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Rosenberg V, Amital H, Chodick G, Faccin F, Watad A, McGonagle D, Gendelman O. Real-World Adherence and Drug Survival of Biologics among Patients with Ankylosing Spondylitis. J Clin Med 2024; 13:4480. [PMID: 39124747 PMCID: PMC11313093 DOI: 10.3390/jcm13154480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 07/19/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Objectives: The objective of this study was to evaluate the real-world drug survival, adherence, and discontinuation risk of biologics disease-modifying anti-rheumatic drugs (bDMARDs) among patients with ankylosing spondylitis (AS). Methods: This was a retrospective study using a computerized database. Biologic-naïve and biologic-experienced AS patients who initiated treatment with bDMARDs (tumor necrosis factor alpha inhibitors {TNF-αis} or interleukin-17 inhibitor {IL-17i}) during 2015-2018 were included. Adherence was assessed using the proportion of days covered (PDC) method. Drug survival was analyzed using Kaplan-Meier estimates. Risk of discontinuation was estimated by the Cox proportional hazard model. Results: We identified 343 eligible patients utilizing 481 lines of therapy. The mean age was 44.6 years (SD ± 13.4), 57.7% were males, and 69.7% were biologic-naïve at baseline. The proportion of highly adherent patients (PDC ≥ 0.8) in the biologic-naïve group was 63.5% for golimumab, 69.2% for etanercept, and 71.6% for adalimumab (p > 0.9). Among the biologic-experienced group, secukinumab had the highest proportion of adherent patients (75.7%) and etanercept the lowest (50.0%) reaching statistical difference (p < 0.001). The Kaplan-Meier analysis did not show a significant difference in drug survival in either the biologic-naïve or the biologic-experienced groups (p = 0.85). Multivariable analysis demonstrated a similar risk for discontinuation for etanercept, golimumab, and secukinumab compared with adalimumab, regardless of biologic-experience status. Conclusions: Adherence, drug survival, and risk for discontinuation were similar for all TNF-αis and the IL-17i SEC, regardless of biologic-experience status. As drug survival is an indirect measure of drug efficacy, n, in real-world settings, we believe caregivers can integrate these results into treatment considerations.
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Affiliation(s)
- Vered Rosenberg
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv 6801296, Israel; (V.R.); (G.C.)
| | - Howard Amital
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (H.A.); (A.W.)
- Internal Medicine B, Sheba Medical Center, Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Gabriel Chodick
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv 6801296, Israel; (V.R.); (G.C.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (H.A.); (A.W.)
| | | | - Abdulla Watad
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (H.A.); (A.W.)
- Internal Medicine B, Sheba Medical Center, Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7JT, UK;
- Leeds Musculoskeletal Biomedical Research Centre, Chapel Allerton Hospital, Leeds LS7 4SA, UK
| | - Omer Gendelman
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (H.A.); (A.W.)
- Internal Medicine B, Sheba Medical Center, Tel-Hashomer, Ramat Gan 5262000, Israel
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2
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Pimentel CQ, Medeiros-Ribeiro AC, Shimabuco AY, Sampaio-Barros PD, Moraes JCB, Schainberg CG, Gonçalves CR, Leon EP, Kupa LDVK, Pasoto SG, Aikawa NE, Silva CA, Bonfa E, Saad CGS. Long-Term Follow-Up of Anti-Infliximab Antibodies in Patients With Radiographic Axial Spondyloarthritis: A Marker of Drug Survival and Tapering. Arthritis Rheumatol 2024. [PMID: 38801195 DOI: 10.1002/art.42923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 04/01/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the influence of anti-infliximab (IFX) antibodies on three different points of care: response/tolerance to IFX, tapering strategy, and in a subsequent treatment with a second tumor necrosis factor inhibitor (TNFi). METHODS A prospective cohort of 60 patients with radiographic axial spondyloarthritis who received IFX were evaluated retrospectively regarding clinical/laboratorial data, IFX levels, and anti-IFX antibodies at baseline, after 6, 12 to 14, 22 to 24, 48 to 54, 96 to 102 weeks, and before tapering or switching. RESULTS Anti-IFX antibodies were detected in 27 patients (45%), of whom 23 (85.1%) became positive in the first year of IFX treatment. In comparison to the group that was negative for anti-IFX antibodies, patients who were positive for anti-IFX antibodies demonstrated the following: less use of methotrexate as a concomitant treatment to IFX (5 [18.5%] vs 14 [42.4%]; P = 0.048), more infusion reactions at 22 to 24 weeks (P = 0.020) and 48 to 54 weeks (P = 0.034), more treatment failures (P = 0.028) at 48 to 54 weeks, reduced overall IFX survival (P < 0.001), and lower sustained responses (P = 0.044). Of note, patients who were positive for anti-IFX antibodies exhibited a shorter tapering survival (9.9 months [95% confidence interval (CI) 4.0-15.8] vs 63.4 months [95% CI 27.9-98.8]; P = 0.004) in comparison with patients who were negative for anti-IFX antibodies. Conversely, for patients who failed IFX, patients who were positive for anti-IFX antibodies had better clinical response to the second TNFi at three months (15 [83.3%] vs 3 [27.3%]; P = 0.005) and six months (15 [83.3%] vs 4 [36.4%]; P = 0.017) than the patients who were negative for anti-IFX antibodies after switching. CONCLUSION This study provided novel data that anti-IFX antibodies is a parameter for reduced tapering survival, reinforcing its detection to guide clinical decision. Additionally, we confirmed in a long-term cohort the anti-IFX antibody association with worse IFX performance and as predictor of the second TNFi good clinical response.
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Affiliation(s)
- Clarissa Q Pimentel
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ana Cristina Medeiros-Ribeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Andrea Y Shimabuco
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Percival D Sampaio-Barros
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Júlio César B Moraes
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Claudia G Schainberg
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Celio Roberto Gonçalves
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Elaine P Leon
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Léonard De Vinci K Kupa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Sandra G Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Nádia E Aikawa
- Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carla G S Saad
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Bautista-Molano W, Fernández-Ávila DG, Brance ML, Ávila Pedretti MG, Burgos-Vargas R, Corbacho I, Cosentino VL, Díaz Coto JF, Giraldo Ho E, Gomes Resende G, Gutiérrez LA, Gutiérrez M, Ibáñez Vodnizza SE, Jáuregui E, Ocampo V, Palleiro Rivero DR, Palominos PE, Pacheco Tena C, Quiceno GA, Saldarriaga-Rivera LM, Sommerfleck FA, Goecke Sariego A, Vera Barrezueta C, Vega Espinoza LE, Vega Hinojosa O, Citera G, Lozada C, Sampaio-Barros PD, Schneeberger E, Soriano ER. Pan American League of Associations for Rheumatology recommendations for the management of axial spondyloarthritis. Nat Rev Rheumatol 2023; 19:724-737. [PMID: 37803079 DOI: 10.1038/s41584-023-01034-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
Axial spondyloarthritis (axSpA) comprises a spectrum of chronic inflammatory manifestations affecting the axial skeleton and represents a challenge for diagnosis and treatment. Our objective was to generate a set of evidence-based recommendations for the management of axSpA for physicians, health professionals, rheumatologists and policy decision makers in Pan American League of Associations for Rheumatology (PANLAR) countries. Grading of Recommendations, Assessment, Development and Evaluation-ADOLOPMENT methodology was used to adapt existing recommendations after performing an independent systematic search and synthesis of the literature to update the evidence. A working group consisting of rheumatologists, epidemiologists and patient representatives from countries within the Americas prioritized 13 topics relevant to the context of these countries for the management of axSpA. This Evidence-Based Guideline article reports 13 recommendations addressing therapeutic targets, the use of NSAIDs and glucocorticoids, treatment with DMARDs (including conventional synthetic, biologic and targeted synthetic DMARDs), therapeutic failure, optimization of the use of biologic DMARDs, the use of drugs for extra-musculoskeletal manifestations of axSpA, non-pharmacological interventions and the follow-up of patients with axSpA.
