1
|
Abud-Mendoza C, Aceves-Ávila FJ, Arce-Salinas CA, Álvarez Nemegyei J, Barile-Fabris L, Durán-Barragán S, Flores-Alvarado DE, Hernández-Núñez E, Irazoque-Palazuelos F, Moctezuma-Ríos JF, Pascual-Ramos V, Portela-Hernández M, Silveira LH, Andrade-Ortega L, Barrera-Vargas A, Carrillo-Vázquez S, Castro-Colin Z, Cuevas-Orta E, Flores-Suárez LF, Guaracha-Basáñez GA, Hernández-Cabrera MF, de Jesús Hernández-Galarza I, Herrera-vanOostdam DA, Lobato-Belmonte AC, Martínez-Martínez LA, Martínez-Martínez MU, Medrano-Ramírez G, Merayo-Chalico FJ, Meza-López Y Olguín G, Olan F, Peña-Santos G, Ramos-Remus C, Reyes-Cordero G, Rivera-Terán V, Rojas-Serrano J, Serna-Peña G, Sicsik-Ayala S, Sifuentes-Cantú CA, Vega-Morales D, Villaseñor-Ovies P, Xibillé-Friedmann D, Pacheco-Tena C. Update of the guidelines for the pharmacological treatment of rheumatoid arthritis by the Mexican College of Rheumatology 2023. REUMATOLOGIA CLINICA 2024; 20:263-280. [PMID: 38796394 DOI: 10.1016/j.reumae.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/02/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE To develop updated guidelines for the pharmacological management of rheumatoid arthritis (RA). METHODS A group of experts representative of different geographical regions and various medical services catering to the Mexican population with RA was formed. Questions based on Population, Intervention, Comparison, and Outcome (PICO) were developed, deemed clinically relevant. These questions were answered based on the results of a recent systematic literature review (SLR), and the evidence's validity was assessed using the GRADE system, considered a standard for these purposes. Subsequently, the expert group reached consensus on the direction and strength of recommendations through a multi-stage voting process. RESULTS The updated guidelines for RA treatment stratify various therapeutic options, including different classes of DMARDs (conventional, biologicals, and JAK inhibitors), as well as NSAIDs, glucocorticoids, and analgesics. By consensus, it establishes the use of these in different subpopulations of interest among RA patients and addresses aspects related to vaccination, COVID-19, surgery, pregnancy and lactation, and others. CONCLUSIONS This update of the Mexican guidelines for the pharmacological treatment of RA provides reference points for evidence-based decision-making, recommending patient participation in joint decision-making to achieve the greatest benefit for our patients. It also establishes recommendations for managing a variety of relevant conditions affecting our patients.
Collapse
Affiliation(s)
- Carlos Abud-Mendoza
- Servicio de Reumatología, Hospital Ignacio Morones Prieto, Facultad de Medicina, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
| | | | | | | | | | - Sergio Durán-Barragán
- Departamento de Clínicas Médicas, Centro Universitario de Ciencias de la Salud Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Diana Elsa Flores-Alvarado
- Servicio de Reumatología, Hospital Universitario «Dr. José Eleuterio González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | | | | | | | - Virginia Pascual-Ramos
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencia Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Margarita Portela-Hernández
- Departamento de Reumatología, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Luis Humberto Silveira
- Departamento de Reumatología, Instituto Nacional de Cardiología «Ignacio Chávez», Mexico City, Mexico
| | - Lilia Andrade-Ortega
- Medicina Interna, Hospital Dr. Gustavo A. Rovirosa Pérez, Villa Hermosa, Tabasco, Mexico; Servicio de Reumatología, Hospital CMN 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Ana Barrera-Vargas
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencia Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sandra Carrillo-Vázquez
- Hospital Regional 1.◦ de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - Zully Castro-Colin
- Hospital de Especialidades Centro Médico Nacional La Raza «Antonio Fraga Mouret», IMSS, Mexico City, Mexico
