2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

Long-term effectiveness and safety of methotrexate-tacrolimus combination therapy versus methotrexate monotherapy in reducing rheumatoid arthritis flares after TNF inhibitor discontinuation: a retrospective cohort study

BACKGROUND

This study evaluates the long-term effectiveness and safety of methotrexate-tacrolimus combination therapy compared to methotrexate monotherapy in maintaining successful tumor necrosis factor (TNF) inhibitor discontinuation in rheumatoid arthritis (RA) patients.

METHODS

We retrospectively analyzed consecutive RA patients who discontinued TNF inhibitors after achieving disease control by October 2022 and received either methotrexate monotherapy or methotrexate-tacrolimus combination therapy for up to 10 years. Per-observation time-to-event analyses assessed treatment failure, treatment intensification, first disease flare, and irreversible functional deterioration. Mixed-effects Cox models, time-dependent Cox models without random effects, and Kaplan-Meier estimates with inverse probability weighting were applied. Safety assessment included treatment-limiting adverse events and renal function trends.

RESULTS

A total of 147 treatment lines (96 methotrexate monotherapy and 51 combination therapy) in 116 patients were analyzed. The combination therapy significantly reduced treatment failure (hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.24-0.72), treatment intensification with the index drugs (HR, 0.38; 95% CI, 0.22-0.67) and with biologics or Janus kinase inhibitors (HR, 0.39; 95% CI, 0.22-0.71), and first flare (HR, 0.55; 95%CI 0.36-0.84), with consistent findings across models. The benefit was most pronounced in patients with prior flares during methotrexate monotherapy after TNF inhibitor discontinuation, with HRs as low as 0.04-0.12 across outcomes. No significant differences in treatment-limiting adverse events were observed. The annual increase in serum creatinine for tacrolimus users was 0.0032 mg/dL, suggesting minimal long-term renal impact.

CONCLUSIONS

Methotrexate-tacrolimus combination therapy significantly reduces relapse risk following TNF inhibitor discontinuation without compromising safety, offering a potentially sustainable treatment alternative after achieving remission with TNF inhibitor therapy.

Discontinuation vs. continuation of concomitant methotrexate in patients with rheumatoid arthritis on certolizumab pegol: results from a randomised, controlled trial

OBJECTIVE

The present non-inferiority study was designed to compare the effect of discontinuing versus continuing methotrexate (MTX) alongside certolizumab pegol (CZP) on maintaining low disease activity (LDA) in rheumatoid arthritis (RA) patients already stable on combination therapy.

METHODS

This multicentre, open-label, randomised, controlled trial included RA patients with sustained LDA (Clinical Disease Activity Index [CDAI] ≤ 10) for ≥ 12 weeks with CZP + MTX. Patients were randomised 1:1 by computer to either continue MTX (CZP + MTX group) or discontinue MTX after a 12-week reduction period (CZP group) using a dynamic allocation strategy with the minimisation method. The primary endpoint was the proportion of patients maintaining LDA without a flare (i.e., a CDAI score > 10 or intervention with rescue treatments for any reason) at week 36 (24 weeks after MTX discontinuation). Non-inferiority is verified if the lower limit of the 90% confidence interval (CI) using normal approximation for the difference in the proportion of cases that maintained LDA at week 36 between the intervention group and control group exceeds the non-inferiority margin.

RESULTS

All 84 screened patients were randomised to the CZP + MTX group (n = 41) and CZP group (n = 43), and were included in the efficacy analysis. Proportions (90% CI) of patients who maintained LDA at week 36 were 85.4% (76.3 to 94.4%) in the CZP + MTX group and 83.7% (74.5 to 93.0%) in the CZP group. The difference (90% CI) between the two groups was - 1.6% (-14.6 to 11.3%), with the lower limit of the 90% CI exceeding the non-inferiority margin of -18%. Reported adverse events were broadly similar between the two groups. The proportion of patients with gastrointestinal symptoms, as assessed by a self-administered questionnaire, was significantly lower in the CZP group than in the CZP + MTX group at week 36 (2.4% vs. 15.8%, P = 0.034).

CONCLUSION

Discontinuing concomitant MTX in RA patients on CZP is clinically feasible for maintaining LDA.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCTs041200048).

Incidence and spectrum of typical complications associated with immunosuppressant use in rheumatic disease: A nationwide retrospective study

AIM

To estimate the incidence and characteristics of typical complications associated with immunosuppressant therapy across various types of rheumatic disease (RD).

METHODS

We conducted a retrospective analysis using Korean claims data, including patients who were first diagnosed with rheumatic disease (rheumatoid arthritis, spondyloarthrosis, lupus erythematosus, vasculitis, sclerosis, Sjögren's syndrome, and polymyalgia rheumatica) and initiated immunosuppressant therapy between 2015 and 2018. We focused on several typical complications, including infections, cancer, cardiovascular complications, bone marrow suppression, gastrointestinal complications, diabetes, interstitial lung disease, demyelinating disease, acute kidney injury, and hepatotoxicity.

RESULTS

Among 464 753 patients prescribed immunosuppressants, 59 548 initiated treatment following their RD diagnosis. The most prevalent complications included opportunistic infections (60.6 events per 1000 person-years), serious infections (41.1), hypertension (31.5), diabetes (18.3), and cancer (14.1). Most complications peaked in the first month after treatment initiation. While the risk of serious infections and cancer increased with age, the incidence of opportunistic infections did not significantly vary. Furthermore, risk of serious infection or cancer did not significantly differ among RD types.

CONCLUSIONS

This investigation elucidated the incidence and spectrum of typical complications associated with immunosuppressants among patients with RD, using a vast real-world dataset to highlight key safety concerns.

Effect of Ozoralizumab Administration with or without Methotrexate in Patients with Rheumatoid Arthritis: A Post-Hoc Analysis

INTRODUCTION

Ozoralizumab (OZR) is a novel tumor necrosis factor (TNF) inhibitor that was launched in Japan for treating patients with rheumatoid arthritis (RA) who have had an inadequate response to existing therapies. This post-hoc analysis aimed to compare the efficacy of OZR administered without methotrexate (MTX) with placebo or OZR administration in combination with MTX.

METHODS

We analyzed the OZR group (30 mg) in the NATSUZORA trial (non-MTX, open trial) (OZR group; n = 94) and the placebo group (MTX group; n = 75) and the 30-mg OZR group (OZR + MTX group; n = 152) in the OHZORA trial (combined MTX, double-blind trial), and the covariates were adjusted by propensity score matching. Subsequently, the American College of Rheumatology (ACR) 20/50/70 response rates from baseline to 24 or 52 weeks were compared. Furthermore, to compare longitudinal data on disease activity indicators, a mixed-effects model for repeated-measures analyses was used.

RESULTS

Comparing the OZR and MTX groups, 52 patients were matched in each group. The OZR group showed improvements in the ACR20 (OZR group, 67.3% vs. MTX group, 34.6%, p = 0.001), ACR50 (51.9% vs. 17.3%, p < 0.001), and ACR70 (26.9% vs. 11.5%, p = 0.047) response rates compared to those in the MTX group. Comparing the OZR and OZR + MTX groups, 77 patients were matched in each group. No significant difference was observed in the ACR20 response rate (OZR group, 58.4% vs. OZR + MTX group, 70.1%, p = 0.130). However, the OZR + MTX group showed higher ACR50 (44.2% vs. 62.3%, p = 0.024) and ACR70 (29.9% vs. 45.5%, p = 0.046) response rates.

CONCLUSION

OZR administration without MTX was associated with an improvement in the signs and symptoms of RA compared to placebo administration (continuation of MTX monotherapy). OZR and MTX administration showed better efficacy than OZR administration alone.

Erosion regression in patients with rheumatoid arthritis after upadacitinib-a pilot study using high resolution peripheral quantitative computed tomography

OBJECTIVES

To evaluate whether inhibition of Janus kinases (JAK) 1 could lead to erosion repair on high-resolution peripheral quantitative CT (HR-pQCT) in patients with active RA.

METHODS

This was a prospective, non-randomized pilot study. We enrolled 20 adult patients with active RA with ≥1 bone erosion on HR-pQCT. They were given upadacitinib 15 mg once daily for 24 weeks. HR-pQCT of the metacarpophalangeal joint was performed at baseline and 24-week. The serum bone biomarkers level was evaluated before and after treatment. Twenty age-and-sex matched RA patients from another study treated with conventional synthetic DMARDs (csDMARDs) were included as active controls.

RESULTS

Nineteen patients in the upadacitinib group completed the study procedures. After 24 weeks, despite similar improvement in disease activity, a reversed trend in the mean erosion volume change on HR-pQCT was observed comparing the upadacitinib and active control group (upadacitinib group: -0.23 ± 3.26 mm3vs control group: 1.32 ± 6.05 mm3, P = 0.131). A greater proportion of erosions in the upadacitinib group demonstrated regression (27% vs 12%, P = 0.085). Using general estimating equation (GEE), the use of upadacitinib was significantly associated with erosion regression (OR: 3.61, 95% CI: 1.00-13.00, P = 0.049) after adjusting for the difference in disease duration. The serum levels of bone resorption markers reduced after upadacitinib treatment. No new safety signal was noted.

CONCLUSION

Despite a similar improvement in RA disease activity after upadacitinib compared with csDMARDs, a differential regression of erosion on HR-pQCT was observed in patients received upadacitinib. The potential role of JAK1 inhibition in erosion repair should be investigated.

[Combination therapy with rituximab and anakinra in the treatment of chronic pericarditis complicating rheumatoid arthritis]

Pericarditis is often an asymptomatic complication of rheumatoid arthritis. It rarely progresses towards tamponade or chronicity. There is little data on the therapeutic management of this serious complication. Recently, some rare data evaluating the place of biotherapy in rheumatoid pericarditis have been published. We report the observation of a patient with immunopositive rheumatoid arthritis escaping several lines of treatment who developed tamponade which recurred after surgical drainage. Only combotherapy with rituximab and anakinra allowed the induction of rheumatological remission and the disappearance of pericarditis.

Glucocorticoid sparing effect of Janus kinase inhibitors compared to biologic disease modifying anti-rheumatic drugs in rheumatoid arthritis, a single-centre retrospective analysis

BACKGROUND

Glucocorticoid sparing in rheumatoid arthritis (RA) treatment is crucial to minimizing adverse effects associated with long-term use. Janus kinase inhibitors (JAKi) could potentially offer a more potent glucocorticoid-sparing effect than biologic DMARDs (bDMARDs).

MATERIAL AND METHODS

This is a single-centre retrospective analysis of RA patients treated with JAKi or bDMARDs. Glucocorticoid tapering, rescue therapy and discontinuation were analysed through mixed-effects models, Poisson regression and multivariable logistic regression, respectively, adjusting for baseline disease activity, demographic factors and treatment line.

RESULTS

A total of 716 RA patients treated with JAKi (n = 156) or bDMARDs (n = 560) were evaluated. JAKi treatment was associated with a more rapid reduction in glucocorticoid dose within the first 6 months and 60% higher odds of discontinuation compared with bDMARDs (adjusted odds ratio 1.63; 95% CI: 1.02, 2.60, P = 0.039). Despite a higher baseline glucocorticoid dose, over 50% of JAKi-treated patients discontinued glucocorticoids after 12 months, vs ∼40% for bDMARDs. The need for glucocorticoid rescue therapy was significantly higher in the bDMARD group (rate ratio 2.66; 95% CI: 1.88, 3.74).