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Affiliation(s)
- Wilson Bautista-Molano
- Hospital Universitario Fundación Santafé de Bogotá, Faculty of Medicine, Universidad El Bosque, Universidad Militar Nueva Granada, Bogotá, Colombia
| | | | - María Lorena Brance
- Bone Biology Laboratory, School of Medicine, Rosario National University, Rosario, Argentina
| | | | | | - Inés Corbacho
- Cátedra de Reumatologia, Universidad de la República UDELAR, Montevideo, Uruguay
| | | | | | | | | | | | - Marwin Gutiérrez
- Center of Excellence of Rheumatic and Musculoskeletal Diseases, C.E.R.M, Mexico City, Mexico
| | | | - Edwin Jáuregui
- Gestor de Reumatología de o en Riesgo de fractura S.A, Bogotá, Colombia
| | - Vanessa Ocampo
- Rheumatology, University of Toronto, Toronto, ON, Canada
| | | | | | - Cesar Pacheco Tena
- Facultad de Medicina, Universidad Autónoma de Chihuahua e Investigación y Biomedicina de Chihuahua SC, Chihuahua, Mexico
| | - Guillermo Andrés Quiceno
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lina María Saldarriaga-Rivera
- Faculty of Medicine, Universidad Tecnológica de Pereira, Hospital Universitario San Jorge de Pereira, Pereira, Risaralda, Colombia
| | | | | | | | | | - Oscar Vega Hinojosa
- Centro Médico Reumacenter y Hospital III Red Asistencial Essalud, Juliaca, Perú
| | - Gustavo Citera
- Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina
| | - Carlos Lozada
- Division of Rheumatology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | - Enrique R Soriano
- Rheumatology Unit, Internal Medicine Services and University Institute, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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Nissen M, Delcoigne B, Di Giuseppe D, Jacobsson L, Hetland ML, Ciurea A, Nekvindova L, Iannone F, Akkoc N, Sokka-Isler T, Fagerli KM, Santos MJ, Codreanu C, Pombo-Suarez M, Rotar Z, Gudbjornsson B, van der Horst-Bruinsma I, Loft AG, Möller B, Mann H, Conti F, Yildirim Cetin G, Relas H, Michelsen B, Avila Ribeiro P, Ionescu R, Sanchez-Piedra C, Tomsic M, Geirsson ÁJ, Askling J, Glintborg B, Lindström U. The impact of a csDMARD in combination with a TNF inhibitor on drug retention and clinical remission in axial spondyloarthritis. Rheumatology (Oxford) 2022; 61:4741-4751. [PMID: 35323903 DOI: 10.1093/rheumatology/keac174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/02/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Many axial spondylarthritis (axSpA) patients receive a conventional synthetic DMARD (csDMARD) in combination with a TNF inhibitor (TNFi). However, the value of this co-therapy remains unclear. The objectives were to describe the characteristics of axSpA patients initiating a first TNFi as monotherapy compared with co-therapy with csDMARD, to compare one-year TNFi retention and remission rates, and to explore the impact of peripheral arthritis. METHODS Data was collected from 13 European registries. One-year outcomes included TNFi retention and hazard ratios (HR) for discontinuation with 95% CIs. Logistic regression was performed with adjusted odds ratios (OR) of achieving remission (Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP < 1.3 and/or BASDAI < 2) and stratified by treatment. Inter-registry heterogeneity was assessed using random-effect meta-analyses, combined results were presented when heterogeneity was not significant. Peripheral arthritis was defined as ≥1 swollen joint at baseline (=TNFi start). RESULTS Amongst 24 171 axSpA patients, 32% received csDMARD co-therapy (range across countries: 13.5% to 71.2%). The co-therapy group had more baseline peripheral arthritis and higher CRP than the monotherapy group. One-year TNFi-retention rates (95% CI): 79% (78, 79%) for TNFi monotherapy vs 82% (81, 83%) with co-therapy (P < 0.001). Remission was obtained in 20% on monotherapy and 22% on co-therapy (P < 0.001); adjusted OR of 1.16 (1.07, 1.25). Remission rates at 12 months were similar in patients with/without peripheral arthritis. CONCLUSION This large European study of axial SpA patients showed similar one-year treatment outcomes for TNFi monotherapy and csDMARD co-therapy, although considerable heterogeneity across countries limited the identification of certain subgroups (e.g. peripheral arthritis) that may benefit from co-therapy.
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Affiliation(s)
- Michael Nissen
- Division of Rheumatology, Geneva University Hospital, Geneva, Switzerland
| | - Bénédicte Delcoigne
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm
| | - Daniela Di Giuseppe
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm
| | - Lennart Jacobsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Glostrup.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Adrian Ciurea
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lucie Nekvindova
- Faculty of Medicine, Charles University, Prague.,Institute of Biostatistics and Analyses, Ltd, Brno, Czech Republic
| | | | - Nurullah Akkoc
- Division of Rheumatology, Department of Medicine, Celal Bayar University, Manisa, Turkey
| | - Tuulikki Sokka-Isler
- University of Eastern Finland, Faculty of Health Sciences and Jyvaskyla Central Hospital, Jyvaskyla, Finland
| | | | - Maria Jose Santos
- Department of Rheumatology, Hospital Garcia de Orta, Almada.,Department of Rheumatology, University of Lisbon, Lisbon, Portugal
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Manuel Pombo-Suarez
- Rheumatology Service, Hospital Clinico Universitario, Santiago de Compostela, Spain
| | - Ziga Rotar
- Department of Rheumatology, University Medical Centre Ljubljana.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research (ICEBIO), University Hospital.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Burkhard Möller
- Department for Rheumatology and Immunology, Inselspital-University Hospital Bern, Bern, Switzerland
| | - Herman Mann
- Institute of Rheumatology and Department of Rheumatology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Fabrizio Conti
- Rheumatology Unit, Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Gozde Yildirim Cetin
- Division of Rheumatology, Department of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
| | - Heikki Relas
- Rheumatology, Inflammation Center, Helsinki University Hospital, Helsinki, Finland
| | - Brigitte Michelsen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo.,Division of Rheumatology, Department of Medicine, Hospital of Southern Norway Trust, Kristiansand, Norway
| | - Pedro Avila Ribeiro
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Ruxandra Ionescu
- Sfanta Maria Hospital, University of Medicine and Pharmacy, Bucharest, Romania
| | - Carlos Sanchez-Piedra
- Health Technology Assessment Agency of Carlos III Institute of Health (AETS), Madrid, Spain
| | - Matija Tomsic
- Department of Rheumatology, University Medical Centre Ljubljana.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Árni Jón Geirsson
- Department for Rheumatology, University Hospital, Reykjavik, Iceland
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet.,Rheumatology, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Glostrup.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulf Lindström
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Bataille P, Layese R, Claudepierre P, Paris N, Dubiel J, Amiot A, Sbidian E. Paradoxical reactions and biologic agents: a French cohort study of 9,303 patients. Br J Dermatol 2022; 187:676-683. [PMID: 35770735 DOI: 10.1111/bjd.21716] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/20/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Paradoxical reactions (PRs) are defined as the occurrence during biologic therapy of a pathological condition that usually responds to these drugs. OBJECTIVE To estimate the incidence of PRs and identify risk factors. METHODS Multicenter study of the database for the Greater Paris University Hospitals including biological-naïve patients receiving anti-tumor necrosis factor-α, anti-interleukin-12/23, anti-interleukin-17 or anti-α4ß7-integrin agents for psoriasis, inflammatory rheumatism or inflammatory bowel disease (IBD). We used natural language processing algorithms to extract data. A cohort and a case-control study nested in the cohort with controls selected by incidence density sampling was used to identify risk factors. RESULTS Most of the 9,303 included patients (median age 43.0; 53.8% women) presented an IBD (3,773 [40.6%]) or a chronic inflammatory rheumatic disease (3,708 [39.9%]), and 8,487 (91.2%) received anti-TNF-α agents. A total of 293 (3.1%) had a PR. The global incidence rate was 7.6 per 1,000 person-years (95%CI 6.7-8.4). Likelihood of PR was associated with IBD (adjusted OR [aOR] 1.9, 95%CI 1.1-3.2, p=0.021) and a combination of two inflammatory diseases (aOR 6.1, 95%CI 3.6-10.6, p<0.001) and was reduced with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and corticosteroids (aOR 0.6, 95%CI 0.4-0.8, p=0.003; 0.4, 0.2-0.7, p<0.001). CONCLUSION Likelihood of PRs was associated with IBD or a combination of a least two inflammatory diseases. More studies are needed to assess the benefit of systematically adding csDMARDs for such high-risk patients.