| | - Enrique Cuevas-Orta
- Servicio de Reumatología, Hospital Ignacio Morones Prieto, Facultad de Medicina, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
| | - Luis Felipe Flores-Suárez
- Clínica de Vasculitis Sistémicas Primarias, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | | | | | - Iván de Jesús Hernández-Galarza
- Servicio de Reumatología, Hospital Universitario «Dr. José Eleuterio González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - David Alejandro Herrera-vanOostdam
- Servicio de Reumatología, Hospital Ignacio Morones Prieto, Facultad de Medicina, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
| | | | | | | | | | - Francisco Javier Merayo-Chalico
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencia Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Francisco Olan
- Medicina Interna, Hospital Dr. Gustavo A. Rovirosa Pérez, Villa Hermosa, Tabasco, Mexico
| | | | - César Ramos-Remus
- Unidad de Investigación en Enfermedades Crónico-Degenerativas, S.C. Guadalajara, Jalisco, Mexico
| | - Greta Reyes-Cordero
- Hospital Angeles Chihuahua, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, Mexico
| | - Vijaya Rivera-Terán
- Registro Mexicano de Acotamientos Adversos de Terapias Biológicas en Enfermedades Reumatológicas (Biobadamex), Colegio Mexicano de Reumatología, Mexico City, Mexico
| | | | - Griselda Serna-Peña
- Servicio de Reumatología, Hospital Universitario «Dr. José Eleuterio González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - Sandra Sicsik-Ayala
- Facultad de Medicina, Universidad Autónoma de Coahuila, Torreón, Coahuila, Mexico
| | | | - David Vega-Morales
- Reumatología y Centro de Infusión, Hospital General de Zona No. 17, IMSS, Nuevo León, Mexico
| | - Pablo Villaseñor-Ovies
- Departamento de Medicina Interna, Hospital General de Tijuana, Tijuana, Baja California, Mexico
| | | | - César Pacheco-Tena
- Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, Mexico.
| |
Collapse
|
2
|
van Esveld L, Cox JM, Kuijper TM, Bosch TM, Weel-Koenders AE. Cost-utility analysis of tapering strategies of biologicals in rheumatoid arthritis patients in the Netherlands. Ann Rheum Dis 2023; 82:1296-1306. [PMID: 37423648 DOI: 10.1136/ard-2023-224190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Current guidelines recommend tapering biological disease-modifying antirheumatoid drugs (bDMARDs) in rheumatoid arthritis (RA) if the disease is under control. However, guidelines on tapering are lacking. Assessing cost-effectiveness of different tapering strategies might provide broader input for creating guidelines on how to taper bDMARDs in patients with RA. The aim of this study is to evaluate the long-term cost-effectiveness from a societal perspective of bDMARD tapering strategies in Dutch patients with RA, namely 50% dose reduction (tapering), discontinuation and a 50% dose reduction followed by discontinuation (de-escalation). METHODS Using a societal perspective, a Markov model with a life-time horizon of 30 years was used to simulate 3-monthly transitions between Disease Activity 28 (DAS28)-defined health states of remission (<2.6), low disease activity (2.63.2). Transition probabilities were estimated through literature search and random effects pooling. Incremental costs, incremental quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits for each tapering strategy were compared with continuation. Deterministic, probabilistic sensitivity analyses and multiple scenario analyses were performed. RESULTS After 30 years, the ICERs were €115 157/QALY lost, €74 226/QALY lost and €67 137/QALY lost for tapering, de-escalation and discontinuation, respectively; mainly driven by bDMARD cost savings and a 72.8% probability of a loss in quality of life. This corresponds to a 76.1%, 64.3% and 60.1% probability of tapering, de-escalation and discontinuation being cost-effective, provided a willingness-to-accept threshold of €50 000/QALY lost. CONCLUSIONS Based on these analyses, the 50% tapering approach saved the highest cost per QALY lost.
