001). DAS28-ESR disease severity significantly improved from baseline to follow-up: (5.1 ± 1.2 vs. 2.7 ± 1.3; P < 0.001). Per EULAR response criteria, 69.7% of patients showed good response to treatment and 20.4% showed moderate response. 54.2% of patients reached remission. CONCLUSION Short-term use of low dose prednisone monotherapy induced disease remission and improved clinical severity of RA in the majority of newly diagnosed patients.
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Affiliation(s)
- John M Stacy
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Jacob R Greenmyer
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - James R Beal
- Department of Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Abe E Sahmoun
- Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Forks, ND, USA
| | - Erdal Diri
- Division of Rheumatology, Trinity Medical Group, Minot, ND, USA.
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10
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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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The characteristics and its contributing factors of refractory rheumatoid arthritis, view of the rheumatologists of China: results of a nationwide cross-sectional survey. Clin Rheumatol 2021; 40:4029-4038. [PMID: 33942201 DOI: 10.1007/s10067-021-05687-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/20/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To explore the characteristics of refractory RA and its contributory factors based on the understanding of the rheumatologists of China. METHODS A national cross-sectional survey was performed in 32 provinces across China, and 1381 rheumatologists were recruited. Information about the sociodemographic background, refractory RA characteristics, and contributory factors was collected using a pre-made questionnaire including fourteen single-choice and four multiple-choice questions, respectively. Each of the single-choice and multiple-choice question had several items. RESULTS In response to the single-choice questions regarding the definition of refractory RA, 52.28% responded that "the 28 joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR) > 5.1 with presence of signs suggestive of inflammatory disease" is characteristic of refractory RA, whereas 50.18% opined that "If target was not achieved with 2 conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) combined with 1 biological or 1 targeted synthetic DMARD (b/tsDMARD), over a total of 3~6 months" should be considered refractory RA. In addition, 39.32% rheumatologists were in favor of inability to taper glucocorticoids (GCs) ≤ 10mg prednisone or equivalent daily. Additional features considered characteristics of refractory RA were extra-articular manifestations (84.94%), interfering comorbidities (76.32%), and radiographic progression (71.83%). Among the contributory factors, 92.03% considered infection, and interstitial lung disease was chosen by 90.95%, vasculitis by 82.26%, osteoporosis by 70.67%, and fibromyalgia syndrome by 70.38%. CONCLUSIONS Our survey has demonstrated a variety of concepts of refractory RA among the rheumatologists of China. Disease activity assessment, treatment options, interfering comorbidities, and radiological progression all were associated with the characteristics of refractory RA. Key Points • This study demonstrated the definition, characteristics, and contributing factors of refractory RA from the rheumatologists' views in China. • The clarification of the insights and concepts on refractory RA will help to make comprehensive guidelines to treat this disease, further improving prognosis and reducing the societal burdens of RA.
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Quantity and Quality of Rheumatoid Arthritis and Osteoarthritis Clinical Practice Guidelines: Systematic Review and Assessment Using AGREE II. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00172-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Venter G, Tieu J, Black R, Lester S, Leonardo N, Whittle SL, Hoon E, Barrett C, Rowett D, Buchbinder R, Hill CL. Perspectives of Glucocorticoid Use in Patients with Rheumatoid Arthritis. ACR Open Rheumatol 2021; 3:231-238. [PMID: 33609083 PMCID: PMC8063143 DOI: 10.1002/acr2.11234] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/20/2020] [Indexed: 12/18/2022] Open
Abstract
Objective Prednisolone is an effective oral glucocorticoid for managing symptoms of rheumatoid arthritis (RA) but has predictable and common adverse effects. We explored patient perspectives of prednisolone use in RA. Methods Patients with RA registered with the Australian Rheumatology Association Database (ARAD) who had completed an ARAD questionnaire in the preceding 12 months were invited to participate in an online survey. Responses were linked to already collected respondent demographics, medication use, and patient‐reported outcome measures. The Beliefs about Medicine Questionnaire (BMQ) measured patient beliefs on medication necessity and concerns. Free‐text responses outlining reasons for stopping or declining prednisolone underwent thematic analysis using NVivo 12. Results The survey response rate was 79.6% (804/1010), including 251 (31.2%) reporting current prednisolone use and 432 (53.7%) reporting previous use. Compared with previous users, current users were older (P = 0.0002) and had worse self‐reported pain, disease activity, health‐related quality of life, and function (all P < 0.001). Current users had higher BMQ scores for prednisolone‐specific necessity (3.6 versus 1.7; P <0.001) and concerns (2.7 versus 2.3; P <0.001). In previous prednisolone users (n = 432), the most frequent themes identified in free‐text responses for cessation were adequate disease control (30.3%), adverse effects (25.2%), and predetermined short courses (21.3%). Of respondents citing adverse effects for cessation (n = 131), weight gain (27.5%), osteoporosis (14.7%), and neuropsychiatric issues (13.8%) were most frequent. Conclusions In our cohort, patients with RA taking prednisolone believed it was necessary yet remained concerned about its use. Adequate disease control and adverse effects were important considerations for patients using prednisolone.
