Polypharmacy among people with rheumatoid arthritis: the role of age, disease duration and comorbidity

Polypharmacy, drug-drug interactions, and adverse drug reactions among systemic sclerosis patients: A cross-sectional risk factor study

OBJECTIVES

Polypharmacy, drug-drug interactions (DDI) and related adverse drug reaction (ADR) are understudied in SSc. The aim of this work was to determine the prevalence and determinants of DDI and ADR in a real-life prospective cohort of SSc patients.

METHODS

We performed a retrospective analysis of the drug prescriptions of SSc patients admitted to the daily scleroderma clinic between January 2020 and April 2022. DDI were identified using 2 prescription analysis applications, and adjudicated related ADRs occurring during a one-year follow-up were reported. Risk factors for DDI and ADR were identified using multivariate analysis.

RESULTS

One hundred and eight SSc patients were included. The median number of medications per patient was 6 [4-9]. Seventy-one (65.7 %) patients had 5 or more medications, and 23 (21.3 %) had 10 or more. Seventy-two (66.7 %) patients had DDIs on their prescriptions at inclusion. Patients with DDIs had more medications than patients without DDIs (7 [5-10] versus 3 [2-5], p < 0.0001). Six (8.3) patients experienced ADRs during the one-year follow-up. Patients with ADRs had more medications (14 [10-18] versus 7 [5-10] p < 0.001) and more DDIs (12 [7-32] versus 3 [1-6]; p < 0.001) than patients without ADRs. Multivariate analysis confirmed that the number of prescribed medications was independently positively associated with DDIs (OR: 2.25 [1.52-3.32], p < 0.0001) as well as with ADRs (OR: 1.68 [1.17-2.40], p < 0.01).

CONCLUSIONS

SSc patients are significantly exposed to polypharmacy, DDIs and related ADRs, particularly in cases of severe illness, and especially if 5 or more medications are prescribed.

Vitamin B12 status and hyperhomocysteinemia in patients with Rheumatoid arthritis treated with methotrexate and folic acid

BACKGROUND

Rheumatoid arthritis (RA) is an inflammatory arthritis in which the immune system targets synovial joints. Methotrexate serves as the mainstay of treatment for RA due to its efficacy. However, patients treated with methotrexate are uniquely at risk for vitamin B12 deficiency and hyperhomocysteinemia due to coincident disease risk factors and the fact that methotrexate use is associated with malabsorption. The objective of this study was to assess for vitamin B12 deficiency among patients with RA treated with methotrexate and folic acid.

METHODS

This cross-sectional study included 50 patients with RA treated with methotrexate and folic acid and 49 patients with RA treated with other therapies. Patients were matched by age, sex, race, renal function, and disease activity. We compared plasma vitamin B12, methylmalonic acid, and homocysteine levels between these two groups utilizing quantitative and categorical analyses.

RESULTS

Thirty-seven (74%) RA patients on methotrexate and folic acid had elevated plasma homocysteine levels compared with only 27 (55%) RA patients receiving other therapies (P < 0.05). The proportion of patients with low vitamin B12 and high methylmalonic acid levels did not differ between the two groups.

CONCLUSIONS

Our data show high plasma homocysteine levels among RA patients treated with methotrexate and folic acid. While plasma vitamin B12 levels were similar between the two groups, high plasma homocysteine is also a sensitive marker of vitamin B12 deficiency. Additional studies should evaluate for the presence of clinical features of vitamin B12 deficiency and hyperhomocysteinemia among RA patients treated with methotrexate and folic acid.

The effect of polypharmacy on rheumatoid and psoriatic arthritis treatment: retrospective study

Background

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are chronic, progressive inflammatory diseases that can be accompanied by other diseases. In recent years, with the increase in the lifespan of individuals, the concept of polypharmacy has become more prominent. We aimed to show the prevalence of polypharmacy and the effects of polypharmacy on disease activity in RA and PsA.

Methods

This study included PsA patients who had peripheral joint involvement and, RA patients. Since PsA has a heterogeneous clinical picture, only patients with peripheral joint involvement were included in the study and patients with inflammatory low back pain or radiological sacroiliitis or spondylitis, dactylitis or enthesitis were not included in the study due to homogeneity concerns. The numbers of medications used by the patients at the onset of their treatment and at sixth months into their treatment were recorded. Polypharmacy was accepted as the simultaneous use of at least five medications by the person. The Disease Activity Score 28 joints C-Reactive Protein (DAS-28 CRP) was used to assess disease activity for both disease. The modified Charlson Comorbidity Index (CCI) scores of the patients were calculated based on their chronic diseases.

Results

The sample of the study included 232 RA and 73 PsA patients. Polypharmacy was present at the treatment onset in 115 (49.6%) of the RA patients and 28 (38.4%) of the PsA patients. At the sixth month of treatment, polypharmacy was present in the sixth month of the treatment in 217 (93.5%) RA and 61 (83.6%) PsA patients. The mean ages of the RA and PsA patients who were receiving polypharmacy treatment at the beginning were significantly older than the mean ages of those who were not receiving polypharmacy treatment. In both the RA and PSA groups, the patients with polypharmacy at the beginning had statistically significantly higher DAS-28 CRP scores at six months of treatment than those without polypharmacy at the beginning (p < 0.001).

Conclusion

Polypharmacy was present both at the time of diagnosis and in the treatment process in the RA and PsA patients, and the presence of polypharmacy at the beginning of the treatment was among the factors that affected the treatment of these patients by significantly affecting their 6th-month DAS-28 CRP values.

Prevalence and factors associated with polypharmacy among patients with rheumatoid arthritis: a single-centre, cross-sectional study

OBJECTIVE

This study aimed to identify factors associated with polypharmacy, including social aspects, among patients with rheumatoid arthritis.

METHODS

We conducted this single-centre, cross-sectional study at a 715-bed regional tertiary care teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as having five or more medications administered orally regularly, and excessive polypharmacy was defined as having 10 or more medications administered orally regularly. The prevalence of polypharmacy and excessive polypharmacy, distribution of medication types, and factors associated with polypharmacy and excessive polypharmacy were investigated among patients with rheumatoid arthritis.

RESULTS

The proportions of polypharmacy and excessive polypharmacy were 61% and 15%, respectively, in 991 patients. Polypharmacy and excessive polypharmacy were associated with older age (odds ratio, 1.03 and 1.03, respectively), high Health Assessment Questionnaire Disability Index (odds ratio, 1.45 and 2.03, respectively), medication with glucocorticoids (odds ratio, 5.57 and 2.42, respectively), high Charlson comorbidity index (odds ratio, 1.28 and 1.36, respectively), and a history of hospitalisation in internal medicine (odds ratio, 1.92 and 1.87, respectively) and visits to other internal medicine clinics (odds ratio, 2.93 and 2.03, respectively). Moreover, excessive polypharmacy was associated with the presence of public assistance (odds ratio, 3.80).