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Affiliation(s)
| | - Richard Layese
- Univ Paris Est Creteil, INSERM, IMRB, CEpiA Team, F-94010 Creteil, France.,AP-HP, Hôpital Henri Mondor, Unité de Recherche Clinique (URC Mondor), Creteil, F-94010, France
| | - Pascal Claudepierre
- AP-HP, Hopital Henri-Mondor, Department of Rheumatology, F-94010 Creteil, France
| | - Nicolas Paris
- WIND Department APHP Greater Paris University Hospital
| | - Julien Dubiel
- WIND Department APHP Greater Paris University Hospital
| | - Aurélien Amiot
- AP-HP, Hopital Henri-Mondor, Department of Gastroenterology, F-94010 Creteil, France
| | - Emilie Sbidian
- Univ Paris Est Creteil, EpiDermE, F-94010 Creteil, France.,AP-HP, Hopital Henri-Mondor, Department of Dermatology, F-94010 Creteil, France
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Cassinotti A, Batticciotto A, Parravicini M, Lombardo M, Radice P, Cortelezzi CC, Segato S, Zanzi F, Cappelli A, Segato S. Evidence-based efficacy of methotrexate in adult Crohn's disease in different intestinal and extraintestinal indications. Therap Adv Gastroenterol 2022; 15:17562848221085889. [PMID: 35340755 PMCID: PMC8949794 DOI: 10.1177/17562848221085889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Methotrexate (MTX) is included in the therapeutic armamentarium of Crohn's disease (CD), although its positioning is currently uncertain in an era in which many effective biological drugs are available. No systematic reviews or meta-analysis have stratified the clinical outcomes of MTX according to the specific clinical scenarios of its use. METHODS Medline, PubMed and Scopus were used to extract eligible studies, from database inception to May 2021. A total of 163 studies were included. A systematic review was performed by stratifying the outcomes of MTX according to formulation, clinical indication and criteria of efficacy. RESULTS The use of MTX is supported by randomized clinical trials only in steroid-dependent CD, with similar outcomes to thiopurines. The use of MTX in patients with steroid-refractoriness, failure of thiopurines or in combination with biologics is not supported by high levels of evidence. Combination therapy with biologics can optimize the immunogenic profile of the biological drug, but the impact on long-term clinical outcomes is described only in small series with anti-TNFα. Other off-label uses, such as fistulizing disease, mucosal healing, postoperative prevention and extraintestinal manifestations, are described in small uncontrolled series. The best performance in most indications was shown by parenteral MTX, favouring higher doses (25 mg/week) in the induction phase. DISCUSSION Evidence from high-quality studies in favour of MTX is scarce and limited to the steroid-dependent disease, in which other drugs are the leading players today. Many limitations on study design have been found, such as the prevalence of retrospective underpowered studies and the lack of stratification of outcomes according to specific types of patients and formulations of MTX. CONCLUSION MTX is a valid option as steroid-sparing agent in steroid-dependent CD. Numerous other clinical scenarios require well-designed clinical studies in terms of patient profile, drug formulation and dosage, and criteria of efficacy.
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Affiliation(s)
| | | | | | | | - Paolo Radice
- Ophtalmology Unit, ASST Sette Laghi, Varese, Italy
| | | | - Simone Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
| | | | | | - Sergio Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
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Abstract
Diagnosis and management of axial spondyloarthritis (axSpA) has vastly improved over the past two decades. With advances in the discernment of immunopathogenesis of this disease, new therapies have become available, which are associated with substantial improvement in symptoms, signs and quality of life. The four broad categories of approved treatment options are physical therapy and exercise (which have been known to be beneficial for millennia), NSAIDs (since the 1950s), TNF inhibitors (first FDA approval in 2003) and IL-17 inhibitors (first FDA approval in 2016). In addition, there have been a host of new developments in the axSpA field, including new treatment guidelines, the FDA approval of three biologic DMARDs to treat non-radiographic axSpA, the FDA and EMA approval of Janus kinase (JAK) inhibitors for ankylosing spondylitis, new data on the effect of biologic DMARDs on structural progression in ankylosing spondylitis, strategy trials on tapering or stopping TNF inhibitors in patients in remission, trials of treat-to-target strategy in axSpA, and several new molecules in phase III studies. This Review explores the developments in the management of axSpA.
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8
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Truong SL, McEwan T, Bird P, Lim I, Saad NF, Schachna L, Taylor AL, Robinson PC. Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis. Rheumatol Ther 2021; 9:1-24. [PMID: 34962620 PMCID: PMC8814294 DOI: 10.1007/s40744-021-00416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders. Aim To update and expand the 2014 consensus statement on the investigation and management of non‐radiographic axial spondyloarthritis (nr-axSpA). Methods We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements. Results We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA. Conclusions We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00416-7.
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Affiliation(s)
- Steven L Truong
- School of Medicine and Dentistry, Griffith University, Brisbane, QLD, Australia.
- Coast Joint Care, Maroochydore, QLD, Australia.
| | - Tim McEwan
- School of Clinical Medicine, University of Queensland, Herston Rd, Herston, QLD, 4006, Australia
| | - Paul Bird
- St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | - Nivene F Saad
- Metro South Hospital and Health Service, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Lionel Schachna
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Andrew L Taylor
- Department of Rheumatology, Medical School, Fiona Stanley Hospital, University of Western Australia, Perth, Australia
| | - Philip C Robinson
- Metro North, Hospital and Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, University of Queensland, Royal Brisbane and Women's Hospital, Bowen Bridge Road, Herston, QLD, 4006, Australia
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9
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Generali E, Carrara G, Bortoluzzi A, De Santis M, Ceribelli A, Scirè CA, Selmi C. Non-adherence and discontinuation rate for oral and parenteral methotrexate: A retrospective-cohort study in 8,952 patients with psoriatic arthritis. J Transl Autoimmun 2021; 4:100113. [PMID: 35005587 PMCID: PMC8716656 DOI: 10.1016/j.jtauto.2021.100113] [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: 08/11/2021] [Accepted: 08/14/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIMS Treatment options for PsA, following non-steroidal anti-inflammatory drugs (NSAIDs), include conventional synthetic disease modifying anti-rheumatic drugs (csDMARDS), particularly methotrexate (MTX). The present study was performed to determine the non-adherence and discontinuation rates of different methotrexate (MTX) formulations in psoriatic arthritis (PsA). APPROACH AND RESULTS We performed a retrospective-cohort study on patients with PsA identified by disease-specific code in the administrative-health-databases of a Northern Italian region (Lombardy) between 2004 and 2015. Subjects were defined as non-adherent if less than 80% of the prescribed MTX dose was taken based on the time between each prescription. Discontinuation rates were calculated using the time between the first and the last MTX prescription over an observation period of 120 months. Among 8952 patients with PsA, 33% were treated with MTX (mean dosage 10 mg/week ± 2.5 mg standard deviation), more frequently (59%) in its parenteral formulation at a 10 mg weekly dosage (35%). Oral glucocorticoids were prescribed to 21% of patients, while non-steroidal anti-inflammatory drugs to 45%. Approximately 37% of patients with PsA were defined as non-adherent to MTX, with the oral formulation associated with an increased risk of non-adherence (hazard ratio 2.08, 95% confidence interval 1.84-2.35, p < 0.001) compared with parenteral 10-15 mg weekly doses. Oral MTX was discontinued in 52% of cases without a significantly increased risk of discontinuation compared to parenteral formulations which, at higher dosages, had a more favorable retention rate. CONCLUSION Oral MTX formulation is associated with a 2-fold risk of non-adherence compared to MTX parenteral route in PsA.