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Affiliation(s)
- Gabriella Venter
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and University of Adelaide, Adelaide, South Australia, Australia
| | - Joanna Tieu
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and University of Adelaide, Adelaide, South Australia, Australia
| | - Rachel Black
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Susan Lester
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and University of Adelaide, Adelaide, South Australia, Australia
| | - Nieves Leonardo
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Samuel L Whittle
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and University of Adelaide, Adelaide, South Australia, Australia
| | - Elizabeth Hoon
- University of Adelaide, Adelaide, South Australia, Australia
| | | | - Debra Rowett
- University of South Australia, Adelaide, South Australia, Australia
| | - Rachelle Buchbinder
- Monash University, Melbourne, Victoria, Australia, and Cabrini Institute, Malvern, Victoria, Australia
| | - Catherine L Hill
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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The Story Behind the Use of Glucocorticoids in the Treatment of Rheumatoid Arthritis. Semin Arthritis Rheum 2020; 51:15-19. [PMID: 33360225 DOI: 10.1016/j.semarthrit.2020.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022]
Abstract
Cortisone was introduced in the treatment of rheumatoid arthritis (RA) in 1948 by Hench and colleagues at the Mayo Clinic which resulted in dramatic improvement of inflammation, function and sense of well-being. It became obvious early on that side effects could develop depending on the dose and duration of use. When cortisone became available in 1950 the practicing physician developed practice patterns without guidance from government agencies, professional organizations or the pharmaceutic industry. The physician did not have guidance about what dose to use or the duration of use, as is available today. In the last 25 years, controlled studies have shown the benefits and safety of low dose prednisone in early RA. The diurnal effect of endogeneous glucocorticoids provides a clue to the timing of a glucocorticoid dose and the duration of the dose is established. The guidelines by the American College of Rheumatology (ACR) particularly but also the European League Against Rheumatism (EULAR) have emphasized side effects and stressed limited use of glucocorticoids in RA. Biologics have been developed and promoted that are used to replace and taper off low dose prednisone. Yet, glucocorticoids used appropriately can be the cornerstone of effective, safe, and inexpensive treatment of early active rheumatoid arthritis.
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George MD, Baker JF, Winthrop K, Hsu JY, Wu Q, Chen L, Xie F, Yun H, Curtis JR. Risk for Serious Infection With Low-Dose Glucocorticoids in Patients With Rheumatoid Arthritis : A Cohort Study. Ann Intern Med 2020; 173:870-878. [PMID: 32956604 PMCID: PMC8073808 DOI: 10.7326/m20-1594] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Low-dose glucocorticoids are frequently used for the management of rheumatoid arthritis (RA) and other chronic conditions, but the safety of long-term use remains uncertain. OBJECTIVE To quantify the risk for hospitalized infection with long-term use of low-dose glucocorticoids in patients with RA receiving stable disease-modifying antirheumatic drug (DMARD) therapy. DESIGN Retrospective cohort study. SETTING Medicare claims data and Optum's deidentified Clinformatics Data Mart database from 2006 to 2015. PATIENTS Adults with RA receiving a stable DMARD regimen for more than 6 months. MEASUREMENTS Associations between glucocorticoid dose (none, ≤5 mg/d, >5 to 10 mg/d, and >10 mg/d) and hospitalized infection were evaluated using inverse probability-weighted analyses, with 1-year cumulative incidence predicted from weighted models. RESULTS 247 297 observations were identified among 172 041 patients in Medicare and 58 279 observations among 44 118 patients in Optum. After 6 months of stable DMARD use, 47.1% of Medicare patients and 39.5% of Optum patients were receiving glucocorticoids. The 1-year cumulative incidence of hospitalized infection in Medicare patients not receiving glucocorticoids was 8.6% versus 11.0% (95% CI, 10.6% to 11.5%) for glucocorticoid dose of 5 mg or less per day, 14.4% (CI, 13.8% to 15.1%) for greater than 5 to 10 mg/d, and 17.7% (CI, 16.5% to 19.1%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). The 1-year cumulative incidence of hospitalized infection in Optum patients not receiving glucocorticoids was 4.0% versus 5.2% (CI, 4.7% to 5.8%) for glucocorticoid dose of 5 mg or less per day, 8.1% (CI, 7.0% to 9.3%) for greater than 5 to 10 mg/d, and 10.6% (CI, 8.5% to 13.2%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). LIMITATION Potential for residual confounding and misclassification of glucocorticoid dose. CONCLUSION In patients with RA receiving stable DMARD therapy, glucocorticoids were associated with a dose-dependent increase in the risk for serious infection, with small but significant risks even at doses of 5 mg or less per day. Clinicians should balance the benefits of low-dose glucocorticoids with this potential risk. PRIMARY FUNDING SOURCE National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Michael D George
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Joshua F Baker
- University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania (J.F.B.)
