Abnormal high-expression of CD154 on T lymphocytes of ankylosing spondylitis patients is down-regulated by etanercept treatment

No Evidence of a Genetic Causal Relationship between Ankylosing Spondylitis and Gut Microbiota: A Two-Sample Mendelian Randomization Study

Objective: Ankylosing spondylitis (AS) is associated with a variety of gut microbiotas. We aim to analyze the causal relationship between the two at the genetic level. Methods: Mendelian randomization (MR) is a type of instrumental variables (IVs) analysis; MR follows the Mendelian genetic rule of "parental alleles are randomly assigned to offspring" and takes genetic variation as IVs to infer the causal association between exposure factors and study outcome in observational studies. Genome-wide association study (GWAS) summary data of AS were from the FinnGen consortium, and the gut microbiota (Bacteroides, Streptococcus, Proteobacteria, Lachnospiraceae) were from the MiBioGen consortium. The TwoSampleMR and MRPRESSO packages of the R were used to perform a two-sample MR study. Random-effects inverse variance weighted (IVW) was the main analysis method, and MR Egger, weighted median, simple mode, and weighted mode were used as supplementary methods. We examined heterogeneity and horizontal pleiotropy, and examined whether the analysis results were influenced by a single SNP. We applied radial variants of the IVW and MR-Egger model for the improved visualization of the causal estimate. We further examined the causal relationship between AS and gut microbiota, and the robustness of the analysis results. Finally, we performed maximum likelihood, penalized weighted median, and IVW (fixed effects) to further identify the potential causal association. Results: The random-effects IVW results showed that Bacteroides (p = 0.965, OR 95% confidence interval [CI] = 0.990 [0.621-1.579]), Streptococcus (p = 0.591, OR 95% CI = 1.120 [0.741-1.692]), Proteobacteria (p = 0.522, OR 95% CI = 1.160 [0.737-1.826]), and Lachnospiraceae (p = 0.717, OR 95% CI = 1.073 [0.732-1.574]) have no genetic causal relationship with AS. There was no heterogeneity, horizontal pleiotropy or outliers, and results were normally distributed. The MR analysis results were not driven by a single SNP. Conclusions: This study showed that Bacteroides, Streptococcus, Proteobacteria and Lachnospiraceae, four common gut microbiotas associated with AS, had no causal relationship with AS at the genetic level. This study makes a positive contribution to the genetics of AS, but the insufficient number of gut microbiota included is a limitation.

Satisfaction of Patients and Physicians with Treatments for Rheumatoid Arthritis: A Population-Based Survey in China

PURPOSE

Rheumatoid arthritis (RA) is a systemic inflammatory disease characterized by chronic destructive synovitis and possible multisystem involvement. This study aimed to survey the treatment satisfaction of physicians and patients with RA, and to explore the potential factors.

PATIENTS AND METHODS

This cross-sectional study was conducted in 12 centers across China between March 2018 and April 2018. The Treatment Satisfaction Questionnaire for Medication version II was used to assess the treatment satisfaction of patients and physicians. Multivariable regression analysis was used to determine the factors independently associated with treatment satisfaction of patients.

RESULTS

The patients' satisfaction (n=335) with biological disease-modifying antirheumatic drugs (bDMARDs) was higher than physicians' satisfaction (n=146) regarding the side effects (95.0±14.3 vs 84.6±15.7, P<0.001) and convenience (74.6±21.2 vs 69.1±16.5, P=0.002). Among physicians, global satisfaction with bDMARDs was higher than that with conventional synthetic DMARDs (csDMARDs). The multivariable regression analysis showed that age was positively associated with satisfaction of patients, while college or above education and self-assessment of disease severity were inversely associated with satisfaction. Treatment satisfaction was associated positively with the quality of communication with the physician and inversely with treatment costs.

CONCLUSION

For bDMARDs, the treatment satisfaction of patients with RA is generally higher than that of physicians'. Physicians' satisfaction with bDMARDs is higher than with csDMARDs. Age, education, disease severity, communication with the physician, and treatment costs are independently associated with the treatment satisfaction among patients. Physician-patient communication should be improved in clinical practice. Treatment costs should be taken into account when physicians make decisions.

Model-Based Meta-Analysis in Ankylosing Spondylitis: A Quantitative Comparison of Biologics and Small Targeted Molecules

Information on the comparative efficacy is important for drug development as well as drug therapy. Up to now, the relative efficacy of approved biologics and many agents under investigation in ankylosing spondylitis (AS) are still unclear. The objective of this study was to quantify the relative efficacy and time course of various treatments measured by the Ankylosing Spondylitis Assessment Study group response criteria 20 scores (ASAS20), change from baseline in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Bath Ankylosing Spondylitis Functional Index (BASFI). There were 34 double-blinded trials of 10 biologics and small molecules encompassing 5,339 patients with AS were included in this analysis. Three mathematical models with nonparametric placebo estimations were used to describe the longitudinal profile for the above three efficacy measures. The results detected significant differences among included treatments, and infliximab and golimumab were found to have the highest efficacy in given dosage regimens across all measures.