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Key Words
- Adherence
- HCQ, hydroxychloroquine
- HR, Hazard ratio
- IQR, inter-quartile range
- LEF, leflunomide
- MTX, methotrexate
- Methotrexate
- NSAIDs, non-steroidal anti-inflammatory drugs
- OGC, oral glucocorticoids
- Oral
- Parenteral
- PsA, psoriatic arthritis
- PsO, psoriasis
- Psoriatic arthritis
- Retention rate
- SSZ, sulfasalazine
- TNF, tumor necrosis factor alpha
- list: csDMARDs, conventional synthetic disease modifying anti-rheumatic drugs
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Affiliation(s)
- Elena Generali
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | | | - Maria De Santis
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Angela Ceribelli
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Carlo A. Scirè
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
- University of Ferrara, Ferrara, Italy
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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10
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Kiltz U, Braun J, Becker A, Chenot JF, Dreimann M, Hammel L, Heiligenhaus A, Hermann KG, Klett R, Krause D, Kreitner KF, Lange U, Lauterbach A, Mau W, Mössner R, Oberschelp U, Philipp S, Pleyer U, Rudwaleit M, Schneider E, Schulte TL, Sieper J, Stallmach A, Swoboda B, Winking M. [Long version on the S3 guidelines for axial spondyloarthritis including Bechterew's disease and early forms, Update 2019 : Evidence-based guidelines of the German Society for Rheumatology (DGRh) and participating medical scientific specialist societies and other organizations]. Z Rheumatol 2020; 78:3-64. [PMID: 31784900 DOI: 10.1007/s00393-019-0670-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- U Kiltz
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Claudiusstr. 45, 44649, Herne, Deutschland.
| | - J Braun
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Claudiusstr. 45, 44649, Herne, Deutschland
| | | | - A Becker
- Allgemeinmedizin, präventive und rehabilitative Medizin, Universität Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Deutschland
| | | | - J-F Chenot
- Universitätsmedizin Greifswald, Fleischmann Str. 6, 17485, Greifswald, Deutschland
| | - M Dreimann
- Zentrum für Operative Medizin, Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20251, Hamburg, Deutschland
| | | | - L Hammel
- Geschäftsstelle des Bundesverbandes der DVMB, Metzgergasse 16, 97421, Schweinfurt, Deutschland
| | | | - A Heiligenhaus
- Augenzentrum und Uveitis-Zentrum, St. Franziskus Hospital, Hohenzollernring 74, 48145, Münster, Deutschland
| | | | - K-G Hermann
- Institut für Radiologie, Charité Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | | | - R Klett
- Praxis Manuelle & Osteopathische Medizin, Fichtenweg 17, 35428, Langgöns, Deutschland
| | | | - D Krause
- , Friedrich-Ebert-Str. 2, 45964, Gladbeck, Deutschland
| | - K-F Kreitner
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - U Lange
- Kerckhoff-Klinik, Rheumazentrum, Osteologie & Physikalische Medizin, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland
| | | | - A Lauterbach
- Schule für Physiotherapie, Orthopädische Universitätsklinik Friedrichsheim, Marienburgstraße 2, 60528, Frankfurt, Deutschland
| | | | - W Mau
- Institut für Rehabilitationsmedizin, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, 06097, Halle (Saale), Deutschland
| | - R Mössner
- Klinik für Dermatologie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
| | | | - U Oberschelp
- , Barlachstr. 6, 59368, Werne a.d. L., Deutschland
| | | | - S Philipp
- Praxis für Dermatologie, Bernauer Str. 66, 16515, Oranienburg, Deutschland
| | - U Pleyer
- Campus Virchow-Klinikum, Charité Centrum 16, Klinik f. Augenheilkunde, Charité, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - M Rudwaleit
- Klinikum Bielefeld, An der Rosenhöhe 27, 33647, Bielefeld, Deutschland
| | - E Schneider
- Abt. Fachübergreifende Frührehabilitation und Sportmedizin, St. Antonius Hospital, Dechant-Deckersstr. 8, 52249, Eschweiler, Deutschland
| | - T L Schulte
- Klinik für Orthopädie und Unfallchirurgie, Orthopädische Universitätsklinik, Ruhr-Universität Bochum, Gudrunstr. 65, 44791, Bochum, Deutschland
| | - J Sieper
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV, Universitätsklinikum Jena, Am Klinikum 1, 07743, Jena, Deutschland
| | | | - B Swoboda
- Abteilung für Orthopädie und Rheumatologie, Orthopädische Universitätsklinik, Malteser Waldkrankenhaus St. Marien, 91054, Erlangen, Deutschland
| | | | - M Winking
- Zentrum für Wirbelsäulenchirurgie, Klinikum Osnabrück, Am Finkenhügel 3, 49076, Osnabrück, Deutschland
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11
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Brahe CH, Ørnbjerg LM, Jacobsson L, Nissen MJ, Kristianslund EK, Mann H, Santos MJ, Reino JG, Nordström D, Rotar Z, Gudbjornsson B, Onen F, Codreanu C, Lindström U, Möller B, Kvien TK, Pavelka K, Barcelos A, Sánchez-Piedra C, Eklund KK, Tomšič M, Love TJ, Can G, Ionescu R, Loft AG, van der Horst-Bruinsma IE, Macfarlane GJ, Iannone F, Hyldstrup LH, Krogh NS, Østergaard M, Hetland ML. Retention and response rates in 14 261 PsA patients starting TNF inhibitor treatment—results from 12 countries in EuroSpA. Rheumatology (Oxford) 2019; 59:1640-1650. [DOI: 10.1093/rheumatology/kez427] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 06/09/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Objective
To investigate TNF inhibitor (TNFi) retention and response rates in European biologic-naïve patients with PsA.
Methods
Prospectively collected data on PsA patients in routine care from 12 European registries were pooled. Heterogeneity in baseline characteristics between registries were explored (analysis of variance and pairwise comparison). Retention rates (Kaplan–Meier), clinical remission [28-joint count DAS (DAS28) <2.6; 28 joint Disease Activity index for Psoriatic Arthritis ⩽4] and ACR criteria for 20% improvement (ACR20)/ACR50/ACR70 were calculated, including LUNDEX adjustment.