| | - Kevin Winthrop
- Oregon Health & Science University, Portland, Oregon (K.W.)
| | - Jesse Y Hsu
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Qufei Wu
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Fenglong Xie
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Huifeng Yun
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
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Buttgereit F. Glucocorticoids: surprising new findings on their mechanisms of actions. Ann Rheum Dis 2020; 80:137-139. [PMID: 33162396 DOI: 10.1136/annrheumdis-2020-218798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Frank Buttgereit
- Charité University Medicine, Department of Rheumatology and Clinical Immunology, Berlin, Germany
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Background Glucocorticoid Therapy Has No Impact on Efficacy and Safety of Abatacept or Adalimumab in Patients with Rheumatoid Arthritis. J Clin Med 2020; 9:jcm9062017. [PMID: 32604962 PMCID: PMC7356046 DOI: 10.3390/jcm9062017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/10/2020] [Accepted: 06/22/2020] [Indexed: 11/21/2022] Open
Abstract
To date, the impact of background glucocorticoids (GC) on the efficacy and safety of abatacept or adalimumab in patients with active rheumatoid arthritis (RA) is not clearly established. This post hoc analysis of (AMPLE) trial (NCT00929864) compared efficacy and safety outcomes over 2 years in patients treated with abatacept or adalimumab plus background methotrexate (MTX), who continued GC (≤10 mg/day) versus those who were not receiving GC (no-GC). Of 646 randomized patients, 317 received abatacept + MTX (161 GC, 156 no-GC) and 326 received adalimumab + MTX (162 GC, 164 no-GC). At Year 2, the adjusted mean changes from baseline in Disease Activity Score (DAS28 C-reactive protein (CRP)) and Health Assessment Questionnaire-Disability Index (HAQ-DI) were not significantly different in the GC versus no-GC subgroups receiving abatacept or adalimumab. A similar proportion of patients achieved remission, HAQ-DI score improvement ≥0.3 and radiographic progression rates. No clinically meaningful safety differences were observed between GC versus no-GC subgroups either with abatacept or adalimumab. In patients with active RA of similar baseline disease activity treated with abatacept or adalimumab plus background MTX, there was no additional value of background GC on clinical, functional or radiographic outcomes over two years.
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Rheumatoid arthritis and osteoarthritis clinical practice guidelines provide few complementary and alternative medicine therapy recommendations: a systematic review. Clin Rheumatol 2020; 39:2861-2873. [PMID: 32385761 DOI: 10.1007/s10067-020-05054-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/19/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
Sixty percent of patients with arthritis have used complementary and alternative medicine (CAM) therapies at least once. The two most common types of arthritis include rheumatoid arthritis (RA) and osteoarthritis (OA). The quality and quantity of CAM recommendations for RA and OA is currently unknown. The purpose of this research was to identify the quantity and assess the quality of CAM recommendations in clinical practice guidelines (CPGs) for the treatment and/or management of RA and OA. A systematic review was conducted to identify CPGs; MEDLINE, EMBASE and CINAHL were searched from 2008 to 2018. The Guidelines International Network and the National Center for Complementary and Integrative Health websites were also searched. Three independent reviewers evaluated the quality of reporting for each guideline that provided CAM recommendations, and the specific section providing CAM recommendations, using the AGREE II instrument. From 525 unique search results, seven guidelines (3 OA, 4 RA) mentioned CAM and 5 guidelines made CAM recommendations. Scaled domain percentages from highest to lowest were (overall, CAM) as follows: clarity of presentation (92.2% vs. 94.1%), scope and purpose (90.1% vs. 87.4%), rigour of development (72.6% vs. 64.2%), stakeholder involvement (64.8% vs. 49.6%), editorial independence (61.1% vs. 60.6%), and applicability (51.4% vs. 33.3%). None of the 5 guidelines was recommended by both appraisers for either the overall guideline or CAM section. For the overall guideline, appraisers agreed in their overall recommendation for 3 of 5 guidelines, including 3 Yes with modifications; of the remaining 2 guidelines, 1 was rated by the three appraisers as 1 No and 2 Yes with modifications, while 1 guideline was rated at 2 Yes and 1 Yes with modifications. For the CAM section, appraisers agreed in their overall recommendation for all 5 guidelines including 1 No, and 4 Yes with modifications. Roughly half of arthritis CPGs found included in this review provided CAM recommendations. The quality of CAM recommendations are of lower quality than overall recommendations across the scope and purpose, stakeholder involvement, rigour of development, applicability, and editorial independence domains. Quality varied within and across guidelines.