CONCLUSION

Our findings indicate that JAKi facilitate more rapid glucocorticoid tapering compared with bDMARDs in RA patients. These results underscore the potential of JAKi to reduce long-term glucocorticoid exposure, highlighting their value in RA management strategies, including minimizing glucocorticoid-related adverse effects.

Vanillic acid ameliorates collagen-induced arthritis by suppressing the inflammation response via inhibition of the MAPK and NF-κB signaling pathways

OBJECTIVE

To explore the potential therapeutic effects and underlying mechanism of vanillic acid (VA) in the treatment of rheumatoid arthritis (RA).

METHODS

A collagen-induced arthritis (CIA) model was established in DBA/1 J mice. Methotrexate (MTX, 1 mg/kg/d) and VA (5 mg/kg/d, 10 mg/kg/d, 20 mg/kg/d) were then administered to investigate their therapeutic efficacy on RA in vivo. The body weight, joint score, and spleen index of the mice in different experimental groups were evaluated. Micro-CT was performed to detect joint destruction in the mice, and HE staining was utilized to observe the pathological conditions of their joints and spleens. Quantitative real-time PCR (qRT-PCR) and enzyme linked immunosorbent assay (ELISA) were used to detect inflammatory cytokines and chemokines. Changes in synovial tissue signaling pathways were detected using immunohistochemistry. For in vitro analysis, RAW 264.7 cells were pretreated with different concentrations of VA (25, 50, 100 μg/ml) and then treated with lipopolysaccharide (LPS), and changes in their signaling pathways were detected by western blot (WB).

RESULTS

VA improved the clinical symptoms and bone destruction of arthritis in CIA mice, reduced pathological damage to ankle synovial and spleen tissue, and inhibited polarization of macrophages to M1 in the synovial tissue as well. In addition, VA inhibited the expression of TNF-α, IL-6, IL-1β, MCP-1, and iNOS in CIA mice and in LPS-stimulated RAW264.7 cells and also inhibited the phosphorylation of p65, IκBα, ERK, JNK, and p38 MAPKs.

CONCLUSIONS

VA can significantly improve the clinical symptoms of RA and exerts anti-inflammatory effects by inhibiting the activation of the NF-κB/MAPK pathway.

Revolutionary Changes in the Management of Lupus Nephritis: Towards De-Glucocorticoid or No-Glucocorticoid

Glucocorticoids (GCs) possess potent anti-inflammatory and immunosuppressive properties and are used to treat various diseases, including systemic autoimmune rheumatic diseases, rheumatoid arthritis, and systemic lupus erythematosus (SLE). However, GCs are associated with several adverse events and are considered risk factors for infections and cardiovascular disorders; furthermore, their application as therapeutics has changed with recent progress in molecular-targeted therapies. Although GCs have been the mainstay of SLE treatment for more than 50 years, the latest European Alliance of Association for Rheumatology recommendations for the management of SLE in 2023 has significantly relegated the use of GCs and recommended that these be used as "bridging therapy" during periods of SLE disease activity. They also recommended the use of GC pulse therapy followed by relatively low doses of GCs even in patients with high disease-activity lupus nephritis, with a focus on the appropriate use of hydroxychloroquine, immunosuppressive drugs, and biological agents. This combination is essential for improving renal survival, minimizing flares, and reducing the side effects of GC. The GC dose was tapered to < 5 mg/day of prednisolone within half a year, maintained for 3 years, and then discontinued with the concomitant use of combination therapies. In contrast to non-renal SLE, the development of more potent molecular targeted therapies for lupus nephritis is required.

Immune Memory: A New Frontier in Treating Recurrent Inflammatory Skin Diseases

The recurrence of inflammatory skin diseases represents a significant challenge in clinical practice, primarily mediated by immune memory. In inflammatory skin diseases, immune memory encompasses adaptive immune memory, trained immunity, and inflammatory memory, which are conducted by adaptive immune cells, innate immune cells, and structural cells, respectively. Adaptive immune memory is established through gene rearrangement, leading to antigen-specific immune memory. In contrast, trained immunity and inflammatory memory are formed through epigenetic and metabolic reprogramming, resulting in non-specific immune memory. Different types of immune memory work synergistically to aggravate localized inflammation in recurrent inflammatory skin diseases. However, immune memory in specific cells, such as macrophages, may also play an immunoregulatory role under certain conditions. We reviewed the immune memory mechanisms in different inflammatory skin diseases and discussed future strategies for targeted regulation of the molecular mechanisms underlying immune memory, such as targeted biological agents and epigenetic modifications. Additionally, we explored the potential for precise regulation of immune memory and its application in personalized treatment for recurrent inflammatory skin diseases.

A theory of change for patient-initiated follow-up care in rheumatoid arthritis

BACKGROUND

Timely, high-quality care is critical to rheumatoid arthritis (RA) management. In Alberta, thousands of individuals with RA are waiting for care due to the resource-intensive nature of lifelong follow-ups and rheumatologist shortages. With 20-50% of routine follow-ups not leading to treatment changes or raising new concerns, many appointments may be avoidable if care were restructured. Patient-initiated models extend rheumatologist follow-up intervals beyond 12 months where appropriate, which can reduce inefficiencies and improve care access. To address provincial RA care challenges, we co-developed a theory of change (TOC) for patient-initiated follow-up care.

METHODS

A TOC serves to define health services interventions and their intended impact prior to implementation testing. We worked with 35 healthcare leaders, implementation experts, and patient partners to co-develop a TOC for patient-initiated RA follow-up care. During the scoping phase, we held discussions with healthcare leaders and reviewed evidence on patient-initiated follow-up models to assess their implementation potential. During the development phase, we drafted a TOC map using scoping phase findings and clinical and patient expertise. During the refinement phase, feedback was collected to optimize the TOC. Meetings were recorded, transcribed, and analyzed using deductive qualitative content analysis alongside anonymous poll results and informal feedback to guide TOC refinement.

RESULTS

The scoping phase identified challenges in RA care, including long waitlists and unnecessary appointments, which patient-initiated follow-up models have the potential to address. TOC discussions highlighted two intended impacts: (1) efficient and effective care for patients when needed, and (2) a sustainable model for RA care. Feedback in the refinement phase covered 4 topics: (1) preference for an interdisciplinary flare clinic, (2) patient selection, (3) patient education, and (4) patient monitoring. Tools and strategies were co-developed with partners to support patients (e.g., decision tool for patient-provider discussions) and the health system (e.g., monthly meetings to monitor burden). The final TOC for patient-initiated follow-up in RA details the care pathway, key resources and considerations, and evaluation outcomes.

CONCLUSIONS

A patient-centered, context-specific patient-initiated RA follow-up care model was co-developed with patient and healthcare partners. An implementation pilot will test its ability to address RA care challenges.

CLINICAL TRIAL REGISTRATION

Not applicable.

Adipose-derived stem cells attenuate rheumatoid arthritis by restoring CX3CR1+ synovial lining macrophage barrier

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune disease and the integrity of CX3CR1+ synovial macrophage barrier significantly impacts its progression. However, the mechanisms driving the dynamic changes of this macrophage barrier remain unclear. Traditional drug therapies for RA have substantial limitations. Mesenchymal stem cells (MSCs)-based cell therapy, especially adipose-derived stem cells (ADSCs), hold therapeutic promise. Nevertheless, the underlying therapeutic mechanism of ADSCs, especially their interactions with CX3CR1+ macrophages, require further investigation.

METHODS

To explore the interaction between ADSCs and CX3CR1+ synovial macrophages during barrier reconstruction, underlying the therapeutic mechanism of ADSCs and the mechanisms on the dynamic changes of the macrophage barrier, scRNA-seq analysis was conducted 4 days after ADSCs injection in serum transfer-induced arthritis model mice. The roles of mitochondria transfer and ADSCs transplantation were also explored. Bulk RNA-seq analysis was performed after the co-culture of ADSCs and CX3CR1+ synovial macrophages. To study the in vivo fate of ADSCs, bulk RNA-seq was performed on ADSCs retrieved at 0, 2, 4, and 7 days post-injection.

RESULTS

Intra-articular injection of ADSCs effectively attenuated the pathological progression of mice with serum transfer-induced arthritis. ADSCs gradually adhered to CX3CR1+ macrophages, facilitating the restore of the macrophage barrier, while the absence of this barrier greatly weakened the therapeutic effect of ADSCs. scRNA-seq analysis revealed an Atf3high Ccl3high subset of CX3CR1+ macrophages with impaired oxidative phosphorylation that increased during RA progression. ADSCs-mediated reduction of this subset appeared to be linked to mitochondrial transfer, and transplantation of isolated ADSCs-derived mitochondria also proved effective in treating RA. Both bulk RNA-seq and scRNA-seq analyses revealed multiple interaction mechanisms between ADSCs and CX3CR1+ macrophages, including Cd74/Mif axis and GAS6/MERTK axis, which contribute to barrier restoration and therapeutic effects. Furthermore, bulk RNA-seq analysis showed that ADSCs primarily contribute to tissue repair and immune regulation subsequently.

CONCLUSIONS

Our results suggest that ADSCs ameliorated the energy metabolism signature of CX3CR1+ lining macrophages and may promote barrier restoration through mitochondria transfer. In addition, we elucidated the fate of ADSCs and the therapeutic potential of mitochondria in RA treatment.

Residual pain and fatigue are affected by disease perception in rheumatoid arthritis in sustained clinical and ultrasound remission

OBJECTIVE

Regardless of remission status, residual pain (RP) might persist in rheumatoid arthritis (RA). The aim of this study was to characterize RP, its perception, and patient-dependent features and to evaluate its possible association with residual synovitis in patients with RA in remission.

METHODS

Ninety-seven patients with RA, including 68 in sustained clinical and ultrasound remission (Rem/RA) and 29 in high/moderate DAS28-CRP disease activity (H-Mo/RA) were enrolled in the study. Thirty patients with fibromyalgia were enrolled as a control group(FIBRO). At study entry, demographic, clinical, ultrasound characteristics, and pain dimension assessment (VAS-pain, FACIT, CSI, GHQ, and RAID) were collected for each patient. RA patients underwent synovial tissue biopsy to evaluate the degree of synovitis using the Krenn synovitis score (KSS).

RESULTS

Forty-eight percent of Rem/RA still declared unacceptable pain (VAS-Pain > 20) compared to 80% of H-Mo/RA patients (p < 0.0001). Furthermore, Rem/RA patients presented comparable levels of pain dimension assessment regardless of KSS. However, classifying Rem/RA group based on RAID score (< 2 as satisfied SAT-Rem/RA and ≥ 2 as unsatisfied UNSAT-Rem/RA), SAT-Rem/RA group presented a lower grade of VAS-Pain (p < 0.0001), lower percentage of patients with an unacceptable pain (p < 0.0001) and lower grade of fatigue(p < 0.0001) compared to the UNSAT-Rem/RA patients. The percentage of SAT-Rem/RA patients who presented a disease flare did not differ from UNSAT-Rem/RA over the 24 months of follow-up. Finally, female Rem/RA patients presented higher VAS-Pain compared to male Rem/RA (p = 0.0119).