Results
Overall, 14 261 patients with PsA initiated a first TNFi. Considerable heterogeneity of baseline characteristics between registries was observed. The median 12-month retention rate (95% CI) was 77% (76, 78%), ranging from 68 to 90% across registries. Overall, DAS28/28 joint Disease Activity index for Psoriatic Arthritis remission rates at 6 months were 56%/27% (LUNDEX: 45%/22%). Six-month ACR20/50/70 responses were 53%/38%/22%, respectively. In patients initiating a first TNFi after 2009 with registered fulfilment of ClASsification for Psoriatic ARthritis (CASPAR) criteria (n = 1980) or registered one or more swollen joint at baseline (n = 5803), the retention rates and response rates were similar to those found overall.
Conclusion
Approximately half of >14 000 patients with PsA who initiated first TNFi treatment in routine care were in DAS28 remission after 6 months, and three-quarters were still on the drug after 1 year. Considerable heterogeneity in baseline characteristics and outcomes across registries was observed. The feasibility of creating a large European database of PsA patients treated in routine care was demonstrated, offering unique opportunities for research with real-world data.
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Affiliation(s)
- Cecilie Heegaard Brahe
- EuroSpA Coordinating Center, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup
- DANBIO Registry, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Lykke Midtbøll Ørnbjerg
- EuroSpA Coordinating Center, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup
- DANBIO Registry, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Lennart Jacobsson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Michael J Nissen
- Department of Rheumatology, Geneva University Hospital, Geneva, Switzerland
| | | | - Herman Mann
- Institute of Rheumatology and Department of Rheumatology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Maria José Santos
- Reuma.pt registry and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - Dan Nordström
- ROB-FIN Registry, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Ziga Rotar
- biorx.si and the Department of Rheumatology, University Medical Centre Ljubljana, Slovenia, Ljubljana
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research, University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Fatos Onen
- TURKBIO Registry and Division of Rheumatology, School of Medicine Dokuz Eylul University, Izmir, Turkey
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Ulf Lindström
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Burkhard Möller
- Leitender Arzt der Universitätsklinik für Rheumatologie, Immunologie und Allergologie Inselspital, Bern, Switzerland
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Karel Pavelka
- Institute of Rheumatology and Department of Rheumatology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Anabela Barcelos
- Rheuma.pt registry, Rheumatology Department—Centro Hospitalar do Baixo Vouga and Ibimed—Institute for Biomedicine, University of Aveiro, Aveiro, Portugal
| | | | - Kari K Eklund
- Inflammation Center, Department of Rheumatology, Helsinki University Hospital, Helsinki, Finland
| | - Matija Tomšič
- biorx.si and the Department of Rheumatology, University Medical Centre Ljubljana, Slovenia, Ljubljana
| | - Thorvardur Jon Love
- University of Iceland, Faculty of Medicine, and Landspitali University Hospital, Reykjavik, Iceland
| | - Gercek Can
- TURKBIO Registry and Division of Rheumatology, School of Medicine Dokuz Eylul University, Izmir, Turkey
| | - Ruxandra Ionescu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Anne Gitte Loft
- DANBIO Registry, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - I E van der Horst-Bruinsma
- Amsterdam Rheumatology & immunology Center (ARC), Academic Medical Center, Amsterdam
- Department of Rheumatology, Amsterdam UMC, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Gary J Macfarlane
- Epidemiology Group, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Florenzo Iannone
- GISEA registry, Rheumatology Unit – DETO, University of Bari, Bari, Italy
| | - Lise Hejl Hyldstrup
- EuroSpA Coordinating Center, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup
| | | | - Mikkel Østergaard
- EuroSpA Coordinating Center, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Merete Lund Hetland
- EuroSpA Coordinating Center, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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Poddubnyy D, Amital H, Rubbert-Roth A. Should we combine biologics with methotrexate in axial spondyloarthritis? Autoimmun Rev 2019; 18:102402. [PMID: 31669544 DOI: 10.1016/j.autrev.2019.102402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 06/30/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany
| | - Howard Amital
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.
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13
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Ørnbjerg LM, Brahe CH, Askling J, Ciurea A, Mann H, Onen F, Kristianslund EK, Nordström D, Santos MJ, Codreanu C, Gómez-Reino J, Rotar Z, Gudbjornsson B, Di Giuseppe D, Nissen MJ, Pavelka K, Birlik M, Kvien T, Eklund KK, Barcelos A, Ionescu R, Sanchez-Piedra C, Tomsic M, Geirsson ÁJ, Loft AG, van der Horst-Bruinsma I, Jones G, Iannone F, Hyldstrup L, Krogh NS, Hetland ML, Østergaard M. Treatment response and drug retention rates in 24 195 biologic-naïve patients with axial spondyloarthritis initiating TNFi treatment: routine care data from 12 registries in the EuroSpA collaboration. Ann Rheum Dis 2019; 78:1536-1544. [DOI: 10.1136/annrheumdis-2019-215427] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/17/2019] [Accepted: 07/13/2019] [Indexed: 12/15/2022]
Abstract
ObjectiveTo study drug retention and response rates in patients with axial spondyloarthritis (axSpA) initiating a first tumour necrosis factor inhibitor (TNFi).MethodsData from 12 European registries, prospectively collected in routine care, were pooled. TNFi retention rates (Kaplan-Meier statistics), Ankylosing Spondylitis Disease Activity Score (ASDAS) Inactive disease (<1.3), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) <40 mm and Assessment of SpondyloArthritis International Society responses (ASAS 20/40) were assessed at 6, 12 and 24 months.ResultsA first TNFi was initiated in 24 195 axSpA patients. Heterogeneity of baseline characteristics between registries was observed. Twelve-month retention was 80% (95% CI 79% to 80%), ranging from 71% to 94% across registries. At 6 months, ASDAS Inactive disease/BASDAI<40 rates were 33%/72% (LUNDEX-adjusted: 27%/59%), ASAS 20/40 response rates 64%/49% (LUNDEX-adjusted 52%/40%). In patients initiating first TNFi after 2009, 6097 patients was registered to fulfil ASAS criteria for axSpA, 2935 was registered to fulfil modified New York Criteria for Ankylosing Spondylitis and 1178 patients was registered as having non-radiographic axSpA. In nr-axSpA patients, we observed lower 12-month retention rates (73% (70%–76%)) and lower 6-month LUNDEX adjusted response rates (ASDAS Inactive disease/BASDAI40 20%/50%, ASAS 20/40 45%/33%). For patients initiating first TNFi after 2014, 12-month retention rate, but not 6-month response rate, was numerically higher compared with patients initiating TNFi in 2009–2014.ConclusionA large European database of patients with axSpA initiating a first TNFi treatment in routine care, demonstrated that 27% of patients achieved ASDAS inactive disease after 6 months, while 59% achieved BASDAI <40. Four of five patients continued treatment after 1 year.
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14
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Hebeisen M, Scherer A, Micheroli R, Nissen MJ, Tamborrini G, Möller B, Zufferey P, Exer P, Ciurea A. Comparison of drug survival on adalimumab, etanercept, golimumab and infliximab in patients with axial spondyloarthritis. PLoS One 2019; 14:e0216746. [PMID: 31145730 PMCID: PMC6542531 DOI: 10.1371/journal.pone.0216746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/27/2019] [Indexed: 11/24/2022] Open
Abstract
Objectives To compare drug survival in patients with axial spondyloarthritis treated with different TNF inhibitors in standard dosage. Methods Patients fulfilling the Assessment in SpondyloArthritis international Society classification criteria for axial spondyloarthritis in the Swiss Clinical Quality Management cohort were included in this study if a first TNF inhibitor on standard dosage was started after recruitment and if a baseline visit was available. Drug maintenance up to drug discontinuation or dose escalation was compared between TNF inhibitors with multiple adjusted Cox proportional hazards models and multiple imputation for missing baseline covariate data. Results A total of 966 patients were included (adalimumab 344, etanercept 237, golimumab 214, infliximab 171). Patients on certolizumab (n = 18) were excluded. Patients starting golimumab had lower disease activity as well as better physical function and quality of life in comparison to patients starting another drug. A higher proportion of patients starting infliximab had a history of extra-articular manifestations. Drug dosage was more often escalated during follow-up in patients treated with infliximab than with subcutaneously administered agents. However, no significant differences in time up to drug discontinuation or dose escalation were observed in multiple adjusted analyses if treatment was initiated after 2009, when all 4 TNF inhibitors were available: hazard ratio for infliximab versus etanercept 1.16 (95% confidence interval 0.80; 1.67), p = 0.44, for golimumab versus etanercept 0.80 (0.58; 1.10), p = 0.17 and for adalimumab versus etanercept 0.93 (0.69; 1.26), p = 0.66. Conclusion In axial spondyloarthritis, drug survival with standard doses of different TNF inhibitors is comparable.