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Lahaye C, Tatar Z, Dubost JJ, Tournadre A, Soubrier M. Management of inflammatory rheumatic conditions in the elderly. Rheumatology (Oxford) 2020; 58:748-764. [PMID: 29982766 PMCID: PMC6477520 DOI: 10.1093/rheumatology/key165] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 05/08/2018] [Indexed: 12/21/2022] Open
Abstract
The number of elderly people with chronic inflammatory rheumatic diseases is increasing. This heterogeneous and comorbid population is at particular risk of cardiovascular, neoplastic, infectious and iatrogenic complications. The development of biotherapies has paved the way for innovative therapeutic strategies, which are associated with toxicities. In this review, we have focused on the scientific and therapeutic changes impacting the management of elderly patients affected by RA, SpA or PsA. A multidimensional health assessment resulting in an integrated therapeutic strategy was identified as a major research direction for improving the management of elderly patients.
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Affiliation(s)
- Clément Lahaye
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Zuzana Tatar
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Jean-Jacques Dubost
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Anne Tournadre
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Martin Soubrier
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
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20
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Li Q, Li X, Wang J, Liu H, Kwong JSW, Chen H, Li L, Chung SC, Shah A, Chen Y, An Z, Sun X, Hemingway H, Tian H, Li S. Diagnosis and treatment for hyperuricemia and gout: a systematic review of clinical practice guidelines and consensus statements. BMJ Open 2019; 9:e026677. [PMID: 31446403 PMCID: PMC6720466 DOI: 10.1136/bmjopen-2018-026677] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Despite the publication of hundreds of trials on gout and hyperuricemia, management of these conditions remains suboptimal. We aimed to assess the quality and consistency of guidance documents for gout and hyperuricemia. DESIGN Systematic review and quality assessment using the appraisal of guidelines for research and evaluation (AGREE) II methodology. DATA SOURCES PubMed and EMBASE (27 October 2016), two Chinese academic databases, eight guideline databases, and Google and Google scholar (July 2017). ELIGIBILITY CRITERIA We included the latest version of international and national/regional clinical practice guidelines and consensus statements for diagnosis and/or treatment of hyperuricemia and gout, published in English or Chinese. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened searched items and extracted data. Four reviewers independently scored documents using AGREE II. Recommendations from all documents were tabulated and visualised in a coloured grid. RESULTS Twenty-four guidance documents (16 clinical practice guidelines and 8 consensus statements) published between 2003 and 2017 were included. Included documents performed well in the domains of scope and purpose (median 85.4%, range 66.7%-100.0%) and clarity of presentation (median 79.2%, range 48.6%-98.6%), but unsatisfactory in applicability (median 10.9%, range 0.0%-66.7%) and editorial independence (median 28.1%, range 0.0%-83.3%). The 2017 British Society of Rheumatology guideline received the highest scores. Recommendations were concordant on the target serum uric acid level for long-term control, on some indications for urate-lowering therapy (ULT), and on the first-line drugs for ULT and for acute attack. Substantially inconsistent recommendations were provided for many items, especially for the timing of initiation of ULT and for treatment for asymptomatic hyperuricemia. CONCLUSIONS Methodological quality needs improvement in guidance documents on gout and hyperuricemia. Evidence for certain clinical questions is lacking, despite numerous trials in this field. Promoting standard guidance development methods and synthesising high-quality clinical evidence are potential approaches to reduce recommendation inconsistencies. PROSPERO REGISTRATION NUMBER CRD42016046104.