Collapse
Affiliation(s)
| | - Juul M Cox
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Tessa M Bosch
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
| | - Angelique Eam Weel-Koenders
- Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
3
|
Kerschbaumer A, Sepriano A, Bergstra SA, Smolen JS, van der Heijde D, Caporali R, Edwards CJ, Verschueren P, de Souza S, Pope JE, Takeuchi T, Hyrich KL, Winthrop KL, Aletaha D, Stamm TA, Schoones JW, Landewé RBM. Efficacy of synthetic and biological DMARDs: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2023; 82:95-106. [PMID: 36368906 DOI: 10.1136/ard-2022-223365] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To update the evidence on efficacy of DMARDs (disease-modifying antirheumatic drugs) and inform the taskforce of the 2022 update of the European Alliance of Associations for Rheumatology (EULAR) recommendations for management of rheumatoid arthritis (RA). METHODS This systematic literature review (SLR) investigated the efficacy of conventional synthetic (cs), biological (b), biosimilar and targeted synthetic (ts)DMARDs in patients with RA. Medline, EMBASE, Cochrane CENTRAL and Web of Science were used to identify all relevant articles published since the previous update in 2019 to 14 January 2022. RESULTS Of 8969 search results, 169 articles were selected for detailed review and 47 were finally included. Trials investigated the efficacy of csDMARDs, bDMARDs and tsDMARDs, DMARD switching, tapering and trials investigating different treatment strategies. The compounds investigated were csDMARDs (methotrexate (MTX), leflunomide, sulfasalazine, hydroxychloroquine), bDMARDs (abatacept, adalimumab, certolizumab-pegol, denosumab, etanercept, infliximab, levilimab, olokizumab, opineracept, rituximab, sarilumab, tocilizumab) and tsDMARDs (baricitinib, filgotinib, tofacitinib, upadacitinib). The efficacy of csDMARDs+ short-term glucocorticoids in early RA was confirmed and similar to bDMARD+MTX combination therapy. Interleukin-6 pathway inhibition was effective in trials on olokizumab and levilimab. Janus kinase inhibitor (JAKi) was efficacious in different patient populations. After insufficient response to JAKi, patients could respond to TNFi treatment. Tapering of DMARDs was feasible for a proportion of patients, who were able to taper therapy while remaining in low disease activity or remission. CONCLUSION The results of this SLR, together with one SLR on safety of DMARD and one on glucocorticoids, informed the taskforce of the 2022 update of the EULAR recommendations for pharmacological management of RA.
Collapse
Affiliation(s)
- Andreas Kerschbaumer
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Alexandre Sepriano
- CHRC Campus Nova Medical School, Universidade Nova de Lisboa, Lisboa, Portugal.,Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Josef S Smolen
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | | | - Christopher John Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick Verschueren
- Department of Rheumatology, University Hospitals Leuven and Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Savia de Souza
- Patient Research Partner Network, European Alliance of Associations for Rheumatology, Zurich, Switzerland
| | - Janet E Pope
- Schulich School of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester and NIHR Manchester Biomedical Research Centre, Manchester University NHS Trust, Manchester, UK
| | - Kevin L Winthrop
- School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel Aletaha
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| |
Collapse
|
4
|
Hazlewood GS, Pardo JP, Barnabe C, Schieir O, Barber CEH, Proulx L, Richards DP, Tugwell P, Bansback N, Akhavan P, Bombardier C, Bykerk V, Jamal S, Khraishi M, Taylor-Gjevre R, Thorne JC, Agarwal A, Pope JE. Canadian Rheumatology Association Living Guidelines for the Pharmacological Management of Rheumatoid Arthritis With Disease-Modifying Antirheumatic Drugs. J Rheumatol 2022; 49:1092-1099. [PMID: 35840155 DOI: 10.3899/jrheum.220209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To provide the initial installment of a living guideline that will provide up-to-date guidance on the pharmacological management of patients with rheumatoid arthritis (RA) in Canada. METHODS The Canadian Rheumatology Association (CRA) formed a multidisciplinary panel composed of rheumatologists, researchers, methodologists, and patients. In this first installment of our living guideline, the panel developed a recommendation for the tapering of biologic and targeted synthetic disease-modifying antirheumatic drug (b/ts DMARD) therapy in patients in sustained remission using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach, including a health equity framework developed for the Canadian RA population. The recommendation was adapted from a living guideline of the Australia & New Zealand Musculoskeletal Clinical Trials Network. RESULTS In people with RA who are in sustained low disease activity or remission for at least 6 months, we suggest offering stepwise reduction in the dose of b/tsDMARD without discontinuation, in the context of a shared decision, provided patients are able to rapidly access rheumatology care and reestablish their medications if needed. In patients where rapid access to care or reestablishing access to medications is challenging, we conditionally recommend against tapering. A patient decision aid was developed to complement the recommendation. CONCLUSION This living guideline will provide contemporary RA management recommendations for Canadian practice. New recommendations will be added over time and updated, with the latest recommendation, evidence summaries, and Evidence to Decision summaries available through the CRA website (www.rheum.ca).