CONCLUSIONS

Considering that polypharmacy and excessive polypharmacy are associated with a history of hospitalisation and glucocorticoid medication in patients with rheumatoid arthritis, medications during hospitalisation should be monitored, and glucocorticoids should be discontinued. Key points • The proportion of polypharmacy (five or more medications administered orally regularly) was 61%. • The proportion of excessive polypharmacy (10 or more medications administered orally regularly) was 15%. • Medications during hospitalisation should be reviewed and examined, and glucocorticoids should be discontinued.

Smoking, but not use of complementary and alternative medicine predicts residual functional disability in patients with inflammatory arthritis on biologic disease-modifying anti-rheumatic drugs: Results from the Singapore National Biologics Register

AIMS

To describe inflammatory arthritis (IA) patients initiating biologic disease-modifying anti-rheumatic drugs (bDMARDs) who use complementary and alternative medicine (CAM), and determine the impact of CAM on predicting modified Health Assessment Questionnaire (mHAQ) at 6 months.

METHODS

This was a prospective inception cohort study of patients ≥21 years old initiating a bDMARD for IA after July 2016. Data were obtained via questionnaires and abstraction from medical records. Baseline characteristics between ever-CAM and CAM non-users were compared. CAM as a predictor of mHAQ ≥1 at 6 months after bDMARD initiation was analyzed using multivariate logistic regression, adjusting for other baseline characteristics.

RESULTS

We recruited 299 patients (36.2% male, mean age 49.0 years). There were 45.8% who had rheumatoid arthritis, 54.2% had a spondyloarthropathy, median disease duration of 1.1 years and median mHAQ of 0.4. Compared to CAM non-users, ever-CAM users had a lower mean body mass index, were less likely to speak English, and more likely to smoke and drink alcohol. There was no association of CAM use with high mHAQ and no interaction with smoking. Smoking (odds ratio [OR] 938.9; 95% CI 3.20-275 884.1), baseline mHAQ (OR 252.2; 95% CI 5.34-11 899.2) and Charlson's Comorbidity Index score ≥4 (OR 237.4; 95% CI 1.22-46 184.4) independently predicted high mHAQ at 6 months.

CONCLUSIONS

CAM use was not associated with high mHAQ at 6 months. Smoking was an independent predictor of residual functional disability at 6 months, even after adjusting for age, comorbidity and baseline mHAQ. Greater emphasis on smoking cessation may improve long-term functional outcomes in IA patients on bDMARDs.

Associations of Polypharmacy With Clinical Parameters, Function, and Health-Related Quality of Life in Psoriatic Arthritis

OBJECTIVE

The aim of this study was to assess predictors of polypharmacy and its effect on health-related quality of life in patients with psoriatic arthritis (PsA).

METHODS

This cross-sectional study was performed between February and December 2019. The number of medications was grouped into minor (2-4) and major (≥5) polypharmacy. Functional status and quality of life were assessed using the Health Assessment Questionnaire and Short-Form 36, respectively. Clinical and demographic characteristics, physical function, and quality of life of the polypharmacy group were compared. Predictive factors for major polypharmacy were evaluated using a logistic regression analysis.

RESULTS

The mean age of the 100 patients (70 females and 30 males) with PsA was 48.43 ± 12.94 years. The proportion of patients with major polypharmacy was 19%. The physical function subscale of Short-Form 36 was lower in the major polypharmacy group ( p = 0.009). Univariable analysis revealed that sex, body mass index, disease duration, disease activity, psoriasis severity, dactylitis, enthesitis, PsA subtypes, smoking, and Health Assessment Questionnaire were not associated with major polypharmacy ( p > 0.10). In the multivariable model, the number of comorbidities (odds ratio, 3.151; 95% confidence interval, 1.828-5.429; p < 0.001) and age ≥60 years (odds ratio, 4.864; 95% confidence interval, 1.159-20.418; p = 0.031) were significantly associated with major polypharmacy.

CONCLUSIONS

The number of comorbid diseases and age ≥60 years were the factors associated with major polypharmacy in patients with PsA. Although physical function was not associated with polypharmacy, patients with major polypharmacy had poorer quality of life.

Identification of Five Quality Needs for Rheumatology (Text Analysis and Literature Review)

Background: While the use of the term "quality" in industry relates to the basic idea of making processes measurable and standardizing processes, medicine focuses on achieving health goals that go far beyond the mere implementation of diagnostic and therapeutic processes. However, the quality management systems used are often simple, self-created concepts that concentrate on administrative processes without considering the quality of the results, which is essential for the patient. For several rheumatic diseases, both outcome and treatment goals have been defined. This work summarizes current mainstreams of strategies with published quality efforts in rheumatology. Methods: PubMed, Cochrane Library, and Web of Science were used to search for studies, and additional manual searches were carried out. Screening and content evaluation were carried out using the PRISMA-P 2015 checklist. After duplicate search in the Endnote reference management software (version X9.1), the software Rayyan QCRI (https://rayyan.qcri.org) was applied to check for pre-defined inclusion and exclusion criteria. Abstracts and full texts were screened and rated using Voyant Tools (https://voyant-tools.org/). Key issues were identified using the collocate analysis. Results: The number of selected publications was small but specific (14 relevant correlations with coefficients >0.8). Using trend analysis, 15 publications with relative frequency of keywords >0.0125 were used for content analysis, revealing 5 quality needs. The treat to target (T2T) initiative was identified as fundamental paradigm. Outcome parameters required for T2T also allow quality assessments in routine clinical work. Quality care by multidisciplinary teams also focusing on polypharmacy and other quality aspects become essential, A global software platform to assess quality aspects is missing. Such an approach requires reporting of multiple outcome parameters according to evidence-based clinical guidelines and recommendations for the different rheumatic diseases. All health aspects defined by the WHO (physical, mental, and social health) have to be integrated into the management of rheumatic patients. Conclusion: For the future, quality projects need goals defined by T2T based initiatives in routine clinical work, secondary quality goals include multidisciplinary cooperation and reduction of polypharmacy. Quality indicators and standards in different health systems will provide new information to optimize patients' care in different health systems.

Etanercept or Methotrexate Withdrawal in Rheumatoid Arthritis Patients in Sustained Remission

OBJECTIVE

Patients with rheumatoid arthritis (RA) in whom remission is achieved following combination therapy with methotrexate plus etanercept face an ongoing medication burden. This study was undertaken to investigate whether sustained remission achieved on combination therapy can be maintained with either methotrexate or etanercept monotherapy, as assessed following discontinuation of one or the other medication from the combination.

METHODS

Of the 371 adult patients with RA who received combination therapy with methotrexate plus etanercept, remission (defined as a Simplified Disease Activity Index [SDAI] score of ≤3.3) was sustained in 253 patients through a 24-week open-label period. These 253 patients then entered a 48-week, double-blind period and were randomized to receive either 1) methotrexate monotherapy (n = 101), 2) etanercept monotherapy (n = 101), or 3) methotrexate plus etanercept combination therapy (n = 51). Patients who subsequently experienced disease-worsening received rescue therapy with the combination regimen at the same dosages as used in the initial run-in period. The primary end point was the proportion of patients in whom SDAI-defined remission was maintained without disease-worsening at week 48 in the etanercept monotherapy group as compared to the methotrexate monotherapy group. Secondary end points included time to disease-worsening, and the proportion of patients in whom SDAI-defined remission was recaptured after initiation of rescue therapy.