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Affiliation(s)
- Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Institute of Health Informatics, University College London, London, UK
| | - Xiaodan Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Wang
- Department of Oto-Rhino-Laryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongdie Liu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Joey Sum-Wing Kwong
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hao Chen
- The Second Clinical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Ling Li
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Sheng-Chia Chung
- Institute of Health Informatics, University College London, London, UK
| | - Anoop Shah
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
- Health Data Research UK London, University College London, London, UK
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Zhenmei An
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Harry Hemingway
- Institute of Health Informatics, University College London, London, UK
- Health Data Research UK London, University College London, London, UK
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - Haoming Tian
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Division of Population Health and Genomics, Ninewells Hospital and School of Medicine, University of Dundee, Dundee, United Kingdom
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Timmermans S, Souffriau J, Libert C. A General Introduction to Glucocorticoid Biology. Front Immunol 2019; 10:1545. [PMID: 31333672 PMCID: PMC6621919 DOI: 10.3389/fimmu.2019.01545] [Citation(s) in RCA: 283] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022] Open
Abstract
Glucocorticoids (GCs) are steroid hormones widely used for the treatment of inflammation, autoimmune diseases, and cancer. To exert their broad physiological and therapeutic effects, GCs bind to the GC receptor (GR) which belongs to the nuclear receptor superfamily of transcription factors. Despite their success, GCs are hindered by the occurrence of side effects and glucocorticoid resistance (GCR). Increased knowledge on GC and GR biology together with a better understanding of the molecular mechanisms underlying the GC side effects and GCR are necessary for improved GC therapy development. We here provide a general overview on the current insights in GC biology with a focus on GC synthesis, regulation and physiology, role in inflammation inhibition, and on GR function and plasticity. Furthermore, novel and selective therapeutic strategies are proposed based on recently recognized distinct molecular mechanisms of the GR. We will explain the SEDIGRAM concept, which was launched based on our research results.
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Affiliation(s)
- Steven Timmermans
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - Jolien Souffriau
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - Claude Libert
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
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22
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Impact of Cumulative Corticosteroid Dosage on Preventable Hospitalization among Taiwanese Patients with Ankylosing Spondylitis and Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8050614. [PMID: 31067630 PMCID: PMC6572534 DOI: 10.3390/jcm8050614] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/22/2019] [Accepted: 04/29/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Corticosteroids are commonly prescribed for autoimmune conditions, but their impact on preventable hospitalization rates is unclear. This study sought to investigate the effect of corticosteroid use on hospitalization for ambulatory care sensitive conditions among Taiwanese patients with ankylosing spondylitis (AS) or inflammatory bowel disease (IBD). Methods: This was a retrospective cohort study using adults in the Taiwan National Health Insurance Research database receiving a new diagnosis of AS (n = 40,747) or IBD (n = 4290) between January 2002 and June 2013. Our main outcome measure was odds of preventable hospitalization for eight ambulatory care-sensitive conditions defined by the Agency for Healthcare Research and Quality. Results: In the first quarter (three months) following diagnosis, corticosteroid usage was common among patients with AS and IBD (18.5% and 30%, respectively). For every 100 mg increase in corticosteroid dose per quarter, adjusted odds of preventable hospitalization in the following quarter increased by 5.5% for patients with AS (aOR = 1.055, 95% CI 1.037-1.074) and 6.4% for those with IBD (aOR = 1.064, 95% CI 1.046-1.082). Conclusions: Relatively low doses of corticosteroids significantly increase AS and IBD patients' short-term odds of hospitalization for ambulatory care-sensitive conditions. As recommended by current clinical guidelines, physicians should use corticosteroids sparingly in these populations, and prioritize initiation/escalation of disease-modifying anti-rheumatic drugs for long-term management. If corticosteroids cannot be avoided, patients may require monitoring and/or prophylaxis for corticosteroid-associated comorbidities (e.g., diabetes) which can result in preventable hospitalizations.