Collapse
Affiliation(s)
- Glen S Hazlewood
- G.S. Hazlewood, MD, PhD, Associate Professor, C. Barnabe, MD, MSc, Professor, C.E.H. Barber, MD, PhD, Associate Professor, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada, Vancouver, British Columbia, Canada;
| | - Jordi Pardo Pardo
- J. Pardo Pardo, Ldo, Cochrane Musculoskeletal, University of Ottawa, Ottawa, Ontario, Canada
| | - Cheryl Barnabe
- G.S. Hazlewood, MD, PhD, Associate Professor, C. Barnabe, MD, MSc, Professor, C.E.H. Barber, MD, PhD, Associate Professor, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Orit Schieir
- O. Schieir, PhD, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Claire E H Barber
- G.S. Hazlewood, MD, PhD, Associate Professor, C. Barnabe, MD, MSc, Professor, C.E.H. Barber, MD, PhD, Associate Professor, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Laurie Proulx
- L. Proulx, B.Com, D.P. Richards, PhD, Canadian Arthritis Patient Alliance, Toronto, Ontario, Canada
| | - Dawn P Richards
- L. Proulx, B.Com, D.P. Richards, PhD, Canadian Arthritis Patient Alliance, Toronto, Ontario, Canada
| | - Peter Tugwell
- P. Tugwell, MD, Professor, Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Nick Bansback
- N. Bansback, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Pooneh Akhavan
- P. Akhavan, MD, MSc, Division of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Claire Bombardier
- C. Bombardier, MD, Professor, Division of Rheumatology, Mount Sinai Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Bykerk
- V. Bykerk, MD, Professor, Hospital for Special Surgery, New York, New York, USA
| | - Shahin Jamal
- S. Jamal, MD, MSc, Clinical Associate Professor, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Majed Khraishi
- M. Khraishi, MD, Clinical Professor, Department of Medicine, Memorial University of Newfoundland, St. Johns, Newfoundland and Labrador, Canada
| | - Regina Taylor-Gjevre
- R. Taylor-Gjevre, MD, MSc, Professor, Division of Rheumatology, Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - J Carter Thorne
- J.C. Thorne, MD, Assistant Professor, The Centre of Arthritis Excellence and The Arthritis Program Research Group, Newmarket, Ontario, Canada
| | - Arnav Agarwal
- A. Agarwal, MD, Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Janet E Pope
- J.E. Pope, MD, MPH, Professor, Dept of Medicine, Western University, Schulich School of Medicine & Dentistry, London, Ontario, Canada
| |
Collapse
|
5
|
Nagy G, Géher P, Tamási L, Drescher E, Keszthelyi P, Pulai J, Czirják L, Szekanecz Z, Kiss G, Kovács L. Real-world evidence on methotrexate-free subcutaneous tocilizumab therapy in patients with rheumatoid arthritis: 24-week data from the SIMPACT study. Rheumatol Adv Pract 2022; 6:rkac038. [PMID: 35663154 PMCID: PMC9154320 DOI: 10.1093/rap/rkac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
The SIMPACT study aimed to evaluate the efficacy and safety of methotrexate (MTX)-free subcutaneous tocilizumab (TCZ) therapy in rheumatoid arthritis (RA) patients.
Methods
SIMPACT was an open-label, non-controlled, non-randomised, non-interventional study, where RA patients, for whom the treating physicians ordered subcutaneous TCZ, were observed during a 24-week treatment period in Hungarian centres. While the use of methotrexate (MTX) was avoided during the study period, other conventional synthetic disease modifying anti-rheumatoid drugs (DMARDs), oral steroid and non-steroid anti-inflammatory agents were allowed. Study endpoints included the change in Disease Activity Score-28 (DAS28) and Clinical Activity Index (CDAI) scores, the proportion of patients achieving remission in the whole population and in subgroups defined based on prior RA treatment history—and age, weight or gender post-hoc. The extent of supplementary medication use was monitored.
Results
337 RA patients were enrolled in 18 study centres. TCZ therapy significantly decreased the disease activity measured both by DAS28 (p = 0.0001) and CDAI (p = 0.0001). Clinical response was more pronounced in biological-naïve patients, and was lower in patients above 75 years. In the whole population DAS28 ESR or CRP and CDAI remission rates were 70.10%, 78.95% and 33.59%, respectively. Below 45 years CDAI remission rate doubled (67.86%). Significant decrease in the frequency of co-administered medication was reported including oral steroids and DMARDs.