RESULTS

Baseline demographic and clinical characteristics of the RA patients were similar across the treatment groups. At week 48, SDAI-defined remission was maintained in significantly more patients in the etanercept monotherapy group than in the methotrexate monotherapy group (49.5% versus 28.7%; P = 0.004). Moreover, as a secondary end point, sustained SDAI-defined remission was achieved in significantly more patients who received combination therapy than in those who received methotrexate monotherapy (52.9% versus 28.7%; P = 0.006). Time to disease-worsening was shorter in those who received methotrexate monotherapy than in those who received etanercept monotherapy or those who received combination therapy (each P < 0.001 versus methotrexate monotherapy). Among the patients who received rescue therapy, SDAI-defined remission was recaptured in 70-80% in each treatment group. No new safety signals were reported.

CONCLUSION

The efficacy of etanercept monotherapy was superior to that of methotrexate monotherapy and similar to that of combination therapy in maintaining remission in patients with RA. SDAI-defined remission was recaptured in most of the patients who were given rescue therapy. These data could inform decision-making when withdrawal of therapy is being considered to reduce treatment burden in patients with well-controlled RA.

Frequency of Prescription Claims for Drugs that May Interact with Janus Kinase Inhibitors Among Patients with Rheumatoid Arthritis in the US

Introduction

This study describes the frequency of prescription claims for drugs that may interact with Janus kinase (JAK) inhibitors among adult patients with rheumatoid arthritis (RA) in a large US claims database.

Methods

This observational, retrospective, cross-sectional study of the IBM^® MarketScan^® Research Commercial and the Medicare Supplemental Database included adults (≥ 18 years) with ≥ 2 outpatient claims 30 or more days apart or ≥ 1 inpatient visit claim with an RA diagnosis between January 1, 2013 and March 31, 2017 (the index period). During the study period, from January 1, 2013 to March 31, 2018, strong organic anion transporter (OAT3) inhibitors, strong cytochrome P450 (CYP) 3A4 inhibitors, and moderate or strong CYP3A4 inhibitors in combination with strong CYP2C19 inhibitors, were identified as drugs with potential for drug–drug interactions (DDIs) with JAK inhibitors approved for RA treatment in the US. Descriptive statistics were conducted.

Results

A total of 152,853 patients met eligibility criteria. Approximately 76% were women and the median age was 57 years. Of these patients, < 0.1% had a claim for a strong OAT3 inhibitor, and 1% had claims for the combination of a strong CYP3A4 and strong CYP2C19 inhibitor; 3% of patients had a claim for a strong CYP3A4 inhibitor and almost 10% had claims for both a moderate CYP3A4 and a strong CYP2C19 inhibitor.

Conclusions

Up to 10% of RA patients have been prescribed a drug with a potential JAK interaction. Rheumatologists should consider potential DDIs when managing patients with RA.

Efficacy, safety, and adherence of tocilizumab therapy in elderly patients with rheumatoid arthritis: A real-world observational study

Objective: We evaluated the efficacy, safety, and drug survival rate of tocilizumab in the elderly patients with rheumatoid arthritis (RA). Methods: This study was conducted in 108 RA patients who started tocilizumab between 2008 and 2018. The patients were divided into a young group (<65 years) and an elderly group (≥65 years). The efficacy, safety, and drug survival rate of tocilizumab were compared between the two groups. Results: At baseline, there were no significant differences between the elderly ( n = 45) and the young group ( n = 63) in RA duration, percentage of biologic-naïve, and RA disease activity. Health Assessment Questionnaire-Disability Index (HAQ-DI) was higher, renal function was worse, and frequency of using methotrexate was lower in the elderly group. Tocilizumab demonstrated similar efficacy in the elderly and the young group with Clinical Disease Activity Index and HAQ-DI. Compared with baseline, the frequency of steroid use was lower at one year after initiation of tocilizumab in both groups. There was no significant difference between the groups in the drug survival rate of tocilizumab for three years. Discontinuation rates of TCZ due to toxic adverse events were similar between the two groups. Conclusions: The efficacy, steroid-sparing effect, and safety of tocilizumab therapy, as well as the drug survival rate for three years, were not inferior in elderly RA compared to young RA patients.

Safety and efficacy of interleukin inhibitors in elderly patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis

Elderly patients with rheumatoid arthritis, psoriasis and psoriatic arthritis encompass those with elderly-onset disease, over 60 years of age, but also those with earlier disease onset who entered old age. Considering the age-related changes of the immune system, possible frailty, susceptibility to infection and concomitant comorbidity that implies multiple medicines, the treatment of these diseases in elderly patients can be challenging. Interleukin inhibitors have been shown to be an efficient and safe treatment for these diseases. However, elderly patients with these diseases were often included in the pivotal clinical trials for interleukin inhibitors in numbers insufficient to determine whether they responded differently from younger subjects. The aim of this paper was to review the findings on the efficacy and safety of interleukin inhibitor treatment in elderly patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis. The findings suggest that, for all the interleukin inhibitors reviewed herein, used in elderly patients with rheumatoid arthritis, or with psoriasis and psoriatic arthritis, the efficacy was comparable to younger patients. Furthermore, the incidence of reported adverse events was similar in these two age groups. Severe adverse events, which were related to sarilumab treatment for rheumatoid arthritis and secukinumab treatment for psoriasis, were higher in elderly patients. The reviewed findings suggest that the interleukin inhibitors approved and currently in use in clinical practice for the treatment of rheumatoid arthritis, psoriasis, and psoriatic arthritis can be considered a safe and efficient option for these diseases in elderly patients.

Polypharmacy in Middle-European Rheumatoid Arthritis-Patients: A Retrospective Longitudinal Cohort Analysis With Systematic Literature Review

Objective: To assess polypharmacy and related medication aspects in Middle-European rheumatoid arthritis (RA) patients, and to discuss the results in view of a systematic literature review.

Methods: In this retrospective cohort study, charts were reviewed from RA-patients consecutively recruited between September 27, 2017 and April 29, 2019. Drugs were assigned to the Anatomical Therapeutic Chemical (ATC) groups as proposed by the World Health Organization (WHO). Results were compared to those of a systematic literature review.

Results: One hundred seventy-five consecutive RA-patients were included. The mean number of drugs was 6.6 ± 3.5, with 2.4 ± 1.2 drugs taken specifically for RA—compared to 2.6 in the literature. 33.7% of patients experienced polypharmacy defined by ≥5 drugs, compared to 61.6% in the literature–with women affected more frequently than men. After 7 years of follow-up, the number of drugs increased in all ATC-groups by an average of 12.7 %, correlating with age (Corrcoeff = 0.46) and comorbidities (Corrcoeff = 0.599). In the literature, polypharmacy is not always defined precisely, and has not been considered in management guidelines so far.

Conclusion: Polypharmacy is a frequent issue in RA-management. With an increasing number of comorbidities during the course of the disease, polypharmacy becomes even more relevant.