Tumor necrosis factor-α blockade treatment decreased CD154 (CD40-ligand) expression in rheumatoid arthritis

Contexts

CD154 (commonly referred to as CD40-ligand) is a critical T cell factor that participates in the pathogenesis of autoimmune and is over-expressed in rheumatoid arthritis (RA). TNF-α blockade treatment had dramatic efficacy in RA.

Objective

To investigate whether TNF-α blockade treatment can inhibit CD154 expression in RA.

Methods

Blood samples were collected from 33 patients with rheumatoid arthritis before and 3 months after TNF-α blockade treatment. Clinical serological data determined by standard assays and T cell CD154 expression levels determined by flow cytometry were statistically analyzed for these two time points.

Results

The percentage of CD154 expression on gated CD4+ T cells of PBMCs from RA patients after 3 months TNF-α blockade treatment was significantly lower than before treatment (2.94 ± 3.21% vs. 7.21 ± 5.64%; p = 0.0001). The disease activity and anti-CCP antibody levels were also significantly reduced after TNF-α blockade treatment. The CD154 expression levels were positively correlated with disease activity index DAS28, and CRP. The post-stimulated CD154 expression percentage of purified CD4+ T cells between baseline and after TNF-α blockade treatment was not significantly different (p = 0.221). Baseline CD154 levels were positively correlated with treatment-induced changes in DAS28 (p = 0.014; r2 = 0.187).

Conclusions

TNF-α blockade treatment significantly decreased the CD154 expression on CD4+ T cells, disease activity and anti-CCP antibody simultaneously in RA patients. However TNF-α blockade did not impair T cell capacity to express CD154 after stimulation. These results suggest that decreased CD154 expression after TNF-α blockade may be due to decreased RA disease activity but not direct inhibition of CD154 responsiveness of T cells.

Possible predictors for relapse from etanercept discontinuation in ankylosing spondylitis patients in remission: a three years' following-up study

The aim of this study is to assess the recurrence probability and the possible predictors in patients with ankylosing spondylitis from etanercept discontinuation in a 3-year observational cohort ( ClinicalTrials.gov : NCT02915354). A cohort of 35 patients who achieved an ASAS 20 response at the end of a randomized controlled trial underwent a 3-year follow-up evaluation. The primary end point was clinical relapse defined as the BASDAI score going back to 80% of its initial level at the beginning of the trial. Prognostic factors of relapse were analyzed using the Cox regression. Median duration of clinical remission was 15.0 months (interquartile range, 3.7-26.3 months). The cumulative probabilities of relapse at 1, 2, and 3 years were 45.7, 57.1, and 60.0%, respectively. The proportion of recurrence was not significantly different between placebo group and etanercept group by Kaplan-Meier analysis (placebo vs. etanercept: 61.11 vs. 58.82%, P = 0.890). Two independent factors associated with increasing risk of relapse were (1) age of patients (25 years or older with risk of 3.07, 95% confidence interval, 1.19-7.97, P = 0.021); (2) onset age (younger than 24 years with risk of 3.12, 95% confidence interval, 1.24-7.83, P = 0.016). No correlation was observed in the present study between the time of relapse and the duration of the treatment with etanercept in AS patients who achieved the ASAS 20 response after receiving the treatment. The older age and younger onset age of patients seems to be important factors associate with an increasing risk of relapse.

DOSAGE AND DURATION OF ETANERCEPT THERAPY FOR ANKYLOSING SPONDYLITIS: A META-ANALYSIS

Objectives: We conducted a meta-analysis of recently published randomized controlled trials (RCTs) to identify the most effective and safe etanercept dosing regimen and duration of therapy for the treatment of patients with ankylosing spondylitis (AS).

Methods: We systematically reviewed PubMed, Embase, Cochrane Library, and Web of Science databases for RCTs. The proportion of patients attaining 20 percent improvement (according to the Spondyloarthritis International Society response criteria [ASAS 20]) was evaluated as a primary outcome. Secondary outcomes included 50 percent increase in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI 50) used for evaluating efficacy, as well as the BASDAI/Bath Ankylosing Spondylitis Functional Index (BASFI) scores and adverse events.