CONCLUSIONS

Moreover,73% satisfied female Rem/Ra patients presented an acceptable pain compared to 23% unsatisfied female Rem/RA patients (p = 0.001). RP in RA patients in remission can represent the way by which the patients communicate their state of non-acceptance of the disease. It can be useful to treat RP with the appropriate treatments. Key Points • Rheumatoid arthritis patients still reported unacceptable residual pain despite sustained clinical and ultrasound remission and despite the low grade/absence of histological synovitis. • Only a small rate of rheumatoid arthritis patients in sustained clinical and ultrasound remission showed residual pain as part of a central sensitivity syndrome or psychiatric disorders. • Rheumatoid arthritis patients in sustained clinical and ultrasound remission complained residual pain and fatigue as part of not acceptance of disease and/or dissatisfaction in the disease management.

RheuMetric Physician 0 to 10 Estimates of Inflammation, Damage, and Patient Distress at Initial Versus Follow-Up Visits in Contemporary Rheumatology Care

OBJECTIVE

We aimed to analyze the RheuMetric physician 0 to 10 visual numeric subscale (VNS) estimates of inflammatory activity (DOCINF), organ damage (DOCDAM), and patient distress (DOCDIS) at initial and follow-up routine rheumatology visits for possible incremental information to clarify physician estimate of global assessment (DOCGL).

METHODS

A retrospective cross-sectional study compared mean DOCGL, DOCINF, DOCDAM, and DOCDIS and the percentage contributed by inflammation, damage, and distress to DOCGL (total = 100%) at initial and follow-up visits in 563 unselected routine care patients, classified into four diagnosis categories: inflammatory (rheumatoid arthritis, systemic lupus erythematosus [SLE], spondylarthritis, vasculitis, and gout), primary osteoarthritis (OA), primary fibromyalgia (FM), and "other" diagnoses. Differences between initial and follow-up visits were estimated using t-tests.

RESULTS

In all patients, mean DOCGL was 4.0/10, DOCINF 1.6/10, DOCDAM 2.9/10, and DOCDIS 2.4/10, indicating higher estimates for damage and distress than for inflammation, including in all inflammatory diagnoses other than SLE. Highest mean estimates were 2.2 for DOCINF in inflammatory diagnoses, 4.9 for DOCDAM in primary OA, 6.3 for DOCDIS in primary FM. However, DOCDAM was 2.8 (0.6 uniyts higher than DOCINF) in inflammatory diagnoses. RheuMetric estimates of inflammation were significantly higher at initial than at follow-up visits, and estimates of damage were significantly lower at initial than at follow-up visits in all patients and in those with inflammatory diagnoses. DOCGL did not differ significantly at initial versus follow-up visits.

CONCLUSION

DOCINF, DOCDAM, and DOCDIS add feasibly recorded, clinically relevant incremental information to DOCGL. Despite excellent contemporary control of inflammation, joint damage and patient distress remain important clinical problems in contemporary routine rheumatology care, documented by quantitative RheuMetric estimates.

Promise of rheumatoid arthritis therapy: From clinical deep remission to drug-free remission

Achieving clinical deep remission (CliDR) in rheumatoid arthritis (RA) is essential to prevent long-term joint damage, enhance patient quality of life, and possibly reduce and discontinue medication eventually. Recent research advances have raised the possibility of achieving deep remission and even drug-free remission. This comprehensive review examines current strategies of RA therapy, concept of deep remission, challenges, and the emerging prospects of drug-free remission. It also reviews the role of different treatments, including conventional disease-modifying antirheumatic drugs (DMARDs), biologic agents, and targeted synthetic drugs, in the journey from deep remission to drug-free remission. In addition, it emphasizes the importance of patient-centered care, early diagnosis, and individualized treatment approaches in optimizing outcomes for patients with RA.

Prevalence and characteristics of adults with difficult-to-treat rheumatoid arthritis in a large patient registry

OBJECTIVES

An estimated 5-20% of patients with rheumatoid arthritis (RA) fail multiple treatments and are considered 'difficult-to-treat' (D2T), posing a substantial clinical challenge for rheumatologists. A European League Against Rheumatism (EULAR) task force proposed a definition of D2T-RA in 2021. We applied EULAR's D2T definition in a cohort of patients with established RA to assess prevalence, and we compared clinical characteristics of participants with D2T-RA with matched comparisons.

METHODS

Data from the longitudinal Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS) registry were used. Participants were classified as D2T if they met EULAR's definition. A comparison group of non-D2T-RA patients were matched 2:1 to every D2T patient, and differences in characteristics were evaluated in descriptive analyses. Prevalence rates of D2T were estimated using Poisson regression.

RESULTS

We estimated the prevalence of D2T-RA to be 14.4 (95% CI: 12.8, 16.3) per 100 persons among 1581 participants with RA, and 22.3 (95% CI: 19.9, 25.0) per 100 persons among 1021 who were biologic/targeted synthetic DMARD experienced. We observed several differences in demographics, comorbidities and RA disease activity between D2T-RA and non-D2T-RA comparisons. Varying EULAR sub-criteria among all participants in BRASS resulted in a range of D2T-RA prevalence rates, from 0.6 to 17.5 per 100 persons.

CONCLUSION

EULAR's proposed definition of D2T-RA identifies patients with RA who have not achieved treatment targets. Future research should explore heterogeneity in these patients and evaluate outcomes to inform the design of future studies aimed at developing more effective RA management protocols.

Low prevalence of methotrexate intolerance in rheumatoid arthritis: a South African study

INTRODUCTION

Methotrexate (MTX) is the first line therapy for rheumatoid arthritis (RA), and despite its widespread use, there is very little information about MTX intolerance in sub-Saharan Africa. The aim of this study was to assess the prevalence of MTX intolerance and other reasons for stopping MTX in RA in South Africa.

METHODS

A retrospective chart review of all RA patients seen at Inkosi Albert Luthuli Hospital in Durban from 2009 to 2019 was undertaken. We included patients who received MTX for at least three months. All patients received folic acid supplements. Patients who discontinued MTX were categorized as having either MTX related toxicity or other reasons.

RESULTS

A total of 695 patients were identified with a female to male ratio of 7:1. The mean age was 57.9 (± 13.3) years, and median duration of MTX use was 67.0 (39.0-106.0) months. Most of the patients were African Blacks (61.2%), and Indians (32.8%). There were 83 (11.9%) patients who stopped MTX, and it was successfully reintroduced in 25 of them. Thus, 58 (8.3%) patients discontinued therapy, 33 (4.7%) due to intolerance and 25 (3.6%) due to factors other than adverse effects. The commonest causes of MTX intolerance were respiratory, gastrointestinal and haematological. The other reasons for discontinuation included co-morbidities and pregnancy related concerns.

CONCLUSIONS

The low prevalence of MTX intolerance in a multiethnic population in this single centre study, confirms the value of MTX as anchor therapy, especially in resource constrained settings. Key Points • We report a low and similar prevalence of methotrexate intolerance in a large population of African Blacks and Indians with RA in sub-Saharan Africa. • Even though there was heterogeneity among other studies, our review indicates that MTX was tolerated better in our patients compared to patients in Europe and the United States of America.

Rheumatoid Factor: Diagnostic and Prognostic Performance and Therapeutic Implications in Rheumatoid Arthritis

Rheumatoid factor (RF) is the first autoantibody identified in rheumatoid arthritis (RA) which targets the fragment crystallizable (Fc) region of immunoglobulin (Ig) G. Although IgM isotype is predominant, other Ig isotypes, including IgG and IgA, also exist. While RF is not specific to RA, it remains a valuable serological test for diagnosing the disease, as evidenced by its inclusion in the 2010 classification criteria for RA based on elevated serum RF levels. RF is also associated with RA severity, including joint damage and extra-articular manifestations, serving as a poor prognostic factor and aiding in the identification of difficult-to-treat RA. Recent studies have demonstrated that high serum RF levels are associated with a reduced response to tumor necrosis factor (TNF) inhibitors. In contrast, anti-TNF antibodies lacking the Fc portion have shown stable efficacy in RA patients regardless of baseline RF levels. These findings reaffirm the clinical significance of RF measurement, 80 years after its initial discovery. This review explores the diagnostic and prognostic significance of RF and its impact on treatment selection in RA management.

Human nasal turbinate stem cells with specific gene signatures (HAS2, CXCL1, KRTAP1-5, GSTT2B, and C4B) attenuate rheumatoid arthritis

This study aimed to investigate the therapeutic effect of human nasal turbinate-derived stem cells (hNTSCs) on mice with rheumatoid arthritis (RA) and identify hNTSC gene signatures with therapeutic effects on RA. hNTSCs were obtained from 20 healthy controls (HCs) who had undergone nasal turbinate surgery. Collagen-induced arthritis (CIA) mice were used to investigate the therapeutic effects of hNTSCs. The engraftment and migration abilities of hNTSCs were evaluated. CD4+CD25- T cells were co-cultured with hNTSCs, and effector T cell proliferation was evaluated by flow cytometry. Osteoclast differentiation was evaluated using mouse bone marrow monocytes which were cultured with M-CSF and RANKL, then TRAP staining was performed to measure effect of hNTSCs on osteoclastogenesis. Microarray assays were performed to identify gene expression differences between hNTSCs with CIA mice therapeutic or not and were validated by RT-qPCR. hNTSCs differentiated well into osteoblasts and adipocytes and expressed high levels of CXCL1 and osteoprotegerin. Single-cell RNA sequencing showed that hNTSCs clustered into 11 cell types, and cell surface markers were compatible with mesenchymal stem cells. hNTSC-treated CIA mice showed reductions in arthritis severity scores and incidence of arthritis. In engraft measurements, hNTSCs survived for 8 to 12 weeks in mice paws. Chemokine receptors expression increased in hNTSCs by IL-1β or TNF-α stimulation. CD4+CD25- T cell proliferation was reduced by hNTSCs and reversed by adding 1-MT (indoleamine 2,3-dioxygenase inhibitor), indicating that indoleamine 2,3-dioxygenase mediated T cell suppression. Osteoclastogenesis was suppressed by hNTSCs, and this was attenuated by anti-OPG Ab. hNTSCs therapeutic in CIA mice showed specific gene signatures with up-regulated genes (KRTAP1-5, HAS2, and CXCL1) and down-regulated genes (GSTT2B and C4B) compared to hNTSCs without CIA therapeutic effects. hNTSCs exhibited therapeutic potential in RA. Therapeutic effects were mediated by effector helper T cell suppression and the inhibition of osteoclastogenesis. In addition, hNTSCs with greater therapeutic effects on RA showed significant differences in their gene signatures.

Safety of baricitinib in Japanese patients with rheumatoid arthritis in clinical use: 3-year data of all-case postmarketing surveillance study

OBJECTIVES

To assess safety of baricitinib in Japanese patients with rheumatoid arthritis (RA) in real-world clinical practice.

METHODS

This all-case postmarketing surveillance study included patients initiating baricitinib for RA from September 2017 to April 2019. Treatment duration was recorded. Safety data were collected for up to 3 years from initiation (up to 4 weeks postdiscontinuation in discontinuing patients).