Conclusion
Real-world clinical evidence on subcutaneous TCZ reported here is in-line with the efficacy outcomes of randomised clinical trials (RCTs). Subgroup analysis revealed that TCZ was more effective in biological-naïve and <75 years patients.
Trial registration
ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT02402686
Collapse
Affiliation(s)
- György Nagy
- Dept. of Rheumatology & Clinical Immunology, Dept. of Internal Medicine & Oncology, Semmelweis University, Budapest, Hungary
- Dept. of Genetics, Cell & Immunobiology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Pál Géher
- Dept. of Rheumatology & Clinical Immunology, Dept. of Internal Medicine & Oncology, Semmelweis University, Budapest, Hungary
| | - László Tamási
- Dept. of Rheumatology, BAZ County Central Hospital, Miskolc, Hungary
| | - Edit Drescher
- Dept. of Rheumatology, Csolnoky Ferenc Hospital, Veszprém, Hungary
| | - Péter Keszthelyi
- Dept. of Rheumatology, Békés County Central Hospital, Gyula, Hungary
| | - Judit Pulai
- Dept. of Rheumatology, Fejér County Saint George Hospital, Székesfehérvár, Hungary
| | - László Czirják
- Rheumatology & Immunology Clinic, Univ. of Pécs Clinical Centre, Pécs, Hungary
| | - Zoltán Szekanecz
- Dept. of Int. Medicine, Rheumatology, Univ. of Debrecen Clinical Centre, Debrecen, Hungary
| | | | - László Kovács
- Rheumatology & Immunology Clinic, Univ. of Szeged Clinical Centre, Szeged, Hungary
| |
Collapse
|
6
|
Uhrenholt L, Christensen R, Dinesen WKH, Liboriussen CH, Andersen SS, Dreyer L, Schlemmer A, Hauge EM, Skrubbeltrang C, Taylor PC, Kristensen S. Risk of flare after tapering or withdrawal of b-/tsDMARDs in patients with RA or axSpA: A systematic review and meta-analysis. Rheumatology (Oxford) 2021; 61:3107-3122. [PMID: 34864896 DOI: 10.1093/rheumatology/keab902] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate flare risk when tapering or withdrawing biological or targeted synthetic disease-modifying antirheumatic drugs (b-/tsDMARDs) compared to continuation in patients with inflammatory arthritis (IA) in sustained remission or low disease activity. METHODS Articles were identified in Cochrane Library, PubMed, EMBASE and Web of Science. Eligible trials were randomised, controlled trials comparing tapering and/or withdrawal of b- and/or tsDMARDs with standard dose in IA. Random-effects meta-analysis was performed with risk ratio (RR), or Peto's Odds Ratio (POR) for sparse events, and 95% confidence intervals (95%CI). RESULTS The meta-analysis comprised 22 trials: 11 assessed tapering and 7 addressed withdrawal (4 assessed both). Only trials with a rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) population were identified. An increased flare risk was demonstrated when b-/tsDMARD tapering was compared to continuation, RR = 1.45 (95%CI: 1.19 to 1.77, I2 = 42.5%), and potentially increased for persistent flare, POR = 1.56 (95%CI: 0.97 to 2.52, I2 = 0%). Comparing tumour necrosis factor inhibitor (TNFi) withdrawal to continuation, a highly increased flare risk (RR = 2.28, 95%CI: 1.78 to 2.93, I2 = 78%) and increased odds of persistent flare (POR = 3.41, 95%CI: 1.91 to 6.09, I2 = 49%) was observed. No clear difference in flare risk between RA or axSpA was observed. CONCLUSION A high risk for flare and persistent flare was demonstrated for TNFi withdrawal whereas an increased risk for flare but not for persistent flare was observed for b-/tsDMARD tapering. Thus, tapering seems to be the more favourable approach. REGISTRATION PROSPERO (CRD42019136905).