Effects of Upadacitinib Coadministration on the Pharmacokinetics of Sensitive Cytochrome P450 Probe Substrates: A Study With the Modified Cooperstown 5+1 Cocktail

The aim of this study was to characterize the effects of upadacitinib, a Janus kinase 1 inhibitor, on in vivo activity of different cytochrome P450 (CYP) enzymes using a cocktail approach. Healthy subjects (n = 20) received single oral doses of the modified Cooperstown 5+1 cocktail drugs (midazolam [CYP3A], caffeine [CYP1A2], warfarin + vitamin K [CYP2C9], omeprazole [CYP2C19], and dextromethorphan [CYP2D6]) without upadacitinib and on day 11 (midazolam) or 12 (all other probes) of a 15-day regimen of upadacitinib 30 mg once daily (extended-release formulation). Serial blood samples and 12-hour urine samples were collected for assays of the probe substrates and select metabolites. The ratio (90%CI) of area under the plasma concentration-time curve from time 0 to infinity (AUCinf ) central values when the cocktail drugs were administered with upadacitinib relative to when administered alone were 0.74 (0.68-0.80) for midazolam, 1.22 (1.15-1.29) for caffeine, 1.11 (1.07-1.15) for S-warfarin, 1.07 (0.95-1.22) for dextromethorphan, and 0.82 (0.72-0.94) for omeprazole. The ratio (90%CI) was 1.09 (1.00-1.19) for 5-hydroxy-omeprazole to omeprazole AUCinf ratio and 1.17 (0.97-1.41) for dextromethorphan to dextrorphan 12-hour molar urinary ratio. Upadacitinib 30 mg once daily (a dose that is twice the optimal dose in rheumatoid arthritis based on phase 3 results) has a limited effect on CYP3A activity (26% decrease in exposure of midazolam, a sensitive CYP3A substrate) and no relevant effects on CYP1A2, CYP2C9, CYP2C19, or CYP2D6 activity in vivo. No clinically relevant changes in plasma exposures are expected for drugs that are substrates for the evaluated CYP enzymes when coadministered with upadacitinib.

A Multicenter, Randomized, Placebo-Controlled Trial of Atorvastatin for the Primary Prevention of Cardiovascular Events in Patients With Rheumatoid Arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is associated with increased cardiovascular event (CVE) risk. The impact of statins in RA is not established. We assessed whether atorvastatin is superior to placebo for the primary prevention of CVEs in RA patients.

METHODS

A randomized, double-blind, placebo-controlled trial was designed to detect a 32% CVE risk reduction based on an estimated 1.6% per annum event rate with 80% power at P < 0.05. RA patients age >50 years or with a disease duration of >10 years who did not have clinical atherosclerosis, diabetes, or myopathy received atorvastatin 40 mg daily or matching placebo. The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, transient ischemic attack, or any arterial revascularization. Secondary and tertiary end points included plasma lipids and safety.

RESULTS

A total of 3,002 patients (mean age 61 years; 74% female) were followed up for a median of 2.51 years (interquartile range [IQR] 1.90, 3.49 years) (7,827 patient-years). The study was terminated early due to a lower than expected event rate (0.70% per annum). Of the 1,504 patients receiving atorvastatin, 24 (1.6%) experienced a primary end point, compared with 36 (2.4%) of the 1,498 receiving placebo (hazard ratio [HR] 0.66 [95% confidence interval (95% CI) 0.39, 1.11]; P = 0.115 and adjusted HR 0.60 [95% CI 0.32, 1.15]; P = 0.127). At trial end, patients receiving atorvastatin had a mean ± SD low-density lipoprotein (LDL) cholesterol level 0.77 ± 0.04 mmoles/liter lower than those receiving placebo (P < 0.0001). C-reactive protein level was also significantly lower in the atorvastatin group than the placebo group (median 2.59 mg/liter [IQR 0.94, 6.08] versus 3.60 mg/liter [IQR 1.47, 7.49]; P < 0.0001). CVE risk reduction per mmole/liter reduction in LDL cholesterol was 42% (95% CI -14%, 70%). The rates of adverse events in the atorvastatin group (n = 298 [19.8%]) and placebo group (n = 292 [19.5%]) were similar.

CONCLUSION

Atorvastatin 40 mg daily is safe and results in a significantly greater reduction of LDL cholesterol level than placebo in patients with RA. The 34% CVE risk reduction is consistent with the Cholesterol Treatment Trialists' Collaboration meta-analysis of statin effects in other populations.

High Levels of Polypharmacy in Rheumatoid Arthritis-A Challenge Not Covered by Current Management Recommendations: Data From a Large Real-Life Study

BACKGROUND

Rheumatoid arthritis (RA) is associated with high frequency of comorbidities and increased risk of polypharmacy. Although there is a great potential for complications, there is a gap in literature on polypharmacy in patients with rheumatic arthritis.

OBJECTIVE

To evaluate the prevalence and factors associated with polypharmacy in a population in a real-life setting.

METHODS

A cross-sectional multicenter study was conducted in Brazil. Patients underwent clinical evaluation and medical records analysis. Polypharmacy was considered as a dependent variable. To test independent variables, we used Poisson regression.

RESULTS

We evaluated 792 patients (89% female, median age 56.6 years). Median duration of disease was 12.7 years, 78.73% had a positive rheumatoid factor. The median of disease activity score-28 was 3.5 (disease with mild activity), median of the clinical disease activity index score was 9, and median of health assessment questionnaire-disability index was 0.875; 47% used corticosteroids, 9.1% used nonsteroidal anti-inflammatory drugs, 90.9% used synthetic disease-modifying antirheumatic drugs, 35.7% used biologic disease-modifying antirheumatic drugs (DMARDs). In total, 537 (67.9%) patients used 5 or more drugs. Polypharmacy showed a relationship with a number of comorbidities and use of specific drugs (corticosteroids, methotrexate, and biological DMARDs).

CONCLUSION

We found a high prevalence of polypharmacy (67.9%) in RA. Solutions to management this problem should be stimulated.

Polypharmacy is associated with treatment response and serious adverse events: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis

Objective

To evaluate whether polypharmacy is associated with treatment response and serious adverse events (SAEs) in patients with RA using data from the British Society for Rheumatology Biologics Register (BSRBR-RA).

Methods

The BSRBR-RA is a prospective observational cohort study of biologic therapy starters and a DMARD comparator arm. A logistic regression model was used to calculate the odds of a EULAR ‘good response’ after 12 months of biologic therapy by medication count. Cox proportional hazards models were used to identify risk of SAEs. The utility of the models were compared with the Rheumatic Disease Comorbidity Index using Receiver Operator Characteristic and Harrell’s C statistic.

Results

The analysis included 22 005 patients, of which 83% were initiated on biologics. Each additional medication reduced the odds of a EULAR good response by 8% [odds ratios 0.92 (95% CI 0.91, 0.93) P < 0.001] and 3% in the adjusted model [adjusted odds ratios 0.97 (95% CI 0.95, 0.98) P < 0.001]. The Receiver Operator Characteristic demonstrated significantly greater areas under the curve with the polypharmacy model than the Rheumatic Disease Comorbidity Index. There were 12 547 SAEs reported in 7286 patients. Each additional medication equated to a 13% increased risk of an SAE [hazard ratio 1.13 (95% CI 1.12, 1.13) P < 0.001] and 6% in the adjusted model [adjusted hazard ratio 1.06 (95% CI 1.05, 1.07) P < 0.001]. Predictive values for SAEs were comparable between the polypharmacy and Rheumatic Disease Comorbidity Index model.