RESULTS

Safety analyses included 4720 patients; 2580 (54.7%) were ≥65 years old. Baricitinib persistence rate was 45.4% (3-year Kaplan-Meier analysis); the most common discontinuation reason was insufficient effectiveness (n = 1005, 21.3%). Serious adverse events occurred in 600 patients [incidence rate (IR) 10.42/100 patient-years (PY); 95% confidence interval, 9.76-11.09]. There were 39 deaths [IR 0.43 (0.30-0.57)/100 PY]. Adverse events of special interest IRs per 100 PY were herpes zoster 4.68 (4.22-5.14), serious infection 3.05 (2.68-3.41), malignancy 1.09 (0.87-1.30), major adverse cardiovascular events 0.35 (0.23-0.48), and venous thromboembolism 0.25 (0.15-0.36). IRs did not increase with prolonged exposure.

CONCLUSIONS

No new safety concerns were identified during this 3-year postmarketing surveillance study of baricitinib in Japanese patients with RA. Patients and clinicians should be cognizant of herpes zoster and other serious infection risks during baricitinib treatment, especially in the first 6 months.

Mortality and Predictive Factors for Death Following the Diagnosis of Interstitial Lung Disease in Patients with Rheumatoid Arthritis: A Retrospective, Long-Term Follow-Up Study

Objective: The aim of this study was to determine mortality and predictive factors for death in patients with rheumatoid arthritis (RA) diagnosed with and without interstitial lung disease (ILD). Methods: We retrospectively performed a long-term follow-up study of patients diagnosed with RA at our medical center between April 2001 and June 2023. The diagnosis and classification of ILD were made based on pulmonary high-resolution computed tomography (HRCT), taken at RA diagnosis and during follow-up. Results: Among 781 patients with RA, 78 were diagnosed with ILD; all cases except one were subclinical. The most common HRCT pattern was definite usual interstitial pneumonia (UIP) followed by nonspecific interstitial pneumonia (NSIP)/UIP, probable UIP, NSIP, and early UIP. During follow-up (mean of 10.0 years), the crude incidence rate of death (95% confidence interval [CI]) was 7.1 (5.2-10.0) and 1.5 (1.0-1.9) per 100 person-years in RA patients with and without ILD. Poor control of RA activity was associated with increased incidence rates of death. The standardized mortality ratio (95% CI) compared with the general population was 1.32 (1.11-1.53) for all RA patients, 2.09 (1.45-2.73) for RA-ILD patients, and 1.16 (0.95-1.38) for non-ILD RA patients. Lung cancer and respiratory failure were the most common causes of death in RA-ILD patients. The Multivariable Fine-Gray regression analysis revealed that ILD (adjusted hazard ratio [HR] 2.97 [95% CI 1.95-4.53]), advanced age (1.08 per additional year [1.05-1.10]), and low body mass index (3.07 [2.10-4.49]) were strong predictive factors for mortality in RA patients. HRCT patterns did not affect the risk of death in RA-ILD patients. Conclusions: Regardless of HRCT pattern, RA-ILD contributes to the increased mortality risk in patients with RA.

Energy metabolism in health and diseases

Energy metabolism is indispensable for sustaining physiological functions in living organisms and assumes a pivotal role across physiological and pathological conditions. This review provides an extensive overview of advancements in energy metabolism research, elucidating critical pathways such as glycolysis, oxidative phosphorylation, fatty acid metabolism, and amino acid metabolism, along with their intricate regulatory mechanisms. The homeostatic balance of these processes is crucial; however, in pathological states such as neurodegenerative diseases, autoimmune disorders, and cancer, extensive metabolic reprogramming occurs, resulting in impaired glucose metabolism and mitochondrial dysfunction, which accelerate disease progression. Recent investigations into key regulatory pathways, including mechanistic target of rapamycin, sirtuins, and adenosine monophosphate-activated protein kinase, have considerably deepened our understanding of metabolic dysregulation and opened new avenues for therapeutic innovation. Emerging technologies, such as fluorescent probes, nano-biomaterials, and metabolomic analyses, promise substantial improvements in diagnostic precision. This review critically examines recent advancements and ongoing challenges in metabolism research, emphasizing its potential for precision diagnostics and personalized therapeutic interventions. Future studies should prioritize unraveling the regulatory mechanisms of energy metabolism and the dynamics of intercellular energy interactions. Integrating cutting-edge gene-editing technologies and multi-omics approaches, the development of multi-target pharmaceuticals in synergy with existing therapies such as immunotherapy and dietary interventions could enhance therapeutic efficacy. Personalized metabolic analysis is indispensable for crafting tailored treatment protocols, ultimately providing more accurate medical solutions for patients. This review aims to deepen the understanding and improve the application of energy metabolism to drive innovative diagnostic and therapeutic strategies.

Exploring drug utilization patterns, healthcare resource utilization, and epidemiology of rheumatoid arthritis in Colombia: a retrospective claims database study

BACKGROUND

In Colombia, there is a lack of recent real- word studies that provide information on the epidemiology and healthcare resource utilization (HCRU) of rheumatoid arthritis (RA) at national level.

METHODS

To describe the burden of RA in Colombia, focusing on trends in drug utilization patterns, healthcare resource utilization (HCRU), and the epidemiology of adult patients diagnosed with RA between January 2017 and December 2022. This retrospective descriptive study used real-world data obtainedfrom a national claim database, SISPRO (Sistema de Información para la Protección Social). We included registries of adult patients diagnosed with RA between 2017 and 2022. We estimated the age-standardized incidence and prevalence of RA each year, drug utilization patterns for disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids, rates of medical consultations, emergency room visits, and hospitalizations, and associated comorbidities and healthcare-related and pharmacy-related costs.

RESULTS

Overall, 327,430 unique patients with RA between 2017 and 2022 were included in the analysis, comprising 94,093 incident cases and 722,569 prevalent cases. The age-standardized incidence of RA ranged between 34.7 and 51.4 per 100,000 inhabitants, and the age-standardized prevalence ranged between 0.282 and 0.382 per 100 inhabitants between 2017 and 2022. The proportion of patients prescribed conventional synthetic DMARDs and biologic DMARDs decreased over the study period, from 39.23% in 2017 to 28.61% in 2021 and from 6.07% in 2017 to 3.72% in 2021, respectively. The proportion of patients prescribed targeted synthetic DMARDs increased from 0.9% in 2017 to 1.8% in 2021. The rate of medical consultations increased over the study period (from 2,406.6 in 2017 to 3,354.2 per 1,000 patients with RA in 2022). Consultation costs were the largest among all-cause annual healthcare-related costs.

CONCLUSION

This study described the heavy burden of RA in Colombia with an increasing incidence of RA, and significant healthcare resource utilization and associated costs. Patients with RA in the country are increasingly able to access consultations with specialists and receive advanced therapies. However, there remains a need for efforts to facilitate treatment among this population. These findings emphasize the importance of tailoring RA management strategies to the local context.

Survival in patients with rheumatoid arthritis and recently diagnosed early-stage colorectal, lung, or prostate cancer receiving tumour necrosis factor inhibitors: a retrospective cohort study

BACKGROUND

Tumor necrosis factor (TNF) inhibitors could impair tumoural immunity in patients with rheumatoid arthritis and cancer. We aimed to investigate the association between survival and TNF inhibitor treatment during the first 3 years after a diagnosis of colorectal, lung, or prostate cancer in patients with rheumatoid arthritis.

METHODS

In this cohort study, we conducted a secondary data analysis of the Surveillance, Epidemiology, and End Results Medicare-linked dataset. We included patients aged 66 years and older with rheumatoid arthritis diagnosed with colorectal, lung, or prostate cancer between Jan 1, 2008, and Dec 31, 2019, using ICD-O-3 site and histology codes. We limited the cohort to patients who had early-stage cancer (localised or regional). We only included patients who received TNF inhibitors, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), or no DMARDs in the first year after cancer diagnosis. The primary outcomes were 5-year overall survival and cancer-specific survival. Exposures were use of TNF inhibitors, conventional synthetic DMARDs, or no DMARDs within 3 years after cancer diagnosis. Other covariates included demographics and comorbidities. We conducted landmark analyses at years 1, 2, and 3, with Cox regression adjusted by propensity scores. People with lived experience of rheumatoid arthritis and cancer were not involved in the design or conduct of this study.

FINDINGS

We identified three cohorts of patients diagnosed with early-stage colorectal cancer (n=514), lung cancer (n=864), or prostate cancer (n=603) between Jan 1, 2008, and Dec 31, 2019. In the colorectal cancer cohort, the mean age was 76·1 years (SD 6·4), 385 (75%) of 514 patients were female, 129 (25%) were male, and 405 (79%) were White and non-Hispanic. In the lung cancer cohort, the mean age was 74·8 years (SD 5·9), 632 (73%) of 864 patients were female, 232 (27%) were male, and 743 (86%) were White and non-Hispanic. In the prostate cancer cohort, the mean age was 73·1 years (SD 5·1), 603 (100%) patients were male, and 492 (82%) were White and non-Hispanic. 80 (16%) of 514 patients with colorectal cancer, 102 (12%) of 864 patients with lung cancer, and 120 (20%) of 603 patients with prostate cancer received TNF inhibitors with or without conventional synthetic DMARDs at any time during the first year after cancer diagnosis. No significant deleterious association was observed for overall survival or cancer-specific survival for any of the cancers at any of the three landmark points. Hazard ratios and 95% CIs for overall survival for year 1 comparing TNF inhibitors with conventional synthetic DMARDs in the three cohorts were 0·72 (0·43-1·21) for colorectal cancer, 0·70 (0·49-1·00) for lung cancer, and 0·80 (0·44-1·44) for prostate cancer. Patients who received glucocorticoids in the first year had significantly worse overall survival and cancer-specific survival than those who did not in the multivariable Cox proportional hazards models for the three cancers.

INTERPRETATION

Treatment with TNF inhibitors during the first 3 years after diagnosis of colorectal, lung, or prostate cancer was not associated with poorer survival compared with those who received conventional synthetic DMARDs or those who did not receive any DMARDs. However, these findings might not be generalisable to other populations or types of cancer.

FUNDING

National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases and NIH/National Cancer Institute through MD Andeson's Cancer Center Support Grant and Komen.

The Etiology of Intracranial Artery Stenosis in Autoimmune Rheumatic Diseases: An Observational High-Resolution MR Imaging Study

BACKGROUND AND PURPOSE

Autoimmune rheumatic diseases (AIRD) can cause intracranial artery stenosis (ICAS) and lead to stroke. This study aimed to characterize patients with ICAS associated with AIRD.

MATERIALS AND METHODS

Using data from a high-resolution MR imaging database, we retrospectively reviewed patients with AIRD with ICAS. Stratification into vasculitis, atherosclerosis, and mixed atherovasculitis subtypes was based on imaging findings, followed by a comparative analysis of clinical characteristics and outcomes across these subgroups.