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Affiliation(s)
- Monika Hebeisen
- Department of Rheumatology, UniversitätsSpital Zürich, Zurich, Switzerland
- Statistics Group, SCQM Foundation, Zurich, Switzerland
| | - Almut Scherer
- Statistics Group, SCQM Foundation, Zurich, Switzerland
| | - Raphael Micheroli
- Department of Rheumatology, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Michael J. Nissen
- Division of Rheumatology, University Hospital Geneva, Geneva, Switzerland
| | | | - Burkhard Möller
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern, Switzerland
| | - Pascal Zufferey
- Division of Rheumatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Adrian Ciurea
- Department of Rheumatology, UniversitätsSpital Zürich, Zurich, Switzerland
- * E-mail:
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15
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Lindström U, Olofsson T, Wedrén S, Qirjazo I, Askling J. Biological treatment of ankylosing spondylitis: a nationwide study of treatment trajectories on a patient level in clinical practice. Arthritis Res Ther 2019; 21:128. [PMID: 31138285 PMCID: PMC6540538 DOI: 10.1186/s13075-019-1908-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/07/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There is substantial evidence that patients with ankylosing spondylitis (AS) have high response rates to tumour necrosis factor inhibitors (TNFi), a low likelihood of successful treatment termination, but yet a limited drug retention. Whereas several reports have assessed drug retention rates for TNFi in AS, there are few, if any, studies investigating the actual treatment trajectories on a patient level, including subsequent therapy changes and dose reductions, of individual patients. The aim of this study was to describe 5-year treatment trajectories in patients with ankylosing spondylitis (AS) starting a first TNFi. METHODS Bio-naïve patients with AS starting a TNFi in 2006-2015 were identified in the nationwide Swedish Rheumatology Quality register and followed until 31 December 2015. All changes in their anti-rheumatic treatment during follow-up were recorded. To further increase precision, these data were complimented by information on the amount of prescribed subcutaneous TNFi collected from pharmacies during each year, retrieved from the Swedish Prescribed Drug Register. RESULTS Two thousand five hundred ninety patients started a first TNFi 2006-2015, and after 1 year, 74% remained on their first TNFi. However, after 5 years, this figure was only 46%, although at that time 63% were still on treatment with any biologic, while 30% had no anti-rheumatic treatment at all. After discontinuing the first TNFi, 46% switched directly to a second TNFi, but the drug retention for the second and third TNFi grew successively shorter compared to that for the first TNFi. In contrast, patients remaining on treatment with their first subcutaneous TNFi gradually reduced the dose, so that during the fifth year of treatment only 66% had collected ≥ 75% of the defined daily doses for that year. CONCLUSION Less than half of patients with AS will remain on their first TNFi after 5 years, but most are still on a biologic. While patients remaining on treatment with their first TNFi appear to be able to reduce the dose over time, a large proportion cycle through several biologics, and 1/3 have no anti-rheumatic treatment after 5 years. This indicates the importance of thorough follow-up programs as well as a need for alternative therapeutic options.
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Affiliation(s)
- Ulf Lindström
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Tor Olofsson
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Sara Wedrén
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ilia Qirjazo
- Rheumatology Department, Linköping University Hospital, Linköping, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Epidemiology Unit, Karolinska University Hospital Solna, Stockholm, Sweden
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Shimabuco AY, Gonçalves CR, Moraes JCB, Waisberg MG, Ribeiro ACDM, Sampaio-Barros PD, Goldenstein-Schainberg C, Bonfa E, Saad CGS. Factors associated with ASDAS remission in a long-term study of ankylosing spondylitis patients under tumor necrosis factor inhibitors. Adv Rheumatol 2018; 58:40. [PMID: 30657103 DOI: 10.1186/s42358-018-0040-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/23/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To determine the clinical and demographic factors associated with disease remission and drug survival in patients with ankylosing spondylitis (AS) on TNF inhibitors. METHODS Data from a longitudinal electronic database of AS patients under anti-TNF therapy between June/2004 and August/2013. Demographic, clinical parameters, disease activity by ASDAS remission (< 1.3) and inactive/low (< 2.1) were analyzed to characterize reasons for drug survival and switching of anti-TNF. RESULTS Among 117 AS patients, 69 (59%) were prescribed only one anti-TNF, 48 (41%) switched to a second anti-TNF and 13 (11%) to a third anti-TNF. Considering ASDAS-CRP < 1.3, 31 (39%) patients were inactive at the end of the study. Non-switchers (P = 0.04), younger age (P = 0.004), non-smoking (P = 0.016), shorter disease duration (P = 0.047), more frequent use of SSZ (P = 0.037) and lower BASDAI (P = 0.027), BASMI (P = 0.034) and BASFI (P = 0.003) at baseline were associated with remission. In the multivariate analysis younger age (P = 0.016) and lower BASDAI (P = 0.032) remained as remission predictors. CONCLUSION This study supports that ASDAS-CRP remission is an achievable goal not only for non-switchers but also for second anti-TNF, particularly in patients with younger age and lower BASDAI at baseline. Co-medication and non-smoker status seems to have a beneficial effect in anti-TNF response in this population.
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Affiliation(s)
- Andrea Y Shimabuco
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Celio R Gonçalves
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Julio C B Moraes
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Mariana G Waisberg
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Ana Cristina de M Ribeiro
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Percival D Sampaio-Barros
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Claudia Goldenstein-Schainberg
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Eloisa Bonfa
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Carla G S Saad
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil.
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Lindström U, Olofsson T, Wedrén S, Qirjazo I, Askling J. Impact of extra-articular spondyloarthritis manifestations and comorbidities on drug retention of a first TNF-inhibitor in ankylosing spondylitis: a population-based nationwide study. RMD Open 2018; 4:e000762. [PMID: 30402269 PMCID: PMC6203098 DOI: 10.1136/rmdopen-2018-000762] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/30/2018] [Accepted: 09/22/2018] [Indexed: 01/21/2023] Open
Abstract
Objectives To assess the impact of extra-articular spondyloarthritis (SpA) manifestations (anterior uveitis, psoriasis and inflammatory bowel disease (IBD)), and of comorbidities, on tumour necrosis factor alpha inhibitor (TNFi) drug retention in ankylosing spondylitis (AS). Methods We identified all bio-naïve patients with AS starting a first ever TNFi July 2006 to December 2015 from the Swedish Rheumatology Quality register and followed these from treatment start through December 2015. We determined the presence of extra-articular SpA-manifestations, comorbidities (cardiovascular disease, affective disease, diabetes, malignancies, chronic lung disease and kidney disease) and socioeconomic status before TNFi start, through linkage to five other national registers, and calculated, for each factor, crude and adjusted HRs for discontinuing the TNFi. Results 2577 patients with AS (71% men) started a first TNFi during the study period. 27% had a history of anterior uveitis, 6% psoriasis and 7% IBD. Anterior uveitis was associated with a superior TNFi drug retention (HR 0.72; 0.62 to 0.83), psoriasis with an inferior (HR 1.48; 1.18 to 1.86), whereas IBD did not affect TNFi drug retention. The effect of the SpA manifestations on TNFi drug retention was of a similar magnitude to that of the comorbidities. Conclusions In AS, anterior uveitis and psoriasis, but not IBD, affect TNFi drug retention. Possible explanations include differential effects of TNFi on these extra-articular SpA manifestations, or inherent differences in AS, associated with the inflammatory phenotype. Further, comorbidities and socioeconomy affect TNFi drug retention to a similar magnitude as the SpA manifestations, and should, as such, receive due attention in clinical practice.