Conclusion

Polypharmacy is a simple but valuable predictor of clinical outcomes in patients with RA. This study supports medication count as a valid measure for use in epidemiologic analyses.

Drug-related problems in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) patients are at risk of acquiring drug-related problems (DRPs). However, there has been a lack of studies on DRPs in patients with RA up to now.

METHOD

This retrospective study was conducted in a tertiary hospital in Malaysia from January 2012 to December 2017 with the purpose of assessing DRPs in RA patients and factors associated with its occurrence. A total of 200 patients who had received pharmacological treatment for RA were enrolled in this study. Assessment of DRPs was based on the Pharmaceutical Network Care Europe tool version 5.01.

RESULTS

A total of 289 DRPs with an average of 1.5±1.0 problems per patient were identified, in which 78.5% of the population had at least one DRP. The most common DRPs encountered were adverse reactions (38.8%), drug interactions (33.6%), and drug-choice problems (14.5%). Factors that had significant association with the occurrence of DRPs were polypharmacy (P=0.003), multiple comorbidities (P=0.001), hyperlipidemia (P=0.009), osteo (P=0.040), and renal impairment (P=0.044). These data indicated that the prevalence of DRPs was high among RA patients.

CONCLUSION

Early identification of types of DRPs and associated factors may enhance the prevention and management of RA.

Pharmacotherapy Pearls in Rheumatology for the Care of Older Adult Patients: Focus on Oral Disease-Modifying Antirheumatic Drugs and the Newest Small Molecule Inhibitors

Providing safe and effective pharmacotherapy to geriatric patients with rheumatologic disorders is challenging. Multidisciplinary care involving rheumatologists, primary care physicians, and other specialties can optimize benefit and reduce adverse outcomes. Oral disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the small molecule inhibitors tofacitinib and apremilast have distinctive monitoring requirements and specific adverse reaction profiles. This article provides clinically relevant pearls for use of these interventions in older patients.

Polypharmacy and Unplanned Hospitalizations in Patients with Rheumatoid Arthritis

OBJECTIVE

Polypharmacy (PP), the prescribing of multiple drugs for an individual, is rising in prevalence. PP associates with an increased risk of adverse drug reactions (ADR) and hospital admissions. We investigated the relationship between PP, characteristics of rheumatoid arthritis (RA), and the risk of unplanned hospital admissions.

METHODS

Patients from a hospital RA cohort were retrospectively analyzed. Information was collected from electronic medical records. Cox proportional hazards were used to compare hospitalization risk according to levels of PP. Admissions were adjudicated to determine whether an ADR was implicated.

RESULTS

The study included 1101 patients; the mean number of all medications was 5. PP correlated with increasing age, disease duration, disease activity, and disability. At least 1 unplanned admission occurred for 16% of patients. Patients taking ≥ 10 medications had an adjusted HR for hospitalization of 3.1 (95% CI 2.1-4.5), compared to those taking 0-5 medications. Corticosteroid use associated with a doubling in adjusted risk of admission of 1.7 (95% CI 1.2-2.4). The most common reason for hospitalization was infection (28%). While in half of all admissions an ADR was a possible contributing factor, only 2% of admissions were found to directly result from an ADR.

CONCLUSION

PP is common in RA and is a prognostic marker associated with increased risk of acute hospitalizations. Our data suggest that PP may be an indicator of comorbidity burden rather than a contributing cause of a drug-related toxicity. PP should be monitored to minimize inappropriate combination of prescribed medications. PP may be a useful predictor of clinical outcomes in epidemiologic studies.

The Challenges of Treating Sciatica Pain in Older Adults

Sciatica is a debilitating condition affecting approximately 25 % of the population. Typically, the patient will complain of lower limb pain that is more severe than pain in the lower back, usually accompanied by numbness and motor weakness. Most international guidelines recommend pharmacological management for the pain relief of sciatica, including paracetamol, non-steroidal anti-inflammatory drugs, opioid analgesics, anticonvulsants, and corticosteroids, among others. However, the evidence for most of these pharmacological options is scarce, and the majority of clinical trials exclude older patients. There is overall very limited information on the efficacy, safety, and tolerability of these medicines in older patients with sciatica. This review presents a critical appraisal of the existing evidence for the pharmacological treatment of sciatica, with a special focus on the older adult. The age-related changes in the health of older patients, as well as their impact on the response to pharmacological treatment, including polypharmacy, drug interactions, and drug-disease interactions, is also discussed.

Polypharmacy and Multimorbidity Among Medicaid Enrollees: A Multistate Analysis

The purpose of this study is to explore the associations between polypharmacy and multimorbidity using conventional and novel measures of polypharmacy. In this cross-sectional study, data on fee-for-service (FFS) Medicaid enrollees with at least 1 chronic condition and aged 18-64 years (N = 38,329) were derived from the 2010 Medicaid Analytic eXtract (MAX) files of Maryland and West Virginia. Polypharmacy, by the authors' novel definition, was determined as simultaneous use of ≥5 drugs for a consecutive period of 60 days. Multimorbidity was defined as having ≥2 chronic conditions based on the US Department of Health and Human Services framework. The association between multimorbidity and polypharmacy was examined with chi-square tests and logistic regression. Polypharmacy prevalence was estimated at 50.9% using the novel definition, as compared to 16.7% and 64.9% for the 2 commonly used conventional measures, respectively. For all 3 definitions, individuals with multimorbidity were more likely to have polypharmacy than those without multimorbidity (P < 0.001). The authors also consistently found, using all definitions, that those who were older, female, white, and eligible for Medicaid because of cash assistance were more likely to have polypharmacy (all P < 0.001). Polypharmacy was highly prevalent and significantly associated with multimorbidity among Medicaid FFS enrollees irrespective of the definitions used. The new measure may provide a more comprehensive and accurate estimation of polypharmacy than the conventional measures. These findings suggest the need for a paradigm shift from disease-specific care to patient-centered collaborative care to manage patients with multimorbidity and polypharmacy.

Effects of Fostamatinib on the Pharmacokinetics of Oral Contraceptive, Warfarin, and the Statins Rosuvastatin and Simvastatin: Results From Phase I Clinical Studies

BACKGROUND AND OBJECTIVES

Fostamatinib is a spleen tyrosine kinase inhibitor that has been investigated as therapy for rheumatoid arthritis and immune thrombocytopenic purpura. The present studies assessed the potential for pharmacokinetic interaction between fostamatinib and the commonly prescribed medications oral contraceptive (OC), warfarin, and statins (rosuvastatin, simvastatin) in healthy subjects.

METHODS

The OC study was a crossover study over two 28-day treatment periods (Microgynon(®) 30 plus placebo or fostamatinib). Concentrations of OC constituents (ethinyl estradiol/levonorgestrel) were measured. Effects on warfarin pharmacokinetics and pharmacodynamics were assessed (21-day study). Warfarin was administered on days 1 and 14, fostamatinib on days 8-20. The statin study was a two-period, fixed-sequence study of the effects of fostamatinib on exposure to rosuvastatin or simvastatin (single doses). Safety was assessed throughout.