RESULTS

Among 139 patients (mean, 45.1 [SD, 17.3] years; 64.7% women), 56 (40.3%) were identified with vasculitis; 57 (41.0%), with atherosclerosis; and 26 (18.7%), with mixed atherovasculitis. The average interval from AIRD onset to high-resolution MRI was 5 years. Patients with vasculitis presented at a younger age of AIRD onset (mean, 34.5 [SD, 19.4] years), nearly 10 years earlier than other groups (P = .010), with a higher artery occlusion incidence (44.6% versus 21.1% and 26.9%, P = .021). Patients with atherosclerosis showed the highest cardiovascular risk factor prevalence (73.7% versus 48.2% and 61.5%, P = .021) but fewer intracranial artery wall enhancement instances (63.2% versus 100% in others, P < .001). The mixed atherovasculitis group, predominantly men (69.2% versus 30.4% and 24.6%, P < .001), exhibited the most arterial involvement (5 arteries per person versus 3 and 2, P = .001). Over an average 21-month follow-up, 23 (17.0%) patients experienced stroke events and 8 (5.9%) died, with the mixed atherovasculitis group facing the highest risk of stroke events (32.0%) and the highest mortality (12.0%).

CONCLUSIONS

Intracranial arteries are injured and lead to heterogeneous disease courses when exposed to AIRD and cardiovascular risk factors. While atherosclerosis acceleration is common, vasculitis may further contribute to the early development of occlusion and multiple artery involvement. Varied intracranial arteriopathies may result in different outcomes.

Rheumatoid arthritis: a comprehensive overview of genetic markers, emerging therapies, and personalized medicine

Rheumatoid arthritis (RA) is a prevalent autoimmune disorder marked by chronic inflammatory arthritis and systemic effects. The etiology of RA is complex, involving genetic factors like HLA-DR4 and HLA-DR1, as well as environmental influences, particularly smoking, which heightens disease risk. Affecting approximately 1% of the global population, RA is associated with considerable morbidity and mortality, with its prevalence expected to increase due to demographic shifts, especially in certain regions. RA symptoms commonly manifest between ages 35 and 60 but can also affect children under 16 in cases of juvenile RA. Symptoms include prolonged joint stiffness, pain, fatigue, and, in advanced cases, joint deformities. Current treatment approaches involve disease-modifying antirheumatic drugs, biologics, and glucocorticoids to manage symptoms and slow disease progression, though these treatments often present limitations due to adverse effects and varied patient response. The identification of genetic markers, such as HLA-DRB1 and PTPN22, supports the growing emphasis on personalized treatment strategies that account for genetic and lifestyle factors. Non-pharmacological approaches - diet adjustments, physical activity, and stress management - are increasingly valued for their complementary role in RA management. Lifestyle interventions, including whole-food, plant-based diets and physical therapy, show promise in reducing inflammation and improving joint function. Technological advancements, like telemedicine, mobile health applications, and artificial intelligence, are enhancing RA diagnosis and treatment, making care more precise and accessible. Despite these advancements, RA remains incurable, necessitating continued research into novel therapeutic targets and approaches. A comprehensive, patient-centered approach that integrates lifestyle modifications, preventive strategies, and innovative treatments is essential for improving RA management and patient outcomes.

Lupus and SARS-CoV-2: What have we learned after the pandemic?

After the end of the COVID-19 public health emergency, we analysed the relationship between Systemic Lupus Erythematosous (SLE) and COVID-19 from the virologist's perspective based on recent findings. SLE and COVID-19 co-morbidity present unique challenges, as individuals with SLE may be at increased risk for severe COVID-19 illness due to immune system abnormalities and ongoing therapies. Effective management of both diseases requires careful monitoring, adherence to vaccination programs, preventive measures and approved and patient-tailored therapies. This review covers various aspects, including the clinical outcome of SLE patients infected by SARS-CoV-2, the impact of this infection on SLE onset or flare-ups and the benefits of vaccination for this population. Furthermore, this review presents the most recent recommendations on clinical management of COVID-19 in rheumatic patients, including those with SLE, discussing the currently available therapeutic options. Finally, we explore the most effective tools for SARS-CoV-2 diagnosis in autoimmune conditions and examine prognostic biomarkers in COVID-19 rheumatic patients with potential implications on their clinical oversight. By adopting a comprehensive approach, we address these complexities from the virologist's perspective, aiming to improve health care for this vulnerable population.

Potential of a Novel Patient-Reported Outcome Assessment Method Utilizing Illustrations in Rheumatoid Arthritis

OBJECTIVES

We investigated whether the "Okomarigoto sheet," a novel patient-reported outcome measure that utilizes illustrations, correlates with disease activity and the Health Assessment Questionnaire Disability Index (HAQ-DI) in rheumatoid arthritis.

METHODS

The Okomarigoto sheet comprises five items each for morning stiffness, pain, and fatigue. Individual items are scored as follows: severe symptoms = 2, mild symptoms = 1, no symptoms = 0. The total score ranges from 0 to 30; higher scores indicate greater symptom burden. Correlations between Okomarigoto sheet scores, disease activity scores, and the HAQ-DI were analyzed in 332 patients. Scores were compared between patients in remission (HAQ-DI ≤ 0.5) and not in remission.

RESULTS

Correlations between the total Okomarigoto sheet score and Disease Activity Score using 28-joint count C-reactive protein, Clinical Disease Activity Index, and Simplified Disease Activity Index were 0.488, 0.591, and 0.572, respectively. The correlation between the total Okomarigoto sheet score and HAQ-DI was 0.593. The mean Okomarigoto sheet score was significantly lower in patients achieving HAQ-DI remission compared to those not in remission (2.47 vs. 10.4, respectively; p < 0.01).

CONCLUSIONS

This novel patient-reported outcome measure performed comparably to existing measures, correlating strongly with disease activity and disability.

New onset work disability in rheumatoid arthritis is an underrecognized cardiovascular risk factor: A retrospective cohort study using the CorEvitas registry

OBJECTIVES

Patients with rheumatoid arthritis (RA) are more likely to develop work disability than the general population. We investigated whether individuals younger than 65 years of age who had both RA and new-onset work disability were at higher risk of CVD compared to similarly aged individuals with RA who did not develop disability. We identified the factors that best explained the excess risk.

METHODS

This was a retrospective cohort study using data from the CorEvitas RA registry. Patients younger than 65 with RA were included. Exposure was new-onset work disability, and comparator was consistently working individuals. Cohorts were age- and sex-matched. Demographics, medications, and disease specific factors were collected for all patients. Incidence rates (IR) for cardiovascular events were calculated using Poisson regression and explanatory multivariable models were built using Cox proportional hazard ratios (HR) to determine the factors that explained the excess CVD risk.

RESULTS

Age and sex-adjusted IR was 5.40 per 1,000 person-years in the new-onset work disability group compared to 2.17 per 1,000 person-years in the working group. Work disability associated with CVD with HR = 2.32 (95 % CI 1.52, 3.53) in the age- and sex-adjusted model. Multivariate models accounting for functional status, education, medications, and traditional CVD risk factors could not fully explain the excess risk for CVD in newly work disabled patients with RA: HR = 1.78 (1.09, 2.91).

CONCLUSIONS

Patients younger than 65 with RA and new-onset work disability are at significantly increased risk for incident CVD compared to working peers. The excess CVD risk remained unexplained after accounting for multiple variables, possibly due to variables we cannot fully account for, such as social determinants of health and allostatic load.

Synovial fluid dual-biomarker algorithm accurately differentiates osteoarthritis from inflammatory arthritis

Osteoarthritis (OA) prevalence increases as the population ages. Diagnosing osteoarthritis often occurs in the late stages when cartilage degradation is severe, making it difficult to distinguish from other types of arthritis. Accurate differentiation of primary osteoarthritis from other arthritic conditions is crucial for effective treatment planning. A new diagnostic test has been developed that uses a dual-biomarker algorithm to inform osteoarthritis diagnosis. Synovial fluid from patients with confirmed primary osteoarthritis showed elevated levels of cartilage oligomeric matrix protein. However, this biomarker alone could not distinguish primary osteoarthritis from other inflammatory conditions that also cause cartilage deterioration. Therefore, a combinatorial algorithm using cartilage oligomeric matrix protein and Interleukin-8 concentrations was developed to differentiate primary osteoarthritis from inflammatory arthritis. Clinical decision limits for cartilage oligomeric matrix protein concentration and the cartilage oligomeric matrix protein to Interleukin-8 ratio were established and validated using 171 human knee synovial fluid specimens. The osteoarthritis algorithm demonstrated clinical sensitivity and specificity of 87.0% and 88.9%, respectively. This is the first report of a biomarker test that can differentiate primary osteoarthritis from inflammatory arthritis with a high degree of accuracy.

Effectiveness of tofacitinib versus tumor necrosis factor inhibitors and in those receiving tofacitinib as different lines of therapy in patients with rheumatoid arthritis: results from the United States CorEvitas Rheumatoid Arthritis Registry

OBJECTIVES

To compare effectiveness of tofacitinib versus tumor necrosis factor inhibitors (TNFi), and across tofacitinib lines of therapy, in patients with rheumatoid arthritis (RA), using US CorEvitas RA Registry data.

METHODS

Analysis included patients with RA initiating tofacitinib or TNFi with a 12-month follow-up visit between November 2012-February 2021. Primary (Clinical Disease Activity Index-defined low disease activity [CDAI-LDA: CDAI ≤ 10]) and secondary (clinical/disease activity/patient-reported) effectiveness outcomes were assessed at month 12. Outcomes were stratified by treatment regimen (overall tofacitinib vs overall TNFi/tofacitinib monotherapy vs tofacitinib combination therapy/TNFi monotherapy vs TNFi combination therapy/tofacitinib monotherapy vs TNFi combination therapy/tofacitinib combination therapy vs TNFi combination therapy), or tofacitinib line of therapy (2nd/3rd/ ≥ 4th line).

RESULTS

3,481 eligible patients initiated tofacitinib (n = 805) or TNFi (n = 2,676). Improvements in effectiveness at month 12 were generally similar across treatment regimens; 25.1% and 30.1% of overall tofacitinib and TNFi initiators achieved CDAI-LDA, respectively (odds ratio 1.29 [95% confidence interval (CI) 0.94, 1.76]). Odds ratios (95% CIs) for achieving CDAI-LDA at 12 months were 0.70 (0.36, 1.37) for 3rd- versus 2nd-line, and 1.09 (0.63, 1.88) for 3rd- versus ≥ 4th-line tofacitinib initiators. At month 12, mean change from baseline in CDAI was greater among 3rd- versus ≥ 4th-line tofacitinib initiators, and mean Health Assessment Questionnaire and patient-reported pain were greater in 3rd- versus 2nd-line and ≥ 4th- versus 3rd-line tofacitinib initiators.

CONCLUSIONS

Generally, there were no differences in effectiveness between tofacitinib versus TNFi regimens. Few differences were observed between tofacitinib lines of therapy; sample sizes were small for 2nd/3rd-line initiators.

STUDY REGISTRATION

NCT01402661 (ClinicalTrials.gov; July 25, 2011). Key Points • Using data from the US CorEvitas rheumatoid arthritis (RA) Registry, this study compared the effectiveness of tofacitinib versus tumor necrosis factor inhibitors (TNFi) and across tofacitinib lines of therapy. • Effectiveness of tofacitinib was similar to TNFi regimens up to month 12, while differences in some effectiveness outcomes at month 12 were observed with tofacitinib across different lines of therapy. • The findings of this study may inform future treatment decision-making in patients with RA.