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Affiliation(s)
- Ulf Lindström
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Tor Olofsson
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Sara Wedrén
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ilia Qirjazo
- Rheumatology Department, Linköping University Hospital, Linköping, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Epidemiology Unit, Karolinska University Hospital Solna, Stockholm, Sweden
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Oral treatment options for AS and PsA: DMARDs and small-molecule inhibitors. Best Pract Res Clin Rheumatol 2018; 32:415-426. [DOI: 10.1016/j.berh.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/25/2018] [Accepted: 07/28/2018] [Indexed: 12/17/2022]
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Flouri ID, Markatseli TE, Boki KA, Papadopoulos I, Skopouli FN, Voulgari PV, Settas L, Zisopoulos D, Iliopoulos A, Geborek P, Drosos AA, Boumpas DT, Sidiropoulos P. Comparative Analysis and Predictors of 10-year Tumor Necrosis Factor Inhibitors Drug Survival in Patients with Spondyloarthritis: First-year Response Predicts Longterm Drug Persistence. J Rheumatol 2018; 45:785-794. [PMID: 29606666 DOI: 10.3899/jrheum.170477] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the 10-year drug survival of the first tumor necrosis factor inhibitor (TNFi) administered to patients with spondyloarthritis (SpA) overall and comparatively between SpA subsets, and to identify predictors of drug retention. METHODS Patients with SpA in the Hellenic Registry of Biologic Therapies, a prospective multicenter observational cohort, starting their first TNFi between 2004-2014 were analyzed. Kaplan-Meier curves and Cox regression models were used. RESULTS Overall, 404 out of 1077 patients (37.5%) discontinued treatment (followup: 4288 patient-yrs). Ten-year drug survival was 49%. In the unadjusted analyses, higher TNFi survival was observed in patients with ankylosing spondylitis (AS) compared to undifferentiated SpA and psoriatic arthritis [PsA; significant beyond the first 2.5 (p = 0.003) years and 7 years (p < 0.001), respectively], and in patients treated for isolated axial versus peripheral arthritis (p = 0.001). In all multivariable analyses, male sex was a predictor for longer TNFi survival. Use of methotrexate (MTX) was a predictor in PsA and in patients with peripheral arthritis. Absence of peripheral arthritis and use of a monoclonal antibody (as opposed to non-antibody TNFi) independently predicted longer TNFi survival in axial disease because of lower rates of inefficacy. Achievement of major responses during the first year in either axial or peripheral arthritis was the strongest predictor of longer therapy retention (HR 0.33, 95% CI 0.26-0.41 for Ankylosing Spondylitis Disease Activity Score inactive disease, and HR 0.35, 95% CI 0.24-0.50 for 28-joint Disease Activity Score remission). CONCLUSION The longterm retention of the first TNFi administered to patients with SpA is high, especially for males with axial disease. The strongest predictor of longterm TNFi survival is a major response within the first year of treatment.
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Affiliation(s)
- Irini D Flouri
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Theodora E Markatseli
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Kyriaki A Boki
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Ioannis Papadopoulos
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Fotini N Skopouli
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Paraskevi V Voulgari
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Loukas Settas
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Dimitrios Zisopoulos
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Alexios Iliopoulos
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Pierre Geborek
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Alexandros A Drosos
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Dimitrios T Boumpas
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden.,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete
| | - Prodromos Sidiropoulos
- From the Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete, Heraklion; Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina; Rheumatology Department, Sismanoglio Hospital; Department of Nutrition and Dietetics, Harokopio University of Athens; Department of Rheumatology, Veterans Administration Hospital; Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens; Fourth Internal Medicine Department, Attikon University Hospital of Athens, Athens; Rheumatology Clinic, General Hospital of Kavala, Kavala; First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; Rheumatology Department, 424 General Army Hospital, Thessaloniki, Greece; Department of Rheumatology, Skȧne University Hospital, Lund, Sweden. .,I.D. Flouri, MD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete; T.E. Markatseli, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; K.A. Boki, MD, PhD, Rheumatology Department, Sismanoglio Hospital; I. Papadopoulos, MD, PhD, Rheumatology Clinic, General Hospital of Kavala; F.N. Skopouli, MD, PhD, Department of Nutrition and Dietetics, Harokopio University of Athens; P.V. Voulgari, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; L. Settas, MD, PhD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School; D. Zisopoulos, MD, First Department of Internal Medicine, Rheumatology Section, AHEPA Hospital of the Aristotle University Medical School, and Rheumatology Department, 424 General Army Hospital; A. Iliopoulos, MD, PhD, Department of Rheumatology, Veterans Administration Hospital; P. Geborek, MD, PhD, Department of Rheumatology, Skȧne University Hospital; A.A. Drosos, MD, PhD, Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina; D.T. Boumpas, MD, PhD, Joint Academic Rheumatology Program, Faculty of Medicine, National and Kapodestrian University of Athens, and Fourth Internal Medicine Department, Attikon University Hospital of Athens; P. Sidiropoulos, MD, PhD, Rheumatology, Clinical Immunology and Allergy Department, Medical School, University of Crete.
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Rios Rodriguez V, Poddubnyy D. Tumor necrosis factor-α (TNFα) inhibitors in the treatment of nonradiographic axial spondyloarthritis: current evidence and place in therapy. Ther Adv Musculoskelet Dis 2017; 9:197-210. [PMID: 28835779 PMCID: PMC5557185 DOI: 10.1177/1759720x17706454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/03/2017] [Indexed: 12/17/2022] Open
Abstract
Nonradiographic axial spondyloarthritis (SpA) and radiographic SpA (also known as ankylosing spondylitis) are currently considered as two stages or forms of one disease (axial SpA). The treatment with tumor necrosis factor-α (TNFα) inhibitors has been authorized for years for ankylosing spondylitis. In recent years, most of the anti-TNFα agents have also been approved for the treatment of nonradiographic axial SpA by the European Medicines Agency (EMA) and similar authorities in many countries around the world (but not in the US), increasing the number of possible therapies for this indication. Data from several clinical trials have demonstrated the good efficacy and safety profiles from those anti-TNFα agents. Presently, a large number of patients achieve a satisfactory clinical control with the current therapies, however, there remains a percentage refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) and TNFα inhibitors; therefore, several new drugs are currently under investigation. In 2015, the first representative of a new class of biologics [an interleukin (IL)-17 inhibitor] secukinumab, was approved for the treatment of ankylosing spondylitis; a clinical trial in nonradiographic axial SpA is currently underway. In this review, we discuss the recent data on efficacy and safety of TNFα-inhibitors focusing on the treatment of nonradiographic axial SpA.