RESULTS

Fostamatinib co-administration with OC increased exposure to ethinyl estradiol [area under the plasma concentration-time curve at steady state (AUCss) 28% [confidence interval (CI 90%) 21-36]; maximum plasma concentration (Cmax) at steady state (Cmax,ss) 34% (CI 26-43)], but not levonorgestrel (AUCss 5%; Cmax,ss -3%), while exposure to luteinizing hormone and follicle-stimulating hormone decreased (≈ 20%). Fostamatinib did not affect the pharmacokinetics/pharmacodynamics of warfarin to a clinically relevant extent, but caused an upward trend in AUC for both R- and S-warfarin [18% (CI 13-23) and 13% (CI 7-19)]. Fostamatinib increased rosuvastatin AUC by 96% (CI 78-115) and Cmax by 88% (CI 69-110), and increased simvastatin acid AUC by 74% (CI 50-102) and Cmax by 83% (CI 57-113).

CONCLUSION

Fostamatinib exhibits drug-drug interactions when co-administered with OC, simvastatin, or rosuvastatin, with the AUC of statins almost doubling. Fostamatinib did not exhibit a clinically relevant DDI on warfarin.

Effects of CYP3A4 Inhibitors Ketoconazole and Verapamil and the CYP3A4 Inducer Rifampicin on the Pharmacokinetic Parameters of Fostamatinib: Results from In Vitro and Phase I Clinical Studies

BACKGROUND

Fostamatinib (R788) is a spleen tyrosine kinase (SYK) inhibitor. The active metabolite of fostamatinib, R406, is primarily metabolized by CYP3A4.

OBJECTIVES

The aim of this study was to characterize hepatic microsomal metabolism of R406 and confirm the role of CYP3A4 in R406 metabolism, determining whether co-administration of CYP3A4 inhibitors (ketoconazole, verapamil) or inducers (rifampicin) affects R406 pharmacokinetics.

METHODS

R406 stability was determined using human hepatic microsomes. The CYP450 isoforms responsible for R406 metabolism in humans were identified using expressed CYP450 isoforms and specific chemical inhibitors. The ketoconazole interaction study (double-blind, randomized, placebo-controlled, two-period crossover) involved fostamatinib administration (single 80-mg dose), alone and with ketoconazole (200 mg twice daily). The verapamil and rifampicin interaction studies (open-label, two-period, fixed-sequence) involved fostamatinib administration (single 150-mg dose), alone and with immediate-release verapamil (80 mg three times daily) or rifampicin (600 mg once daily). Standard pharmacokinetic parameters were calculated in all studies.

RESULTS/DISCUSSION

Hepatic microsomes showed time-dependent loss of R406 and formation of para-O-demethylated R406. Microsomal metabolism of R406 was markedly inhibited by CYP3A4 inhibitors and, in the expressed CYP450 studies, the rate of R406 disappearance was greatest with CYP3A4. In the clinical studies, co-administration of ketoconazole caused a 2-fold (CI 1.77-2.30) increase in R406 exposure. Verapamil increased R406 exposure (39% increase, CI 8-80), whereas rifampicin co-administration decreased exposure by 75% (CI 68-81). Fostamatinib was well tolerated.

CONCLUSION

The oxidative metabolism of R406 is predominantly catalyzed by CYP3A4. In clinical studies, exposure to R406 is affected by concomitant administration of CYP3A4 inducers/inhibitors. These findings should be taken into account when considering co-prescription of fostamatinib with such agents.

Pharmacotherapy Pearls for the Geriatrician: Focus on Oral Disease-Modifying Antirheumatic Drugs Including Newer Agents

Providing safe and effective pharmacotherapy to the geriatric patients with rheumatological disorders is an ongoing struggle for the rheumatologist and geriatrician alike. Cohesive communication and partnership can improve the care of these patients and subvert adverse outcomes. Disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the newest oral agent for treatment of rheumatoid arthritis, tofacitinib, have distinctive monitoring and adverse effect profiles. This article provides the general practitioner or geriatrician with clinically relevant pearls regarding the use of these interventions in older patients.

Efficacy of a Rheumatoid Arthritis-Specific Smoking Cessation Program: A Randomized Controlled Pilot Trial

OBJECTIVE

Smoking adversely influences comorbidities in rheumatoid arthritis (RA). The aim of this pilot study was to investigate whether smoking cessation is increased following a 3-month smoking cessation intervention tailored for people with RA.

METHODS

Thirty-nine current smokers with RA were recruited. Participants were randomized into the control group to receive the current local standard of care for smoking cessation (i.e., ABC = brief advice and subsidized nicotine replacement therapy [NRT], or into the intervention group to receive ABC plus additional smoking cessation advice for 3 months (ABC+), including face-to-face, telephone, and e-mail contact. Advice was tailored to the participants' specific needs from a range of intervention tools focused on education about smoking and RA, pain control, exercise, coping, and support. The primary outcome was smoking cessation at 6 months. The secondary outcome was sustained reduction in smoking at 6 months. Disease and psychosocial characteristics of quitters and nonquitters were examined.

RESULTS

The overall smoking cessation rate was 24%. There was no significant difference in smoking cessation rates between the ABC and ABC+ groups (21% versus 26%; P = 0.70). The mean number of cigarettes smoked daily was reduced by 44% (P < 0.001) but did not differ between ABC and ABC+ groups (mean reduction 47% versus 41%; P = 0.72). Successful quitters had more years in education and had smoked less across their lifetime, but these differences were not statistically significant.

CONCLUSION

Smoking cessation in RA may lead to a reduced comorbid burden. The lack of added benefit of the tailored intervention suggests that brief advice and NRT are currently the best practice for supporting people with RA who wish to quit smoking.

Polypharmacy and Health-Related Quality of Life Among US Adults With Arthritis, Medical Expenditure Panel Survey, 2010-2012

INTRODUCTION

Our objective was to determine the relationship between polypharmacy (treatment with prescription drugs from 6 or more drug classes concurrently) and health-related quality of life (HRQoL) among US adults with arthritis.

METHODS

We conducted a retrospective cohort study that used 2-year longitudinal data from the Medical Expenditure Panel Survey to analyze a cohort of 6,132 adults aged over 21 years with arthritis. Measures of HRQoL were the summary scores from the mental component summary (MCS) and physical component summary (PCS) of the 12-item short-form health survey. Unadjusted and adjusted regression models were used to evaluate the association between polypharmacy and HRQoL measures. We used SAS, version 9.4, (SAS Institute Inc) to conduct all analyses.

RESULTS

In unadjusted analyses, adults with arthritis taking prescription drugs from 6 or more drug classes concurrently had significantly lower MCS and PCS scores (β, -3.11, P < .001 and β, -10.26, P < .001, respectively) than adults taking prescription drugs from fewer than 6. After controlling for the demographic characteristics, number of mental and physical chronic conditions, and baseline MCS and PCS scores, adults taking prescription drugs from 6 or more drug classes concurrently had significantly lower PCS scores (β, -1.68, P < .001), than those taking prescription drugs from fewer than 6. However, no significant difference in MCS scores was found between adults taking prescription drugs from 6 or more drug classes concurrently and those taking prescription drugs from fewer than 6 (β, -0.27, P = .46).