Credibility of Blood Flow Restriction Training in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis

Background

The effectiveness and practicality of blood flow restriction training (BFRT) as a nonsurgical intervention for treating patients with knee injuries are uncertain because of the small size of BFRT trials and inconsistent results.

Purpose

To conduct a meta-analysis comparing the effectiveness of BFRT versus traditional resistance training in patients with knee osteoarthritis (OA) in terms of pain, muscle strength, functional performance, self-reported function, muscle size, and adverse events during exercise.

Study Design

Systematic review; Level of evidence: 1.

Methods

Under the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Web of Science, PubMed, EMBASE, and other databases for randomized controlled trials of BFRT interventions in patients with knee OA. Methodological and quality evaluations, heterogeneity analysis, and subgroup analysis of the included studies were conducted, and effect sizes were evaluated using mean differences or standardized mean differences (SMDs). Subgroup and sensitivity analyses were used to explore the sources of heterogeneity.

Results

Of 2826 initial studies, 6 studies (N = 228 patients) were included. The results of the meta-analysis indicated that compared with resistance training, BFRT did not significantly affect pain relief (SMD, -0.02 [95% CI, -0.30 to 0.26]; P = .88), muscle strength (SMD, 0.32 [95% CI, -0.33 to 0.96]; P = .33), functional performance (SMD, 0.25 [95% CI, -0.29 to 0.80]; P = .36), or self-reported function (SMD, -0.252 [95% CI, -0.88 to 0.45]; P = .52). However, BFRT reduced the risk of adverse events (risk ratio, 0.45 [95% CI, 0.20 to 1.01]; P = .05). Subgroup analysis revealed that compared with low-load resistance training, BFRT significantly increased muscle size (SMD, 0.88 [95% CI, 0.09 to 1.68]; P = .02). The quality-of-evidence assessment indicated that the evidence level for the above outcomes was low and that the strength of the recommendation was weak.

Conclusion

The results of our meta-analysis indicated that compared with resistance training, BFRT did not significantly improve symptom outcomes in patients with knee OA. It is important to acknowledge that the findings were limited by the small number of studies and sample sizes that were included.

Ivarmacitinib, a selective Janus kinase 1 inhibitor, in patients with moderate-to-severe active rheumatoid arthritis and inadequate response to conventional synthetic DMARDs: results from a phase III randomised clinical trial

OBJECTIVE

To assess the efficacy/safety of ivarmacitinib, a selective Janus kinase (JAK) 1 inhibitor, in patients with moderate-to-severe active rheumatoid arthritis (RA) who had an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

METHODS

Patients were randomised (1:1:1) to receive either placebo (n=188), ivarmacitinib 4 mg (n=189) or ivarmacitinib 8 mg (n=189) once daily, with background csDMARDs allowed. After 24 weeks, patients on placebo switched to ivarmacitinib 4 mg for an additional 28 weeks, while those on ivarmacitinib continued their initial dosage. The primary endpoint was the proportion of patients achieving a 20% improvement in the American College of Rheumatology response criteria (ACR20) at week 24.

RESULTS

At week 24, ACR20 response rates were significantly higher in the ivarmacitinib 4 mg (70.4%) and 8 mg (75.1%) groups compared with the placebo group (40.4%; both p<0.0001). Both ivarmacitinib doses achieved numerically higher Disease Activity Score 28-joint count C reactive protein of <2.6/≤3.2 response rates compared with placebo. Improvements in efficacy and patient-reported outcomes were sustained through 52 weeks and were noted in patients who switched from placebo after week 24. During the placebo-controlled period, treatment-emergent adverse events (TEAEs) occurred in 81.5% and 90.5% of patients in the ivarmacitinib 4 mg and 8 mg groups, versus 79.3% in the placebo group. Infection-related TEAEs were slightly higher in the ivarmacitinib groups.

CONCLUSIONS

Ivarmacitinib may offer a potential therapeutic option for patients with RA who have an inadequate response to csDMARDs, with a safety profile that was generally manageable over 1 year of treatment and similar to other JAK inhibitors.

TRIAL REGISTRATION NUMBER

NCT04333771.

Predicting abatacept retention using machine learning

BACKGROUND

The incorporation of machine learning is becoming more prevalent in the clinical setting. By predicting clinical outcomes, machine learning can provide clinicians with a valuable tool for refining precision medicine approaches and improving treatment outcomes.

METHODS

This was a post hoc analysis of pooled patient-level data from the global, real-world ACTION and ASCORE trials in patients with rheumatoid arthritis (RA) initiating abatacept. Patient demographic and disease characteristics were input across 10 machine learning models used to predict 12-month treatment retention. Retention was defined as treatment for > 365 days or ≤ 365 days in patients who achieved remission or major clinical response (based on European Alliance of Associations for Rheumatology response criteria). The pooled dataset was split into a training/validation cohort for model development and a test cohort for an unbiased evaluation of performance. SHapley Additive exPlanation (SHAP) values determined the level of importance and directionality for key patient features predicting abatacept retention.

RESULTS

The pooled ACTION and ASCORE dataset included 5320 patients with RA (mean [standard deviation] age 57.7 [12.7] years; 79% female). The 12-month abatacept retention rate was 61% (n = 3236) with a discontinuation rate of 39% (n = 2037). In the training set (n = 4218), the gradient-boosting classifier model demonstrated the best performance (testing accuracy: 62%). This model had an area under the receiver operating characteristic curve (95% confidence interval) of 0.620 (0.586, 0.653) and F1 score of 0.659 (0.625, 0.689) in the test set of patients (n = 1055). Using this model, the five most important variables predicting 12-month abatacept retention were low body mass index (BMI), low American College of Rheumatology functional status class, anti-citrullinated protein antibody (ACPA) positivity, low Patient Global Assessment, and younger age.

CONCLUSIONS

The gradient-boosting classifier model identified key patient features predictive of abatacept retention from this large, real-world study population. The SHAP values conveyed the directionality and importance of BMI, functional status, ACPA serostatus, Patient Global Assessment, and age for abatacept retention. Findings are consistent with previous observations and help validate the machine learning approach for predictive modelling in RA treatment, and may help inform clinical decision making.

TRIAL REGISTRATION

NCT02109666 (ACTION), NCT02090556 (ASCORE).

Rheumatoid arthritis-associated interstitial lung disease: Advancing the identification and management

BACKGROUND

Interstitial lung disease (ILD) is an extra-articular manifestation of rheumatoid arthritis (RA) that causes substantial morbidity and mortality. Effective, evidence-based strategies to screen for, and manage, RA-ILD are lacking.

OBJECTIVES

Highlight recent research advances in, and further opportunities to improve, the identification and management of RA-ILD.

FINDINGS

The goals of RA-ILD screening are early disease detection while avoiding unnecessary testing. Such an approach requires the ability to accurate risk stratify RA patients. With only a few recognized clinical risk factors for RA-ILD, a growing body of evidence on peripheral biomarkers for RA-ILD appears well suited to support a precision medicine approach. There is a paucity of evidence to guide management after RA-ILD diagnosis. While initial trials of antifibrotics have been conducted in RA-ILD and show the potential to slow the rate of pulmonary function decline, there have been no randomized trials of immunomodulatory therapies in RA-ILD. Supporting such trials, and addressing the barriers to conducting them, is a high priority.

CONCLUSION

Robust characterization of peripheral biomarkers in large, RA populations is essential to inform a precision medicine approach to RA-ILD identification. Randomized trials of treatments and treatment strategies that consider the systemic nature of RA-ILD are necessary to inform evidence-based RA-ILD treatment.

Anti-rheumatic arthritis efficacy of Pueraria montana extract against type-II collagen-induced rheumatoid arthritis rat model an in vitro and in vivo assessment

ETHNOPHARMACOLOGICAL RELEVANCE

Pueraria montana (PM) is a Chinese medicinal herb used to treat alcoholism, inflammation, swelling, and anti-apoptosis. However, the mechanisms and active compounds of PM remain poorly understood.

AIM OF THE STUDY

Chronic inflammatory diseases such as rheumatoid arthritis (RA) can affect multiple joints. Inflammation begins in the synovium and spreads to the surrounding cartilage and bone if left untreated. This study assessed the probable anti-arthritic mechanisms of action of PM extracts. Type II collagen emulsion-induced rheumatoid used as an in vivo model.

MATERIALS AND METHODS

TNF-α-stimulated MC cells were used to investigate the mechanism of PM extract in RA, and the PM extract was confirmed using HPLC analysis. The antiproliferative efficacy of PM was assessed by MTT assay, and apoptotic activity was evaluated using Hoechst staining and flow cytometry assessment. Furthermore, the matrix metalloproteinase (MMP) ratio and mRNA expression of Bcl-2, Cas-3, Cas-9, and SOCS1 were determined using ELISA and qRT-PCR.

RESULTS

PM extract treatment possesses anti-arthritic properties in CIA rats and can suppress inflammation and inhibit the invasion and migration of MH7A cells. The upregulation of Bcl-2, a recognized inhibitor of apoptotic genes, prevents the release of cyto-C into the cytoplasm. The in vivo outcomes showed that PM reduced the arthritis score and toe swelling in CIA rats. In vitro, PM extract exhibited substantial antiproliferative and pro-apoptotic properties on TNF-α-induced MH7A cell lines. The invasive and adhesive properties of MH7A cells decreased, and MMP secretion was reduced.

CONCLUSION

This study suggests that the PM extract possesses anti-arthritic properties in the CIA model and is an extension of the clinical treatment of rheumatic arthritis.

Pharmacological pain management in patients with rheumatoid arthritis: a narrative literature review

BACKGROUND

Pain is a major challenge for patients with rheumatoid arthritis (RA), with many people suffering chronic pain. Current RA management guidelines focus on assessing and reducing disease activity using disease-modifying anti-rheumatic drugs (DMARDs). Consequently, pain care is often suboptimal, with growing evidence that analgesics are widely prescribed to patients with RA, despite potential toxicities and limited evidence for efficacy. Our review provides an overview of pharmacological treatments for pain in patients with RA, summarising their efficacy and use.

FINDINGS

Thirteen systematic reviews of drug efficacy for pain in patients with RA were included in this review. These showed moderate- to high-quality evidence from clinical trials in more contemporary time-periods (mainly 1990s/2000s for synthetic DMARDs and post-2000 for biological/targeted synthetic DMARDs) that, in patients with active RA, short-term glucocorticoids and synthetic, biologic, and targeted synthetic DMARDs have efficacy at reducing pain intensity relative to placebo. In contrast, they showed low-quality evidence from trials in more historical time-periods (mainly in the 1960s-1990s for opioids and paracetamol) that (aside from naproxen) analgesics/neuromodulators provide any improvements in pain relative to placebo, and no supportive evidence for gabapentinoids, or long-term opioids. Despite this evidence base, 21 studies of analgesic prescribing in patients with RA consistently showed substantial and sustained prescribing of analgesics, particularly opioids, with approximately one quarter and > 40% of patients receiving chronic opioid prescriptions in each year in England and North America, respectively. Whilst NSAID prescribing had fallen over time across countries, gabapentinoid prescribing in England had risen from < 1% of patients in 2004 to approximately 10% in 2020. Prescribing levels varied substantially between individual clinicians and groups of patients.