Collapse
Affiliation(s)
- Line Uhrenholt
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Section for Biostatistics and Evidence-Based Research, Bispebjerg and Frederiksberg Hospital, The Parker Institute, Copenhagen, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, Bispebjerg and Frederiksberg Hospital, The Parker Institute, Copenhagen, Denmark.,Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | | | - Stine S Andersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lene Dreyer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Annette Schlemmer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Rheumatology, Randers Regional Hospital, Randers, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Conni Skrubbeltrang
- Department of Medical Library, Aalborg University Hospital, Aalborg, Denmark
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
7
|
Ledingham JM, MacPhie E, Bosworth A. Covid-19: surging demand for some arthritis drugs. Assoc Med J 2021. [DOI: 10.1136/bmj.n2700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
8
|
Tascilar K, Hagen M, Kleyer A, Simon D, Reiser M, Hueber AJ, Manger B, Englbrecht M, Finzel S, Tony HP, Schuch F, Kleinert S, Wendler J, Ronneberger M, Figueiredo CP, Cobra JF, Feuchtenberger M, Fleck M, Manger K, Ochs W, Schmitt-Haendle M, Lorenz HM, Nuesslein H, Alten R, Kruger K, Henes J, Schett G, Rech J. Treatment tapering and stopping in patients with rheumatoid arthritis in stable remission (RETRO): a multicentre, randomised, controlled, open-label, phase 3 trial. THE LANCET. RHEUMATOLOGY 2021; 3:e767-e777. [PMID: 38297524 DOI: 10.1016/s2665-9913(21)00220-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 02/02/2024]
Abstract
BACKGROUND Owing to increasing remission rates, the management of patients with rheumatoid arthritis in sustained remission is of growing interest. The Rheumatoid Arthritis in Ongoing Remission (RETRO) study investigated tapering and withdrawal of disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis in stable remission to test whether remission could be retained without the need to take DMARD therapy despite an absence of symptoms. METHODS RETRO was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, parallel-group phase 3 trial in patients aged at least 18 years with rheumatoid arthritis for at least 12 months before randomisation who were in sustained Disease Activity Score using 28 joints with erythrocyte sedimentation rate (ESR) remission (score <2·6 units). Eligible patients were recruited consecutively from 14 German hospitals or rheumatology practices and randomly assigned (1:1:1) without stratification and regardless of baseline treatment, using a sequence that was computer-generated by the study statistician, to continue 100% dose DMARD (continue group), taper to 50% dose DMARD (taper group), or 50% dose DMARD for 6 months before stopping DMARDs (stop group). Neither patients nor investigators were masked to the treatment assignment. Patients were assessed every 3 months and screened for disease activity and relapse. The primary endpoint was the proportion of patients in sustained DAS28-ESR remission without relapse at 12 months, analysed using a log-rank test of trend and Cox regression. Analysis by a trained statistician of the primary outcome and safety was done in a modified intention-to-treat population that included participants with non-missing baseline data. This study is completed and closed to new participants and is registered with ClinicalTrials.gov (NCT02779114). FINDINGS Between May 26, 2010, and May 29, 2018, 303 patients were enrolled and allocated to continue (n=100), taper (n=102), or stop DMARDs (n=101). 282 (93%) of 303 patients were analysed (93 [93%] of 100 for continue, 93 [91%] of 102 for taper, and 96 [95%] of 101 for stop). Remission was maintained at 12 months by 81·2% (95% CI 73·3-90·0) in the continue group, 58·6% (49·2-70·0) in the taper group, and 43·3% (34·6-55·5) in the stop group (p=0·0005 with log-rank test for trend). Hazard ratios for relapse were 3·02 (1·69-5·40; p=0.0003) for the taper group and 4·34 (2·48-7·60; p<0.0001)) for the stop group, in comparison with the continue group. The majority of patients who relapsed regained remission after reintroduction of 100% dose DMARDs. Serious adverse events occurred in ten of 93 (11%) patients in the continue group, seven of 93 (8%) patients in taper group, and 13 of 96 (14%) patients in the stop group. None were considered to be related to the intervention. The most frequent type of serious adverse event was injuries or procedural complications (n=9). INTERPRETATION Reducing antirheumatic drugs in patients with rheumatoid arthritis in stable remission is feasible, with maintenance of remission occurring in about half of the patients. Because relapse rates were significantly higher in patients who tapered or stopped antirheumatic drugs than in patients who continued with a 100% dose, such approaches will require tight monitoring of disease activity. However, remission was regained after reintroduction of antirheumatic treatments in most of those who relapsed in this study. These results might help to prevent overtreatment in a substantial number of patients with rheumatoid arthritis. FUNDING None.