CONCLUSION

Polypharmacy is significantly associated with lower PCS scores among adults with arthritis. Because polypharmacy can lead to drug-drug and drug-disease interactions, health care providers need to consider the risk and adopt a cautious approach in prescribing multiple drugs to manage chronic conditions and in choosing therapies to improve HRQoL among adults with arthritis.

Targeting Low Disease Activity in Elderly-Onset Rheumatoid Arthritis: Current and Future Roles of Biological Disease-Modifying Antirheumatic Drugs

Elderly rheumatoid arthritis (RA) is classified into two clinical subsets, elderly-onset RA (EORA) and younger-onset elderly RA. With the improvement of life expectancy in the general population and advent of the super-aging society, the number of patients with EORA is anticipated to increase. Both large and small joints are affected initially at onset, and individuals with early EORA have higher scores of disease activity and levels of acute-phase reactants than those with early younger-onset RA. EORA is a progressive disease similar to younger-onset RA. Tumor necrosis factor (TNF) inhibitors are equally or slightly less effective in elderly patients than in younger patients with RA, and disease duration may have a greater impact on disease outcomes than age. Evidence of non-TNF biological disease-modifying antirheumatic drug use in EORA is limited. TNF inhibitors may not increase the risk for infection in elderly patients any more than methotrexate; however, increasing age is an independent and strong risk factor for serious infections in patients with RA. Treatment choice in patients with EORA is strongly influenced by comorbidities, especially cardiovascular disease, chronic lung disease, and frailty. To prevent progression to irreversible geriatric syndromes, non-frail patients with EORA, who are aging successfully should undergo intensive treatment using the treat-to-target strategy, and pre-frail and frail patients with EORA should be treated with the aim of returning to a non-frail or pre-frail stage, respectively. An appropriate treatment strategy for EORA and younger-onset elderly RA should be developed in the next decade using a multi-disciplinary approach.

The impact of multimorbidity status on treatment response in rheumatoid arthritis patients initiating disease-modifying anti-rheumatic drugs

OBJECTIVE

When treating RA patients, remission (REM) or at least low disease activity (LDA) is the ultimate therapeutic goal. The aim of this study was to assess the impact of multimorbidity on achieving REM or LDA.

METHODS

In a prospective RA cohort, we identified patients initiating any DMARD with follow-up data 1 year after. Treatment effects were measured using the clinical disease activity index (CDAI) and the modified health assessment questionnaire (MHAQ); multimorbidity status was assessed using a counted multimorbidity index (cMMI). The proportion of patients reaching REM or LDA 1 year after DMARD commencement with respect to the cMMI was evaluated. In regression models, we calculated the odds ratio of achieving REM or LDA, and predicted CDAI and MHAQ 1 year after DMARD commencement for various levels of cMMI, adjusting for age, sex, disease duration, serostatus, disease activity at DMARD commencement, number of previous DMARDs, and type of DMARD, steroid and NSAID use.

RESULTS

A total of 815 patients started DMARDs; 414 were on the same DMARD after 1 year. The proportion of these patients achieving REM or LDA after 1 year was significantly lower in the patients with higher cMMI, following a linear trend (P < 0.01). After accounting for covariates, the odds ratio for REM associated with each additional morbidity in the cMMI was 0.72 (95% CI 0.55, 0.97) and 0.81 (95% CI 0.70, 0.94) for LDA. One year after DMARD initiation, CDAI (+0.16 per additional morbidity) and MHAQ scores (+0.15 per additional morbidity) were significantly worse (both P < 0.05).

CONCLUSION

Increased multimorbidity negatively affects the therapeutic goal of REM and LDA.

Developing a Tailored Smoking Cessation Intervention for Rheumatoid Arthritis Patients

PURPOSE

Smoking is associated with an increased risk of comorbidities in rheumatoid arthritis (RA) and may reduce the efficacy of anti-rheumatic therapies. Smoking cessation is therefore an important goal in RA. Our previous qualitative research identified five RA-related barriers to smoking cessation: lack of support; limited knowledge of the relationship between smoking and RA; uncontrolled pain; inability to exercise; and using smoking as a coping strategy. The aim of this article is to describe the process of developing a smoking cessation intervention for RA patients based on these themes.

METHODS

A comprehensive review of the literature on smoking cessation was undertaken. A tailored smoking cessation programme was designed to address each RA-specific barrier. A meeting was convened with key staff of Arthritis New Zealand to develop a consensus on feasible design to deliver a smoking cessation programme based on existing best practice and smoking cessation resources, and tailored within existing Arthritis New Zealand service delivery frameworks.

RESULTS

A three-month intervention was designed to be delivered by trained arthritis educators, with the following key components: nicotine replacement therapy for eight weeks; a telephone or face-to-face interview with each patient to determine their individual specific RA-related barriers to smoking cessation; and individualized education and support activities which addressed these barriers. The intervention also included three follow-up telephone calls; a support website; and 12 weekly smoking cessation advice emails.

CONCLUSIONS

A RA-specific smoking cessation invention was developed, matching support to specific issues within each patient's experience. A pilot study is in progress to evaluate the programme's efficacy. Copyright © 2015 John Wiley & Sons, Ltd.

Muscle wasting in rheumatoid arthritis: The role of oxidative stress

Rheumatoid arthritis (RA), the commonest inflammatory arthritis, is a debilitating disease leading to functional and social disability. In addition to the joints, RA affects several other tissues of the body including the muscle. RA patients have significantly less muscle mass compared to the general population. Several theories have been proposed to explain this. High grade inflammation, a central component in the pathophysiology of the disease, has long been proposed as the key driver of muscle wasting. More recent findings however, indicate that inflammation on its own cannot fully explain the high prevalence of muscle wasting in RA. Thus, the contribution of other potential confounders, such as nutrition and physical activity, has also been studied. Results indicate that they play a significant role in muscle wasting in RA, but again neither of these factors seems to be able to fully explain the condition. Oxidative stress is one of the major mechanisms thought to contribute to the development and progression of RA but its potential contribution to muscle wasting in these patients has received limited attention. Oxidative stress has been shown to promote muscle wasting in healthy populations and people with several chronic conditions. Moreover, all of the aforementioned potential contributors to muscle wasting in RA (i.e., inflammation, nutrition, and physical activity) may promote pro- or anti-oxidative mechanisms. This review aims to highlight the importance of oxidative stress as a driving mechanism for muscle wasting in RA and discusses potential interventions that may promote muscle regeneration via reduction in oxidative stress.

Comorbidities are associated with poorer outcomes in community patients with rheumatoid arthritis

OBJECTIVE

To evaluate the impact of comorbidities on achieving remission by examining changes in the clinical disease activity index (CDAI) in RA patients in the community-based Consortium of Rheumatology Researchers of North America (CORRONA) registry.