CONCLUSIONS

In patients with active RA, DMARDs have efficacy at reducing pain, supporting the role of treat-to-target strategies. Despite limited evidence that analgesics improve pain in patients with RA, these medicines are widely prescribed. The reasons for this are unclear. We consider that closing this evidence-to-practice gap requires qualitative research exploring the drivers of this practice, high-quality trials of analgesic efficacy in contemporary RA populations, alongside an increased focus on pain management (including pharmacological and non-pharmacological options) within RA guidelines.

Impact of glucocorticoids on the therapeutic efficacy of denosumab against osteoporosis in patients with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) and prolonged high-dose glucocorticoid (GC) treatment are established risk factors for osteoporosis.

Objectives

In this study, we aimed to evaluate the therapeutic efficacy of denosumab according to the GC dose considered to increase the risk of glucocorticoid-induced osteoporosis (GIOP) in patients with RA.

Design

A retrospective analysis of collected data on RA patients with osteoporosis starting denosumab.

Methods

We included 418 patients with RA who were started on denosumab therapy and categorized them into those with and without GC intake ⩾2.5 mg/day for >3 months. The T-score and areal bone mineral density (aBMD) at the lumbar spine, total hip, and femur neck, as well as serum bone turnover markers, were measured at baseline and 12 months. We performed between-group and within-group comparisons of the BMD values at baseline and at 12 months.

Results

Denosumab significantly increased the T-scores and aBMD at the lumbar spine, total hip, and femur neck after 12 months, regardless of GC intake. However, apart from the T-score at the lumbar spine, the other parameters did not show significant between-group differences. Similarly, in patients with anti-cyclic citrullinated peptide (CCP) antibody positivity or those treated with biologic or targeted synthetic disease-modifying antirheumatic drugs (DMARDs), although there were significant increases in the T-score and areal BMD at all sites in both groups, there were no significant between-group differences.

Conclusion

Our findings suggest that the GC dose considered to increase the risk of GIOP did not significantly attenuate the therapeutic efficacy of denosumab in RA patients, including those positive for anti-CCP antibodies and users of biologic or targeted synthetic DMARDs.

Tetracyclines in Rheumatoid Arthritis: Dual Anti-Inflammatory and Immunomodulatory Roles, Effectiveness, and Safety Insights

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by persistent inflammation, joint pain, and progressive cartilage and bone erosion. Despite advancements in RA management with disease-modifying antirheumatic drugs (DMARDs) and biologics, some patients remain refractory to conventional treatments. Tetracyclines, such as minocycline and doxycycline, exhibit anti-inflammatory and immunomodulatory properties, making them potential supplementary treatments. This narrative review explores their effectiveness, mechanisms of action, safety profiles, and current challenges in RA care. Tetracyclines have demonstrated significant immunomodulatory effects, including the inhibition of pro-inflammatory cytokines and matrix metalloproteinases (MMPs), which are critical in RA pathology. Clinical trials, including double-blind, placebo-controlled studies, have shown efficacy in reducing RA symptoms, particularly in early and refractory cases. However, their use remains limited by inconsistent evidence, small sample sizes, and concerns about antimicrobial resistance. Current guidelines for RA management do not explicitly recommend tetracyclines due to these limitations, although off-label use may be considered in specific cases. The use of tetracycline for RA is restricted by drug interactions causing bacterial resistance alongside unpredictable patient responses, hence the necessity for prudence in its prescription within a clinical setting. To overcome these limitations, the development of safer compounds, in-depth in silico analyses, and integration with personalized medicine approaches are needed. Overall, tetracyclines show promise as adjunct therapies in RA management due to their dual anti-inflammatory and immunomodulatory actions. This review highlights the need for further research to address gaps in evidence, including the development of modified tetracyclines with reduced antimicrobial effects and improved safety profiles, as well as the integration of personalized medicine approaches to optimize patient outcomes.

Low-dose methotrexate in Rheumatology: A reinvented drug

Low-dose methotrexate (LD-MTX) is the anchor drug used in the treatment of various rheumatological illnesses. There are a lot of misconceptions associated with the long-term use of MTX in the minds of practitioners. The origin of most of these myths stems from the ill effects associated with high-dose MTX used in cancer chemotherapy. In this review, we have summarised and discussed the latest data regarding the safety of LD-MTX. The current evidence underscores the safety of LD-MTX. It is not associated with liver and lung fibrosis as previously thought. Other major concerns such as bone marrow suppression and increased risk of infection are rare with chronic LD-MTX therapy. Hypersensitivity pneumonitis is a rare acute lung toxicity associated with MTX intake, it does not cause interstitial lung disease and in fact, may be protective against it. There is a slight concern about the increased risk of skin malignancy associated with MTX intake; however, association with no other malignancy has been found. It has taken many decades for researchers to clear the various preconceptions associated with MTX. It is time for the academic community to embrace LD-MTX as a new, separate and reinvented drug.

Association of methotrexate polyglutamates concentration with methotrexate efficacy and safety in patients with rheumatoid arthritis treated with predefined dose: results from the MIRACLE trial

OBJECTIVES

The usefulness of methotrexate-polyglutamates (MTX-PGs) concentration for management of rheumatoid arthritis has been debated. We aimed to clarify the association of MTX-PGs concentration with efficacy and safety in MTX-naïve patients initiating MTX in a prospective interventional clinical trial.

METHODS

The MIRACLE trial enrolled 300 MTX-naïve patients. Oral MTX was initiated and increased to the maximum tolerated dose by week 12. Patients who did not achieve remission according to the Simplified Disease Activity Index at week 24 were randomised to either the continued dose or reduced dose group and were started on subcutaneous adalimumab. We measured the concentrations of MTX-PGs in erythrocytes using liquid chromatography-tandem mass spectrometry and analysed the association of these concentrations with efficacy and safety.

RESULTS

The mean concentration of total MTX-PGs increased with an increasing dose of MTX and continued to elevate for another 12 weeks after the dose was fixed. At week 24, the total MTX-PGs concentration was 110.5 (SD 43.8) nmol/L with MTX dose of 12.6 (3.0) mg/week (0.23 (0.07) mg/kg/week). During MTX monotherapy, the higher MTX-PGs concentration was an independent factor for lower disease activity; however, this association disappeared after adalimumab initiation in patients with continued MTX dose. Hepatotoxicity was related to the higher MTX-PGs concentration regardless of adalimumab use. The total MTX-PGs concentration was significantly elevated by lower estimated glomerular filtration rate, serum albumin and body mass index.

CONCLUSIONS

The MIRACLE trial demonstrated that higher total MTX-PGs concentration in erythrocytes is related to the higher efficacy and lower safety of MTX.

TRIAL REGISTRATION NUMBER

NCT03505008.

Bioinformatics identification based on causal association inference using multi-omics reveals the underlying mechanism of Gui-Zhi-Shao-Yao-Zhi-Mu decoction in modulating rheumatoid arthritis

OBJECT

Rheumatoid arthritis (RA) is a prevalent and currently incurable autoimmune disease. Existing conventional medical treatments are limited in their efficacy, prolonged disease may lead to bone destruction, joint deformity, and loss of related functions, which places a huge burden on RA patients and their families. For millennia, the use of traditional Chinese medicine (TCM), exemplified by the Gui-Zhi-Shao-Yao-Zhi-Mu decoction (GZSYZM), has been demonstrated to offer distinct therapeutic advantages in the management of RA. Exploring the potential mechanism of GZSYZM in the treatment of RA is a hot topic in the field of TCM.

METHOD

High-throughput sequencing data of RA at bulk level and single cell level and Chinese Materia Medica target-related databases were used as data sources. Ultra-high-performance liquid chromatography coupled with high-resolution mass spectrometry was employed for the identification of the most relevant compounds to the active ingredients present in the GZSYZM granules. Potential disease genes were identified using a combination of differential expression analysis and weighted gene co-expression network analysis, and the "Chinese Materia Medica-Ingredient-Target" network was constructed to obtain candidate drug target genes. The GZSYZM-RA hub genes were then identified based on Molecular Complex Detection algorithm. To explore the associations and potential mechanisms between the GZSYZM-RA hub gene set and RA, Mendelian randomization (MR) analysis and Bayesian co-localization analysis were used to further identify the GZSYZM-RA core genes that were causally associated with RA. A nomogram was constructed based on a multifactorial logistic regression model using the GZSYZM-RA core genes as predictors of RA. To evaluate its diagnostic value, receiver operating characteristic (ROC) curves, calibration curves, and decision curves were plotted. The potential downstream regulatory mechanisms of the gene of interest in GZSYZM in RA therapy were finally investigated using single- gene set enrichment analysis and molecular docking. The aim was to model the optimal conformation of its target protein receptor binding to the small molecule ligand in GZSYZM to identify the key constituents.

RESULT

Functional enrichment analysis revealed that the GZSYZM-RA hub gene set is enriched in several autoimmune-related mechanistic pathways, with a particular emphasis on the phosphoinositide 3 kinase (PI3K)‑serine/threonine kinase (AKT) signaling pathway. AUCell scores demonstrated active expression of the GZSYZM-RA hub gene set with the PI3K-AKT signaling pathway on monocytes, especially non-classical monocytes. Immunol infiltration analysis based on the CIBERSORT algorithm also showed a strong correlation between several genes in the GZSYZM-RA hub gene set and monocytes by calculating Spearman's rank correlation coefficients. MR analysis with co-localization analysis further identified seven core genes (CASP8, PPARG, IKBKB, PPARA, IFNG, MYC, and STAT3) causally associated with RA. Diagnostic value for clinical decision making was demonstrated by a multivariable logistic regression model constructed with GZSYZM-RA core genes. Molecular docking analysis indicates that CASP8 and GZSYZM have high docking scores, with three key constituents (quercetin, kaempferol, and diosmetin) exhibiting strong binding affinities.

CONCLUSION

GZSYZM may regulate the abnormal over-proliferation and apoptotic imbalance of fibroblast-like synoviocytes in RA patients by inhibiting signaling of the PI3K-AKT signaling pathway while activating CASP8-mediated pro-apoptotic effects. And it may be effective in directly or indirectly inhibiting monocyte-to-osteoclast differentiation, ultimately improving the poor prognosis of joint destruction in RA patients.

Chinese Registry of Rheumatoid Arthritis (CREDIT) VI: Temporal Trends in Patients With Early Rheumatoid Arthritis and Moderate-To-Severe Disease Activity - A Multicenter Cohort Study of Treatment Strategies and Outcomes

AIM

The continuous update of international guidelines and enhanced availability of biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) have made a significant impact on the diagnosis and treatment of early rheumatoid arthritis (ERA). This study aims to systematically evaluate the current treatment strategies and outcomes within a large-scale cohort of patients with ERA.

METHODS

Data from the Chinese Registry of Rheumatoid Arthritis (CREDIT), a large multicenter Chinese registry of RA, were collected to analyze temporal trends in clinical profiles, therapeutic strategies, and treatment outcomes among patients with ERA.