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Buttgereit F, Strand V, Lee EB, Simon-Campos A, McCabe D, Genet A, Tammara B, Rojo R, Hey-Hadavi J. Fosdagrocorat (PF-04171327) versus prednisone or placebo in rheumatoid arthritis: a randomised, double-blind, multicentre, phase IIb study. RMD Open 2019; 5:e000889. [PMID: 31168411 PMCID: PMC6525626 DOI: 10.1136/rmdopen-2018-000889] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/27/2019] [Accepted: 03/21/2019] [Indexed: 02/06/2023] Open
Abstract
Objectives Glucocorticoids have anti-inflammatory, transrepression-mediated effects, although adverse events (AEs; transactivation-mediated effects) limit long-term use in patients with rheumatoid arthritis (RA). We evaluated the efficacy and safety of fosdagrocorat (PF-04171327), a dissociated agonist of the glucocorticoid receptor, versus prednisone or placebo. Methods In this 12-week, phase II, randomised controlled trial, 323 patients with moderate to severe RA were randomised 1:1:1:1:1:1:1 to fosdagrocorat (1 mg, 5 mg, 10 mg or 15 mg), prednisone (5 mg or 10 mg) or placebo, once daily. The primary endpoints (week 8) were American College of Rheumatology 20% improvement criteria (ACR20) responses, and percentage changes from baseline in biomarkers of bone formation (procollagen type 1 N-terminal peptide [P1NP]) and resorption (urinary N-telopeptide to urinary creatinine ratio [uNTx:uCr]). Safety was assessed. Results ACR20 responses with fosdagrocorat 10 mg and 15 mg were superior to placebo, and fosdagrocorat 15 mg was non-inferior to prednisone 10 mg (week 8 model-predicted ACR20 responses: 47%, 61%, 69% and 73% vs 51%, 71% and 37% with fosdagrocorat 1 mg, 5 mg, 10 mg and 15 mg vs prednisone 5 mg, 10 mg and placebo, respectively). Percentage changes from baseline in P1NP with fosdagrocorat 1 mg, 5 mg and 10 mg met non-inferiority criteria to prednisone 5 mg. Corresponding changes in uNTx:uCr varied considerably. All fosdagrocorat doses reduced glycosylated haemoglobin levels. AEs were similar between groups; 63 (19.5%) patients reported treatment-related AEs; 9 (2.8%) patients reported serious AEs. No patients had adrenal insufficiency, treatment-related significant infections or laboratory abnormalities. No deaths were reported. Conclusion In patients with RA, fosdagrocorat 10 mg and 15 mg demonstrated efficacy similar to prednisone 10 mg and safety similar to prednisone 5 mg. Trial registration number NCT01393639
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Affiliation(s)
- Frank Buttgereit
- Rheumatology and Clinical Immunology, Charité University Medicine Berlin (CCM), Berlin, Germany
| | - Vibeke Strand
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Eun Bong Lee
- Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Palmowski Y, Buttgereit F, Boers M. Reply. Arthritis Care Res (Hoboken) 2019; 71:577-578. [DOI: 10.1002/acr.23452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Maarten Boers
- University of Twente, Enschede, The Netherlands and VU University Medical Center Amsterdam The Netherlands
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Masi AT, Imrich R, Cutolo M. Hypothesis: Can Neuroendocrine Immune Testing in Individual Rheumatoid Arthritis Patients Guide the Benefits‐To‐Harms Ratio in Glucocorticoid Therapy? Comment on the Article by Palmowski et al. Arthritis Care Res (Hoboken) 2019; 71:576-577. [DOI: 10.1002/acr.23453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Alfonse T. Masi
- University of Illinois College of Medicine at Peoria Peoria IIllinois
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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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Hafström I, Ajeganova S, Andersson MLE, Bala SV, Bergman S, Bremander A, Forslind K, Malm K, Svensson B. A Swedish register-based, long-term inception cohort study of patients with rheumatoid arthritis - results of clinical relevance. Open Access Rheumatol 2019; 11:207-217. [PMID: 31565006 PMCID: PMC6744369 DOI: 10.2147/oarrr.s218448] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/13/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE At the end of the twentieth century, the outcome of rheumatoid arthritis (RA) was shown to be unsatisfactory and new therapeutic strategies were introduced. This initiated a register-based long-term study of early RA, the Better Anti-Rheumatic PharmacOTherapy (BARFOT) study. The aims were to evaluate the disease course and to acquire knowledge for improved care. PATIENTS AND METHODS BARFOT is a multicentre observational study of patients with early RA, consecutively included 1992-2006. The patients are followed in daily practice according to a structured protocol for 15 years and data recorded in a web-based register. Also, through linkage of the BARFOT register to national registers we have acquired information on comorbidity and mortality. RESULTS In all, 2857 patients have been included and over 80 scientific articles have been published. Phenotypic characteristics at disease onset, i.e. gender, smoking habits and autoantibody profiles have been addressed. The disease course over 15 years was described. Early predictors for persistent disease activity, impaired function, joint damage and co-morbidities have been identified. Treatment strategies have been studied. A randomized sub-study gave strong support for the treatment of recent RA with low-dose prednisolone in combination with disease-modifying anti-rheumatic drug. Furthermore, the impact of lifestyle factors, such as smoking, alcohol consumption, body weight and physical activity has been addressed. CONCLUSION A register-based study like BARFOT has provided a basis for optimal long-term management of patients with RA. In addition, the register has made it possible to perform a diversity of studies of RA addressing various issues of major relevance to the patients.