METHODS

A subcohort of 1548 RA subjects with varying disease duration met the following inclusion criteria: started a DMARD/biologic agent, continued therapy ≥ 3 months, CDAI ≥ 2.8 at study entry and followed longitudinally from baseline to follow-up (mean time 7.46 months). Patients reported comorbidities according to a standardized list of 33 conditions. Entry characteristics were compared across age categories using one-way analysis of variance. Linear and logistic regression models were constructed to assess characteristics [e.g. age, disease duration, number of previous DMARDs/biologics, baseline modified health assessment questionnaire (MHAQ), baseline CDAI and number of comorbidities] associated with primary outcomes: change in CDAI (baseline to follow-up) and CDAI remission (yes/no).

RESULTS

Although disease activity measures at entry were similar across age categories, older patients had more comorbidities, less improvement in CDAI/MHAQ and were less likely to attain remission at follow-up. However, after adjusting covariates an increasing number of patient-reported comorbidities and higher baseline CDAI (but not age) were consistently and independently associated with a lower likelihood of clinical improvement or remission (P < 0.001).

CONCLUSION

In this observational cohort of community RA patients an increasing number of patients reported comorbidities, independently correlated with less CDAI improvement over time. These results reaffirm that comorbidities may be an important factor in consideration of treat-to-target recommendations and aid in understanding achievable RA therapeutic goals.

Inflammatory arthritis as a novel risk factor for cardiovascular disease

Cardiovascular disease (CVD) comorbidity is a significant issue for the inflammatory arthritides (IA). There is a wealth of mortality studies showing increased cardiovascular mortality in rheumatoid arthritis (RA) and the evidence suggests that the same is likely to be true of psoriatic arthritis (PsA) and ankylosing spondylitis (AS). CVD co-morbidity is due to ischaemic pathologies driven by accelerated atherosclerosis and relates to the increased prevalence and clustering of classical risk factors, which may also be affected by treatments for IA, and their interplay with novel risk factors, namely systemic inflammation. Currently we are unable to quantify the contribution that classical and novel risk factors make to an individuals' CVD risk and specific algorithms need to be developed and validated in RA, PsA and AS to facilitate clinical management. Furthermore, large clinical trials are required to assess the effect of lifestyle modifications, primary prevention strategies and effective immunosuppression on hard CVD endpoints. However, in the meantime, a pragmatic approach should be adopted towards CVD risk management. Consensus opinion has generated guidelines for the management of CVD risk in IA and we discuss the importance of assessing each individual for CVD risk and establishing a system for routine risk factor identification alongside a commitment to treat identified risk factors to specific targets.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Disease activity and low physical activity associate with number of hospital admissions and length of hospitalisation in patients with rheumatoid arthritis

INTRODUCTION

Substantial effort has been devoted for devising effective and safe interventions to reduce preventable hospital admissions in chronic disease patients. In rheumatoid arthritis (RA), identifying risk factors for admission has important health policy implications, but knowledge of which factors cause or prevent hospital admissions is currently lacking. We hypothesised that disease activity/severity and physical activity are major predictors for the need of hospitalisation in patients with RA.

METHODS

A total of 244 RA patients were assessed for: physical activity (International Physical Activity Questionnaire), RA activity (C-reactive protein: CRP; disease activity score: DAS28) and disability (Health Assessment Questionnaire: HAQ). The number of hospital admissions and length of hospitalisation within a year from baseline assessment were collected prospectively.

RESULTS

Disease activity and disability as well as levels of overall and vigorous physical activity levels correlated significantly with both the number of admissions and length of hospitalisation (P < 0.05); regression analyses revealed that only disease activity (DAS28) and physical activity were significant independent predictors of numbers of hospital admissions (DAS28: (exp(B) = 1.795, P = 0.002 and physical activity: (exp(B) = 0.999, P = 0.046)) and length of hospitalisation (DAS28: (exp(B) = 1.795, P = 0.002 and physical activity: (exp(B) = 0.999, P = 0.046). Sub-analysis of the data demonstrated that only 19% (n = 49) of patients engaged in recommended levels of physical activity.

CONCLUSIONS

This study provides evidence that physical activity along with disease activity are important predictors of the number of hospital admissions and length of hospitalisation in RA. The combination of lifestyle changes, particularly increased physical activity along with effective pharmacological therapy may improve multiple health outcomes as well as cost of care for RA patients.

Making the rheumatologist aware of patients' non-adherence does not improve medication adherence in patients with rheumatoid arthritis

OBJECTIVES

We have developed an instrument that provides the physician structured information about medication use and patients' (non-)adherence. This study aimed to determine the effectiveness of this instrument on adherence and medication beliefs in outpatients with rheumatoid arthritis (RA).

METHODS

In this within-subject controlled prospective cohort study, 50 outpatients were assessed during three consecutive visits to their rheumatologist. At these three points in time, patients' adherence, medication beliefs, satisfaction about information about medication, and physical functioning were measured using validated self-report questionnaires. An intervention was scheduled during the second visit. The intervention consisted of a written report informing the physician about medication use and adherence to medication for each patient. The effectiveness of the intervention was evaluated by comparing outcome measures at the third visit to the same measures assessed prior to the intervention.

RESULTS

At baseline, 30% of the patients (n = 50) were non-adherent. No significant changes in adherence were found between the first and second visit prior to the intervention. Adherence did not change after the intervention, compared to both of the adherence assessments prior to the intervention. Beliefs about medication, patients' satisfaction about information on medication, and physical functioning were also not significantly altered.

CONCLUSION

Supplying the rheumatologist a report with information about medication use and adherence did not change adherence or patients' beliefs about medication. Further research is necessary to ensure effective support for adherence for individual patients with RA.

Galectin-2 (LGALS2) 3279C/T polymorphism may be independently associated with diastolic blood pressure in patients with rheumatoid arthritis

The galectin-2 (LGALS2) 3279 C/T single nucleotide polymorphism (SNP) has recently been associated with myocardial infarction (MI). Although hypertension, a very prevalent entity in rheumatoid arthritis (RA), is one of the greatest risk factors for MI, the possible association of LGALS2 3279 C/T and hypertension has not been investigated. We genotyped 386 RA patients, 272 hypertensives and 114 normotensives. Diastolic blood pressure (DBP) was significantly lower in TT compared to CC homozygotes (-4.11 mmHg, p = 0.044) even when adjusted for multiple confounders (-4.28 mmHg, p = 033). Further studies are required to replicate the potential association of LGALS2 3279 C/T with DBP, and examine whether this SNP could be used as a marker of increased risk for future cardiovascular events in RA populations.

Hypertension in rheumatoid arthritis

RA associates with an increased burden of cardiovascular disease, which is at least partially attributed to classical risk factors such as hypertension (HT) and dyslipidaemia. HT is highly prevalent, and seems to be under-diagnosed and under-treated among patients with RA. In this review, we discuss the mechanisms that may lead to increased blood pressure in such patients, paying particular attention to commonly used drugs for the treatment of RA. We also suggest screening strategies and management algorithms for HT, specific to the RA population, although it is clear that these need to be formally assessed in prospective randomized controlled trials designed specifically for the purpose, which, unfortunately, are currently lacking.