RESULTS

From November 2016 to October 2023, A total of 2722 patients with follow-up information for 6 months were included. The use of methotrexate (MTX) increased annually and has become the predominant DMARD as the initial treatment. Following initial therapy, 1059 (38.9%) patients achieved the therapeutic target of low disease activity and remission. Age ≥ 50 years (adjusted OR 0.70 [95% CI 0.59-0.83]; p < 0.001), high baseline disease activity (adjusted OR 0.48 [95% CI 0.41-0.57]; p < 0.001), csDMARD monotherapy other than MTX (adjusted OR 0.55 [95% CI 0.41-0.73]; p < 0.001), and the use of b/tsDMARDs without a csDMARD combination (adjusted OR 0.57 [95% CI 0.36-0.87]; p = 0.011) were associated with lower target attainment rates. For patients who did not achieve the treatment target after initial therapy, the use of b/tsDMARDs increased after 2020, although the extent of therapeutic escalation remained suboptimal.

CONCLUSION

Treatment of patients with ERA in China has become more standardized. Adherence to guideline-directed therapeutic regimens has emerged as a significant determinant of therapeutic target achievement. The increased prevalence of b/tsDMARDs would benefit more patients in ameliorating the disease.

Understanding the Dual Challenge: Adverse Drug Reactions and Adherence in Rheumatoid Arthritis Treatment

OBJECTIVES

The primary aim of this study was to investigate the real-world occurrence of various adverse drug reactions (ADRs) and assess medication adherence among patients using disease-modifying antirheumatic drugs (DMARDs). Additionally, the study sought to evaluate the degree of methotrexate intolerance among these patients.

METHODS

This cross-sectional, observational study was conducted at a tertiary care hospital and involved 100 adult patients diagnosed with rheumatoid arthritis (RA) who were currently undergoing treatment with methotrexate. The study systematically recorded all adverse drug reactions reported by the patients as well as those identified through laboratory tests. Medication adherence was measured using the Compliance Questionnaire Rheumatology (CQR5) and both intentional and non-intentional non-adherence questionnaires. The methotrexate intolerance was assessed using the Methotrexate Intolerance Severity Score (MISS).

RESULTS

Out of the total 74 reported ADRs, gastrointestinal were the most common, accounting for 62 (76.53%) of cases, followed by hematological problems at 13 (16.07%), with other types of ADRs comprising the remaining. Despite the prevalence of gastrointestinal ADRs, the study found high levels of medication adherence among the patients. Additionally, the methotrexate intolerance was relatively low, which may be attributed to the use of folic acid supplementation by all participants.

CONCLUSION

Gastrointestinal adverse drug reactions were the most frequently observed side effects in this study. Despite these reactions, patients demonstrated a high level of adherence to methotrexate therapy. The factors contributing to this adherence- such as patient counseling, disease knowledge, or the duration of the disease- merit further investigation to understand their impact on treatment outcomes.

Cost-effectiveness analysis of tofacitinib for the treatment of moderate to severe rheumatoid arthritis: a systematic review and meta-analysis

BACKGROUND

As rheumatoid arthritis (RA) is a chronic and progressive disease that requires lifelong therapeutic intervention, it represents a considerable economic burden on those affected. This study investigated whether tofacitinib is a cost-effective therapeutic alternative to other DMARDs for treating moderate-to-severe RA.

RESEARCH DESIGN AND METHODS

All economic evaluation studies of tofacitinib compared to other DMARDs were identified. Using random-effects meta-analysis, we pooled incremental net benefit (INB) in (purchasing power parity) adjusted US$ with 95% confidence intervals. The modified economic evaluation bias checklist and Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) instrument for quality appraisal were used. The subgroup analysis was done based on the comparator regimen.

RESULTS

Of the selected 11 studies, the number of studies from high-, upper-middle- and lower-middle-income countries was 7, 3, and 1, respectively. The subgroup analysis showed that tofacitinib with an INB of 19,180 US$ [95% CI, -34520 to -3840; p-value = 0.01] was not statistically cost-effective compared with cDMARDs (p-value > 0.0001). Compared to other DMARDs, the estimated pooled INB of tofacitinib was US$ 7260 [95% CI, 3030 to 11,480; p-value < 0.001], but there was substantial heterogeneity among the included studies, and the observed publication bias.

CONCLUSION

While tofacitinib shows potential as a cost-effective treatment, tailored economic evaluations are needed to account for the diverse and evolving contexts of RA treatment.

REGISTRATION

PROSPERO: CRD42023405970.

Emerging Phytochemical Formulations for Management of Rheumatoid Arthritis: A Review

Rheumatoid arthritis (RA) is a T-cell-mediated chronic inflammatory disorder affecting 0.5-1% of the global population. The disease with unknown etiology causes slow destruction of joints, advancing to significant deterioration of an individual's quality of life. The present treatment strategy comprises the use of disease-modifying anti-rheumatic drugs (DMARDs) coupled with or without nonsteroidal anti-inflammatory drugs or glucocorticoids. Additionally, involves co-therapy of injectable biological DMARDs in case of persistent or recurrent arthritis. The availability of biological DMARDs and the implementation of the treat-to-target approach have significantly improved the outcomes for patients suffering from RA. Nevertheless, RA requires continuous attention due to inadequate response of patients, development of tolerance and severe side effects associated with long-term use of available treatment regimens. An estimated 60-90% of patients use alternative methods of treatment, such as herbal therapies, for the management of RA symptoms. Over the past few decades, researchers have exploring natural phytochemicals to alleviate RA and associated symptoms. Enormous plant-origin phytochemicals such as alkaloids, flavonoids, steroids, terpenoids and polyphenols have shown anti-inflammatory and immunomodulatory activity against RA. However, phytochemicals have certain limitations, such as high molecular weight, poor water solubility, poor permeability, poor stability and extensive first-pass metabolism, limiting absorption and bioavailability. The use of nanotechnology has aided to extensively improve the pharmacokinetic profile and stability of encapsulated drugs. The current review provides detailed information on the therapeutic potential of phytochemicals. Furthermore, the review focuses on developed phytochemical formulations for RA, with emphasis on clinical trials, regulatory aspects, present challenges, and future prospects.

An erythrocyte macrocytosis by methotrexate is associated with early initiation of biologic or targeted synthetic agents in patients with rheumatoid arthritis

Objective

An association between increased erythrocyte mean corpuscular volume (MCV) and treatment response in patients with inflammatory arthritis receiving methotrexate (MTX) has been reported. We investigated the frequency of red blood cell (RBC) macrocytosis and its clinical implications regarding the initiation of biological or targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) in patients starting MTX for rheumatoid arthritis (RA).

Methods

RBC macrocytosis (MCV >100 fL) and clinical characteristics were retrospectively examined in 1,156 patients starting MTX for RA. Multivariable logistic regression analyses were performed to identify the independent predictors of RBC macrocytosis. The initiation of b/tsDMARDs was assessed using a multivariable Cox proportional hazards regression model.

Results

RBC macrocytosis was observed in 21.6% of RA patients over 35 [8, 89] months following MTX initiation and was persistent in 63.6% of the patients during MTX treatment. Anemia coexisted in only 20.0% of the patients with RBC macrocytosis. The occurrence of RBC macrocytosis was independently associated with age, MTX dose, and concomitant use of sulfasalazine or leflunomide (all p<0.001). A higher dose of MTX and double- or triple-DMARDs therapy were more frequently used in the group with RBC macrocytosis than in the group with normal MCV. Patients experiencing RBC macrocytosis were more likely to use b/tsDMARDs (hazard ratio 1.45 [95% confidence interval 1.13, 1.87], p=0.003).

Conclusion

RBC macrocytosis was possibly associated with the use of b/tsDMARD and could be a supplementary marker for assessing MTX resistance.

Assessment of disease activity and quality of life of Korean patients with rheumatoid arthritis

The management of rheumatoid arthritis (RA) follows a treat-to-target approach, as recommended by guidelines from the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR). RA treatment recommendations include an emphasis on frequent disease activity assessments to optimize therapy, recognizing the possibility of timely therapies to slow progression and improve long-term results. The evaluation of joint inflammation, pain, physical function, and clinical indicators is required for comprehensive RA therapy. Current therapeutic goals include achieving low disease activity or remission to enhance the quality of life (QoL) for patients. ACR-endorsed RA disease activity measures, such as the Disease Activity Score in 28 Joints with erythrocyte sedimentation rate or C-reactive protein level, Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), Patient Activity Scale-II, and Routine Assessment of Patient Index Data 3, are recommended for their precision and sensitivity in supporting treat-to-target strategies. The ACR and EULAR have implemented Boolean-based and index-based remission criteria (SDAI and CDAI, respectively) to evaluate therapeutic effectiveness. The use of these markers regularly aligns with the ACR guidelines, improving adherence to quality indicators in clinical practice and confirming the provision of high-quality RA therapy. This review examines disease activity, function, and QoL measurements in line with the ACR and EULAR guidelines to aid doctors in treating Korean patients with RA.

Nano-based Therapeutics for Rheumatoid Arthritis: Recent Patents and Development

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease marked by inflammation of synovium and generation of autoantibodies. Bone and cartilage are frequently damaged along with weakening of tendons and ligaments resulting in disability. An effective RA treatment needs a multi-disciplinary approach which relies upon pathophysiology that is still partially understood. In RA patients, inflammation was induced by pro-inflammatory cytokines including IL-1, IL-6 & IL-10. The conventional dosage regimens for treating RA have drawbacks such as ineffectiveness, greater doses, frequent dosing, relatively expensive and serious adverse effects. To formulate an effective treatment plan for RA, research teams have recently focused on producing several nanoformulations containing anti-inflammatory APIs with an aim to target the inflamed area. Nanomedicines have recently gained popularity in the treatment of RA. Interestingly, unbelievable improvements have been observed in current years in diagnosis and management of RA utilizing nanotechnology. Various patents and clinical trial data have been reported in relevance to RA treatment.

Integrating different perspectives to define a concept of comprehensive remission in rheumatoid arthritis: The SUMAR project

INTRODUCTION AND OBJECTIVES

The SUMAR project aimed to establish a consensus on the concept of remission in patients with rheumatoid arthritis (RA) that takes into account the different perspectives of patients, health care professionals and health care managers.

MATERIALS AND METHODS

The scientific committee comprised a rheumatologist who acted as a national coordinator, 4 rheumatologists, 1 primary care physician, 1 nurse, 2 hospital pharmacists, 2 health care managers and 1 member of a patient advocacy group. The study was undertaken from 2020 to 2021 in three phases: (1) analysis of several perspectives on remission in RA with the participation of 275 patients, 160 rheumatologists and 31 health care managers; (2) an integrative definition of remission, which included two multidisciplinary workshops with 11 and 12 participants; and (3) extension and dissemination with up to 200 participants in 7 regional multidisciplinary meetings.

RESULTS

The concept of remission in the different settings and by the different stakeholders was heterogeneous. It was agreed that, in addition to inflammatory activity, remission should include pain and functionality as well as the duration of remission. For the participants, the definition of remission varied depending on the clinical scenario, without or with structural damage, seeking to "normalize" the outcomes in the former and avoid progression in the latter. The implementation of the concept of comprehensive remission was considered less feasible, and the main barriers to implementation were the lack of time for consultation and the variability in information technology systems across the different autonomous communities.

DISCUSSION AND CONCLUSIONS

This definition of remission is not only based on the concept of the presence or absence of inflammatory activity based on existing indexes, but also includes variables directly reported by the patient that are related to their health and quality of life.