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Affiliation(s)
- Ingiäld Hafström
- Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, and Rheumatology Unit, Karolinska University Hospital, Stockholm, Sweden
- Correspondence: Ingiäld HafströmRheumatology Unit, R92, Karolinska University Hospital, 141 86Stockholm, SwedenTel +46 73 699 6235Email
| | - Sofia Ajeganova
- Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Rheumatology Division, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Maria LE Andersson
- Faculty of Medicine, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
- Spenshult Research and Development Center, Halmstad, Sweden
| | - Sidona-Valentina Bala
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
- Department of Medicine, Section of Rheumatology, Helsingborg’s Hospital, Helsingborg, Sweden
| | - Stefan Bergman
- Spenshult Research and Development Center, Halmstad, Sweden
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann Bremander
- Faculty of Medicine, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
- Spenshult Research and Development Center, Halmstad, Sweden
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Kristina Forslind
- Faculty of Medicine, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
- Department of Research and Education, Skånevård Sund, Region Skåne, Helsingborg´s Hospital, Helsingborg, Sweden
| | - Karina Malm
- Spenshult Research and Development Center, Halmstad, Sweden
- Rheumatology, Capio Movement, Halmstad, Sweden
| | - Björn Svensson
- Faculty of Medicine, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
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Abstract
Rheumatoid arthritis is a complex disease state with multiple associated comorbidities. Perioperative evaluation of the rheumatoid patient from a multidisciplinary approach is necessary to achieve favorable outcomes. A complete history and physical, laboratory, cervical, cardiovascular, pulmonary, and medication assessment before surgery should be performed. Educating the patient on potential complications, such as wound dehiscence, infection, and venous thromboembolism, as well as general postoperative expectations, is essential when evaluating the rheumatoid patient for surgery.
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Affiliation(s)
- Jesse Wolfe
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA
| | - Joshua Wolfe
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA
| | - H John Visser
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA.
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Palmowski Y, Buttgereit T, Buttgereit F. The 70th anniversary of glucocorticoids in rheumatic diseases: the second youth of an old friend. Rheumatology (Oxford) 2018; 58:580-587. [DOI: 10.1093/rheumatology/key169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/09/2018] [Indexed: 12/20/2022] Open
Abstract
Abstract
Seventy years ago, the first administration of cortisone in a patient with RA marked a milestone in the treatment of inflammatory diseases. However, the initial enthusiasm rapidly vanished as the administration of high doses for lengthy periods revealed worrisome adverse effects. It has taken several decades to overcome the (sometimes excessive) mistrust and to achieve a more differentiated evaluation of the benefit–risk profile and the adequate usage of glucocorticoids (GCs). Today, GCs remain indispensable for the treatment of many inflammatory conditions and their usefulness in RA as a disease-modifying low-dose co-medication is widely acknowledged. Recent studies show promising results concerning both traditional GCs and new formulations. Still, decades of relatively little scientific attention have resulted in a continuing lack of detailed evidence. Hence there is an ongoing need for further research regarding mechanisms of GC actions, the further optimization of treatment parameters for traditional GCs and new formulations.
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Affiliation(s)
- Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Nikas SN. Long-term treatment with low dose glucocorticoids in Rheumatoid Arthritis: New tricks of an old drug. Mediterr J Rheumatol 2018; 29:13-16. [PMID: 32185291 PMCID: PMC7045951 DOI: 10.31138/mjr.29.1.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/28/2018] [Accepted: 03/10/2018] [Indexed: 12/17/2022] Open
Abstract
Glucocorticoids (GC) have been used for more than 70 years in the management of rheumatoid arthritis (RA). The immediate improvement of the clinical picture is one of their main advantages. However, RA is a chronic disease and unfortunately, long-term GC administration is associated with several serious adverse events. This is the major reason why GC therapy should be administered for the shortest possible period of time, with tapering as far as it is feasible. Although this is accepted as a “dogma”, there is recently growing evidence suggesting that low doses, even in the long-term, might not be as dangerous as previously believed. On the contrary, GC may be beneficial for RA patients in several ways, considering their protective role in radiographic progression or lymphoma development.