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Affiliation(s)
- Valeria Rios Rodriguez
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
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Abstract
The term axial spondyloarthritis covers both patients with non-radiographic and radiographic axial spondyloarthritis, which is also termed ankylosing spondylitis. The disease usually starts in the third decade of life with a male to female ratio of two to one for radiographic axial spondyloarthritis and of one to one for non-radiographic axial spondyloarthritis. More than 90% heritabilty has been estimated, the highest genetic association being with HLA-B27. The pathogenic role of HLA-B27 is still not clear although various hypotheses are available. On the basis of evidence from trials the cytokines tumour necrosis factor (TNF)-α and interleukin-17 appear to have a relevant role in pathogenesis. The mechanisms of interaction between inflammation and new bone formation is still not completely understood but clarification will be important for the prevention of long-term structural damage of the bone. The development of new criteria for classification and for screening of patients with axial spondyloarthritis have been crucial for the early indentification and treatment of such patients, with MRI being the most important existing imaging method. Non-steroidal anti-inflammatory drugs and TNF blockers are effective therapies. Blockade of interleukin-17 is a new and relevant treatment option.
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Affiliation(s)
- Joachim Sieper
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
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Nair AM, Sandhya P, Yadav B, Danda D. TNFα blockers followed by continuation of sulfasalazine and methotrexate combination: a retrospective study on cost saving options of treatment in Spondyloarthritis. Clin Rheumatol 2017. [PMID: 28646368 DOI: 10.1007/s10067-017-3726-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
High cost deters continuous use of tumor necrosis factor α blockers (TNFi) in developing countries. The objective of this study was to evaluate outcome and expenditure incurred in Spondyloarthritis (SpA) patients beyond a year of follow-up after receiving four doses of infliximab (IFX) over and above background therapy of methotrexate (MTX) and sulfasalazine (SSZ) combination. Electronic medical records were screened for patients with SpA satisfying the Assessment of Spondyloarthritis International Society (ASAS) criteria between 2008 and 2014. Patients who completed at least 1 year of follow-up after receiving four doses of IFX (5 mg/kg at 0, 2, 6, and 14 weeks) on a background therapy of MTX (10-25 mg/week) and SSZ (2-3 g/day) combination were enrolled after obtaining an informed consent. Primary outcome assessed was "time to disease flare". Changes in acute phase reactants, patient reported outcomes (BASDAI, BASFI), and cost were also assessed. Forty-five patients were enrolled. Mean (SD) duration of follow up after fourth IFX dose was 28.9 (18.7) months. Disease flare occurred in 33.3% (15/45) after a mean (SD) duration of 14.5 (10.8) months as compared to 4-6 months described in literature on discontinuing TNFi. Reduction in ESR, CRP, BASDAI and BASFI continued to be statistically significant at follow-up as compared to baseline. As compared to continuous IFX therapy, this treatment reduced cost by 57.1% for each patient-month of follow-up. Short course IFX dosing followed by continuation of MTX and SSZ combination can prolong time to disease flare and decrease requirement for additional IFX dose in SpA. This regimen could be a cost saving option for patients with SpA.
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Affiliation(s)
- Aswin M Nair
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - P Sandhya
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, Tamil Nadu, 632004, India.
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Deodhar A, Yu D. Switching tumor necrosis factor inhibitors in the treatment of axial spondyloarthritis. Semin Arthritis Rheum 2017; 47:343-350. [PMID: 28551170 DOI: 10.1016/j.semarthrit.2017.04.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/11/2017] [Accepted: 04/24/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the impact of switching tumor necrosis factor (TNF)-alpha inhibitors on patients with axial spondyloarthritis (axSpA). METHODS PubMed literature searches were conducted using combinations of search terms including ankylosing spondylitis, spondyloarthropathy, spondyloarthritis, switch/switching, drug survival, and TNF/tumor necrosis factor to identify published articles with data on outcomes related to switching biologic therapies in patients with axSpA. RESULTS Of the 134 studies screened, 21 were identified as reporting data on switching TNF inhibitors in patients carrying a diagnosis of axSpA or ankylosing spondylitis. The most common reasons for switching from the first TNF inhibitor were lack of efficacy (14-68%), loss of efficacy (13-61%), and adverse events/poor tolerability (13-57%). Switching TNF inhibitors was beneficial for a substantial proportion of patients with axSpA who failed to respond to initial or even second TNF inhibitor therapy and adverse effects were not enhanced. Drug survival rates were generally lower for the second (47-72% at 2 years) or third TNF inhibitor (49% at 2 years) than for the first TNF inhibitor (58-75% at 2 years). Predictors of responses in TNF-naïve patients included HLA-B27 positivity, absence of enthesitis, age ≤40 years, elevated C-reactive protein level, good functional status, and shorter disease duration. Predictors of drug survival included male sex and peripheral arthritis. Common characteristics of patients who switched TNF inhibitors included female sex, older age, more severe disease, greater symptom burden, higher erythrocyte sedimentation rate, complete ankyloses, and enthesitis. CONCLUSION When the first or even the second TNF inhibitor fails, switching to an alternate one is not an unreasonable clinical therapeutic decision.
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Affiliation(s)
- Atul Deodhar
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97299.
| | - David Yu
- Ronald Reagan UCLA Medical Center, Los Angeles, CA
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Svedbom A, Storck C, Kachroo S, Govoni M, Khalifa A. Persistence with golimumab in immune-mediated rheumatic diseases: a systematic review of real-world evidence in rheumatoid arthritis, axial spondyloarthritis, and psoriatic arthritis. Patient Prefer Adherence 2017; 11:719-729. [PMID: 28435230 PMCID: PMC5391163 DOI: 10.2147/ppa.s128665] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE In immune-mediated rheumatic diseases (IMRDs), persistence to treatment may be used as a surrogate marker for long-term treatment success. In previous comparisons of persistence to tumor necrosis factor α inhibitors (TNFis), a paucity of data for subcutaneous (SC) golimumab was identified. The aim of this study was to conduct a systematic review of persistence to SC golimumab in clinical practice and contextualize these data with five-year persistence estimates from long-term open-label extension (OLE) trials of SC TNFis in IMRDs. PATIENTS AND METHODS PubMed, Embase, MEDLINE, and conference proceedings from European League Against Rheumatism (EULAR), American College of Rheumatology (ACR), and International Society for Pharmacoeconomics and Outcomes Research (ISPOR) were searched. All studies on patients treated with SC golimumab for IMRD were included if they reported data on the persistence to golimumab. RESULTS Of 376 available references identified through the searches, 12 studies with a total of 4,910 patients met the inclusion criteria. Furthermore, nine OLE trials were available. Among the included studies from clinical practice, at six months, one year, two years, and three years, the proportion of patients persistent to treatment ranged from 63% to 91%, 47% to 80%, 40% to 77%, and 32% to 67%, respectively. In the four studies that included comparisons to other biologics, golimumab was either statistically noninferior or statistically superior to other treatments, an observation that was supported by indirect comparisons of unadjusted point estimates of OLE trials. CONCLUSION The data reviewed in this study indicate that golimumab may have higher persistence than other TNFis, a notion that is supported by indirect comparisons of persistence data from OLEs of randomized controlled trials (RCTs). Furthermore, the study suggests that persistence may be lower in biologic-experienced compared with biologic-naive patients and higher in axial spondyloarthritis compared with rheumatoid arthritis and psoriatic arthritis.
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Affiliation(s)
- Axel Svedbom
- Real World Strategy and Analytics, Mapi Group, Stockholm, Sweden
| | - Chiara Storck
- Real World Strategy and Analytics, Mapi Group, Munich, Germany
| | - Sumesh Kachroo
- Center for Observational and Real-World Evidence (CORE), Merck & Co, Kenilworth, NJ, USA
| | | | - Ahmed Khalifa
- Medical Affairs Immunology, MSD Switzerland, Luzern, Switzerland
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