Results: ASAS 20 indicated that the efficacy of etanercept did not differ amongst dosing regimens (25 mg twice-weekly versus 50 mg once-weekly: relative risk [RR], 2.18, 95 percent confidence interval [CI], 1.78–2.67 versus RR, 2.00, 95 percent CI, 1.70–2.37). The ASAS 20 reported subgroup differences among treatment durations of less than 12 weeks (RR, 2.70; 95 percent CI, 2.09–3.49); 12 weeks (RR, 1.74; 95 percent CI, 1.37–2.22); and more than 12 weeks (RR, 2.56; 95 percent CI, 1.88–3.48). Other outcomes included BASDAI, BASDAI 50, and BASFI. Drug safety differed according to the treatment regimen and duration.

Conclusion: Our meta-analysis found that there was no significant efficacy difference between 50 mg once-weekly and 25 mg twice-weekly dosing for the treatment of AS, and a dosing duration of less than 12 weeks was more effective for treating AS patients.

The comparative safety of tumor necrosis factor inhibitors in rheumatoid arthritis: a meta-analysis update of 44 trials

OBJECTIVE

The study objective was to evaluate and update the safety data from randomized controlled trials of tumor necrosis factor inhibitors in patients treated for rheumatoid arthritis.

METHODS

A systematic literature search was conducted from 1990 to May 2013. All studies included were randomized, double-blind, controlled trials of patients with rheumatoid arthritis that evaluated adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab treatment. The serious adverse events and discontinuation rates were abstracted, and risk estimates were calculated by Peto odds ratios (ORs).

RESULTS

Forty-four randomized controlled trials involving 11,700 subjects receiving tumor necrosis factor inhibitors and 5901 subjects receiving placebo or traditional disease-modifying antirheumatic drugs were included. Tumor necrosis factor inhibitor treatment as a group was associated with a higher risk of serious infection (OR, 1.42; 95% confidence interval [CI], 1.13-1.78) and treatment discontinuation due to adverse events (OR, 1.23; 95% CI, 1.06-1.43) compared with placebo and traditional disease-modifying antirheumatic drug treatments. Specifically, patients taking adalimumab, certolizumab pegol, and infliximab had an increased risk of serious infection (OR, 1.69, 1.98, and 1.63, respectively) and showed an increased risk of discontinuation due to adverse events (OR, 1.38, 1.67, and 2.04, respectively). In contrast, patients taking etanercept had a decreased risk of discontinuation due to adverse events (OR, 0.72; 95% CI, 0.55-0.93). Although ORs for malignancy varied across the different tumor necrosis factor inhibitors, none reached statistical significance.

CONCLUSIONS

These meta-analysis updates of the comparative safety of tumor necrosis factor inhibitors suggest a higher risk of serious infection associated with adalimumab, certolizumab pegol, and infliximab, which seems to contribute to higher rates of discontinuation. In contrast, etanercept use showed a lower rate of discontinuation. These data may help guide clinical comparative decision making in the management of rheumatoid arthritis.

Etanercept in the treatment of ankylosing spondylitis: A systematic review and meta-analysis

Etanercept (ETN) has been widely applied in the treatment of ankylosing spondylitis (AS). As the use of ETN has increased, associated adverse effects have been reported frequently. Previous meta-analyses have focused on comparing the differences in clinical outcomes between ETN and placebo (PBO). The present meta-analysis evaluated randomised controlled trials (RCTs) to compare the effects of ETN and a PBO or sulfasalazine (SSZ) in patients with AS. The study population characteristics and the main results, including the Assessment in AS 20% response (ASAS 20), the Bath AS Disease Activity Index (BASDAI) and the Bath AS Functional Index (BASFI), were extracted. The pooled odds ratios (ORs) or weighted mean differences (MDs) were calculated using a fixed or random effects model. Fifteen randomised controlled trials (RCTs) involving 2,194 subjects were included. Compared with a PBO, ETN significantly improved the ASAS 20 [P<0.00001; OR, 8.25; 95% confidence interval (CI), 5.92–11.50], BASDAI (P<0.00001; MD, −18.81; 95% CI, −24.47 to −13.15) and BASFI (P<0.00001; standard MD, −0.68; 95% CI, −0.85 to −0.50). In comparison with SSZ, ETN significantly decreased the BASDAI (P<0.00001; MD, −2.40; 95% CI, −2.89 to −1.90) and C-reactive protein (CRP) levels (P<0.0001; MD, −8.01; 95% CI, −11.73 to −4.29). The most common adverse effect of ETN was an injection site reaction. This meta-analysis shows that ETN monotherapy is effective in improving physical function and reducing disease activity in patients with AS. Compared with SSZ, ETN markedly decreased the BASDAI and CRP levels. However, the efficacy of ETN in treating AS requires further evaluation by more RCTs in a larger population of patients prior to recommending ETN as a substitute for synthetic disease-modifying antirheumatic drug (DMARD) monotherapy, or combinations of synthetic DMARDs.