Collapse
Affiliation(s)
- Koray Tascilar
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Melanie Hagen
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Arnd Kleyer
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - David Simon
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Michaela Reiser
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Axel J Hueber
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany; Rheumatology Section, Sozialstiftung Bamberg, Bamberg, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Stephanie Finzel
- Department of Rheumatology and Clinical Immunology, University of Freiburg, Freiburg, Germany
| | - Hans-Peter Tony
- Department of Internal Medicine 2, University of Wuerzburg, Wuerzburg, Germany
| | | | - Stefan Kleinert
- Department of Internal Medicine 2, University of Wuerzburg, Wuerzburg, Germany; Rheumatology Practice, Erlangen, Germany
| | | | | | - Camille P Figueiredo
- Division of Rheumatology, Faculty of Medicine, Sao Paulo University, Sao Paulo, Brazil
| | | | - Martin Feuchtenberger
- Rheumatology Practice and Department of Internal Medicine 2, Clinic Burghausen, Burghausen, Germany
| | - Martin Fleck
- Department of Internal Medicine I, University of Regensburg, Regensburg, Germany; Asklepios Medical Center Bad Abbach, Bad Abbach, Germany
| | | | | | | | - Hanns-Martin Lorenz
- Department of Internal Medicine V, Division of Rheumatology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Joerg Henes
- Department of Internal Medicine 2, University of Tubingen, Tubingen, Germany
| | - Georg Schett
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany.
| | - Juergen Rech
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| |
Collapse
|
9
|
Maassen JM, van Ouwerkerk L, Allaart CF. Tapering of disease-modifying antirheumatic drugs: an overview for daily practice. THE LANCET. RHEUMATOLOGY 2021; 3:e659-e670. [PMID: 38287612 DOI: 10.1016/s2665-9913(21)00224-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/25/2021] [Accepted: 07/08/2021] [Indexed: 01/31/2024]
Abstract
In this Review, we discuss the possibility of drug tapering in patients with rheumatoid arthritis in remission or low disease activity, for glucocorticoids and disease-modifying antirheumatic drugs. We review international guidelines and recommendations, as well as remaining uncertainties, and provide an overview of the current literature. Three strategies of tapering are discussed: (1) tapering by discontinuation of one of the drugs in combination therapy regimens, (2) tapering by reducing the dose of one of the drugs in combination therapy regimens, and (3) tapering by dose reduction of monotherapy with disease-modifying antirheumatic drugs. We discuss the outcomes and robustness of evidence of trials and observational cohorts, and we give a trajectory for further research and drug tapering in daily practice.
Collapse
Affiliation(s)
| | - Lotte van Ouwerkerk
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | | |
Collapse
|
10
|
Morel J, Tournadre A, Sellam J, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. Practical Management of patients on anti-IL6R therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105221. [PMID: 34183155 DOI: 10.1016/j.jbspin.2021.105221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland & Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
| | | |
Collapse
|
11
|
YAZICI A. Remisyonda olan romatoid artritli hastada tedavi kararı. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.863635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
12
|
Asai S, Takahashi N, Hayashi M, Hanabayashi M, Kanayama Y, Takemoto T, Yabe Y, Shioura T, Ishikawa H, Yoshioka Y, Kato T, Hirano Y, Fujibayashi T, Hattori Y, Kobayakawa T, Ando M, Kuwatsuka Y, Matsumoto T, Asai N, Sobue Y, Nishiume T, Suzuki M, Ishiguro N, Kojima T. Predictors of disease flare after discontinuation of concomitant methotrexate in Japanese patients with rheumatoid arthritis treated with tocilizumab. Joint Bone Spine 2020; 87:596-602. [PMID: 32534200 DOI: 10.1016/j.jbspin.2020.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/05/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate predictors of disease flare after methotrexate discontinuation in Japanese rheumatoid arthritis (RA) patients with sustained low disease activity undergoing tocilizumab plus methotrexate combination therapy. METHODS Participants of this multicenter, open-label, uncontrolled, prospective study were RA patients maintaining low disease activity (Clinical Disease Activity Index [CDAI]≤10) for≥12weeks with tocilizumab plus methotrexate. Methotrexate was discontinued after 12weeks of biweekly administration while continuing tocilizumab therapy. Disease flare was defined as either a CDAI score>10 or intervention with rescue treatments for any reason even if the CDAI score was≤10. The impact of baseline characteristics on disease flare at week 64 (52weeks after methotrexate discontinuation) was assessed with logistic regression models. RESULTS Efficacy analyses were performed in 49 patients, of whom 15 had a disease flare by week 64. The proportion (95% confidence interval [CI]) of patients who maintained low disease activity without a flare at week 64 was 69.4% (54.6-81.8%). The dosing interval of tocilizumab was longer than that described on the drug label in Japan (i.e., intravenously every 4weeks, or subcutaneously every 2weeks) in 27% and 6% of patients with and without a flare, respectively. Multivariate analysis revealed that male sex (odds ratio [OR]: 18.00, 95% CI: 2.80-115.56) and extended dosing interval of tocilizumab (OR: 12.00, 95% CI: 1.72-83.80) were independent predictors of disease flare. CONCLUSION Male patients and those receiving tocilizumab at an extended dosing interval are at high risk of disease flare after discontinuation of concomitant methotrexate. TRIAL REGISTRATION NUMBER jRCTs041180071, UMIN000021247.