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Moltó A, Nikiphorou E. Comorbidities in Spondyloarthritis. Front Med (Lausanne) 2018; 5:62. [PMID: 29594122 PMCID: PMC5857562 DOI: 10.3389/fmed.2018.00062] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/20/2018] [Indexed: 12/18/2022] Open
Abstract
Comorbidities in spondyloarthritis (SpA) add to the burden of disease by contributing to disease activity, functional and work disability, and mortality. Thus, awareness of comorbidities in SpA is crucial to improve their screening and management and to ultimately improve outcomes in those affected. Osteoporosis has been reported to be the most prevalent comorbidity in SpA, and its risk is increased in these patients, compared with the general population; the risk of vertebral fractures requires further evaluation. Cardiovascular risk is also increased in this population, both due to an increase of the traditional cardiovascular risk factors in these patients, but also due to the presence of inflammation. The role of non-steroidal anti-inflammatory drugs in this increased risk needs further elucidation, but there is consensus on the need to encourage smoking cessation and to perform periodic evaluation of cardiovascular risk in these patients, particularly in the case of change in treatment course. Concerning the risk of cancer, no increased risk inherent to SpA seems to exist. However, an increased neoplastic risk can occur due to SpA treatments, e.g., P-UVA. Data are sparse on the risk of infections compared with rheumatoid arthritis, but there appears to be no risk in the absence of TNF-inhibitor exposure. Regardless of which comorbidity, a gap exists between recommendations for their management and actual implementation in clinical practice, suggesting that there is still a need for improvement in this area. Systematic screening for these comorbidities should improve both short- and long-term outcomes in SpA patients.
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Affiliation(s)
- Anna Moltó
- Rheumatology B Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM (U1153) PRES Sorbonne Paris-Cité, Paris, France
| | - Elena Nikiphorou
- Academic Rheumatology Department, King's College London, London, United Kingdom.,Department of Rheumatology, Whittington Hospital, London, United Kingdom
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Li Q, Wang B, Mu K, Zhang J, Yang Y, Yao W, Zhu J, Zhang JA. Increased Risk of Thyroid Dysfunction Among Patients With Rheumatoid Arthritis. Front Endocrinol (Lausanne) 2018; 9:799. [PMID: 30687237 PMCID: PMC6336701 DOI: 10.3389/fendo.2018.00799] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background: Thyroid dysfunction seems to be common among rheumatoid arthritis (RA) patients, but the risk of thyroid dysfunction in RA has not been well-defined. Methods: We performed a case-control study of 65 RA patients and 550 matched non-RA subjects to assess the risk of thyroid dysfunction among Chinese RA patients. A systematic review and meta-analysis was also conducted to comprehensively define the relationship between RA and thyroid dysfunction. Results: The case-control study indicated that the prevalence of thyroid dysfunction was significantly higher in RA patients than controls (OR = 2.89, P < 0.001). Further subgroup analyses revealed positive correlations of RA with hypothyroidism (OR = 2.28, P = 0.006) and hyperthyroidism (OR = 8.95, P < 0.001). Multivariate logistic regression analysis revealed an independent association between RA and thyroid dysfunction (Adjusted OR = 2.89, 95%CI 1.63-5.12, P < 0.001). Meta-analysis of 15 independent studies also showed an obviously increased risk of thyroid dysfunction among RA patients (RR = 2.86, 95%CI 1.78-4.58, P < 0.001). Further subgroup analysis showed RA could obviously increase risk of hyperthyroidism (RR = 2.73, 95%CI 1.29-5.77, P = 0.043) and hypothyroidism (RR = 2.02, 95%CI 1.49-2.74, P < 0.001). Conclusion: Our study provides strong evidence for the increased risk of thyroid dysfunction among RA patients. Screening of thyroid dysfunction may be recommended for RA patients.
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Affiliation(s)
- Qian Li
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Bin Wang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Kaida Mu
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Jing Zhang
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Yanping Yang
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Wei Yao
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Jie Zhu
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Jin-an Zhang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
- *Correspondence: Jin-an Zhang
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Rodrigues JC, Walsh M. Risks and Benefits of Glucocorticoids in ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0081-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buttgereit F, Bijlsma JW. Glucocorticoids in rheumatoid arthritis: the picture is shaping up. Ann Rheum Dis 2017; 76:1785-1787. [DOI: 10.1136/annrheumdis-2017-211187] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 03/29/2017] [Accepted: 04/05/2017] [Indexed: 02/04/2023]
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Mahajan T, O'Dell JR. It is the Best of Treatments, It is the Worst of Treatments: The Continuing Love-Hate Relationship With Glucocorticoids in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2016; 69:1131-1133. [PMID: 28029747 DOI: 10.1002/acr.23184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 12/22/2016] [Indexed: 12/27/2022]
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