Collapse
Affiliation(s)
- Shuji Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Nobunori Takahashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Masatoshi Hayashi
- Department of Rheumatology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano, Nagano 380-8582, Japan
| | - Masahiro Hanabayashi
- Department of Rheumatology, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, Aichi 491-8558, Japan
| | - Yasuhide Kanayama
- Department of Rheumatology, Toyota Kosei Hospital, 500-1 Ibobara, Josui-cho, Toyota, Aichi 470-0396, Japan
| | - Toki Takemoto
- Department of Orthopedic Surgery, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi 446-8602, Japan
| | - Yuichiro Yabe
- Department of Rheumatology, Tokyo Shinjuku Medical Center, 5-1 Tsukudo-cho, Shinjuku-ku, Tokyo 162-8543, Japan
| | - Tomone Shioura
- Department of Rheumatology, Shizuoka Kosei Hospital, 23 Kitaban-cho, Aoi-ku, Shizuoka, Shizuoka 420-8623, Japan
| | - Hisato Ishikawa
- Department of Rheumatology, Japanese Red Cross Nagoya Daiichi Hospital, 3-35 Michishita-cho, Nakamura-ku, Nagoya, Aichi 453-8511, Japan
| | - Yutaka Yoshioka
- Department of Rheumatology, Handa Municipal Hospital, 2-29 Toyo-cho, Handa, Aichi 475-8599, Japan
| | - Takefumi Kato
- Kato Orthopedic Clinic, 8-4 Minamimyodaiji-cho, Okazaki, Aichi 444-0852, Japan
| | - Yuji Hirano
- Department of Rheumatology, Toyohashi Municipal Hospital, 50 Aotake-cho, Toyohashi, Aichi 441-8570, Japan
| | - Takayoshi Fujibayashi
- Department of Orthopedic Surgery, Konan Kosei Hospital, 137 Omatsubara, Takaya-cho, Konan, Aichi 483-8704, Japan
| | - Yosuke Hattori
- Department of Orthopedic Surgery and Rheumatology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001, Japan
| | - Tomonori Kobayakawa
- Department of Rheumatology, Chutoen General Medical Center, 1-1 Shobugaike, Kakegawa, Shizuoka 436-8555, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Takuya Matsumoto
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan; Department of Rheumatology, Shizuoka Kosei Hospital, 23 Kitaban-cho, Aoi-ku, Shizuoka, Shizuoka 420-8623, Japan
| | - Nobuyuki Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan; Department of Orthopedic Surgery and Rheumatology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Tsuyoshi Nishiume
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Mochihito Suzuki
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan.
| |
Collapse
|
13
|
Ogata A, Kato Y, Higa S, Maeda K. Subcutaneous tocilizumab: recent advances for the treatment of rheumatoid arthritis. Expert Opin Drug Deliv 2019; 16:639-648. [PMID: 31088167 DOI: 10.1080/17425247.2019.1618828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Atsushi Ogata
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yasuhiro Kato
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shinji Higa
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
| | - Keiji Maeda
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
| |
Collapse
|