Successfully living with chronic arthritis

Therapeutic advances in rheumatoid arthritis

Rheumatoid arthritis (RA) is one of the most common immune mediated inflammatory diseases. People with rheumatoid arthritis present with pain, swelling, and stiffness that typically affects symmetrically distributed small and large joints. Without effective treatment, significant joint damage, disability, and work loss develop, owing to chronic inflammation of the joint lining (synovium). Over the past 25 years, the management of this condition has been revolutionized, resulting in substantially higher levels of disease remission and better long term outcomes. This improvement reflects a paradigm shift towards early and aggressive pharmacological intervention coupled with a proliferation in treatment choice, in turn related to enhanced pathobiological understanding and the advent of new drugs for rheumatoid arthritis. Following an overview of these developments from a historical perspective, and with a general audience in mind, this review focuses on newer, targeted treatments in an ever evolving landscape. The review highlights ongoing areas of debate and unmet need, including the proportion of patients with persistent, difficult-to-treat disease, despite recent advances. Also discussed are personalized, strategic approaches to individual patients, the role for imaging in clinical decision making, and the goal of sustained, drug free remission and disease prevention in the future.

Evaluation of a multidisciplinary care model to improve quality of life in rheumatoid arthritis: a randomised controlled trial

BACKGROUND AND PURPOSE

Health-Related Quality of Life (HR-QOL) is an important patient-reported domain in patients with rheumatoid arthritis (RA). The uptake of multidisciplinary team (MDT) care in RA is generally low, due to initial high demand for resources. We hypothesised that whilst pharmacological treatments are effective in controlling disease activity, a multipronged intervention in an MDT may have a positive impact on HR-QOL.

METHODS

This was a single-centre randomized parallel group, single-blind controlled trial of MDT vs. usual care in an established RA clinic. Data were collected through face-to-face questionnaires, medical records review, and joint counts by a blinded assessor at 0, 3 and 6 months. Adult RA patients were randomly assigned in a single visit to a 6-member MDT (rheumatologist, nurse, social worker, physiotherapist, occupational therapist, and podiatrist) or usual care. MDT providers prescribed medications and counselled patients on managing flares, medication adherence, coping, joint protection, exercise, footwear. The primary outcome was minimal clinically important difference (MCID) in HR-QOL (increase in European QOL-5-Dimension-3-Level, EQ-5D-3L by 0.1) at six months.

RESULTS

140 patients (86.3% female, 53.4% Chinese, median (IQR) age 56.6 (46.7, 62.4) years); 70 were randomized to each arm. Median (IQR) disease duration was 5.5 (2.4, 11.0) years and disease activity in 28 joints (DAS28) was 2.87 (2.08, 3.66). 123 patients completed the study. Twenty-six (40.6%) MDT vs. 23 (34.3%) usual care patients achieved an MCID in EQ-5D-3L, OR 1.3 (0.6, 2.7). In multivariable logistic regression, baseline EQ-5D-3L was the only predictor of achieving MCID. There was more disease modifying anti-rheumatic drug escalation in MDT (34.4% vs. 19.4%). Patients with high disease activity were more likely to achieve MCID in the MDT arm.

CONCLUSIONS

A single visit by stable patients with low disease activity to an MDT failed to achieve MCID in the EQ-5D-3L; however, did achieve small but significant improvements in the EQ-5D-3L, DAS28, pain, coping and self-efficacy. To be sustainable, MDT care should be targeted at patients with high disease activity or those with a new diagnosis of RA.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov, identifier: NCT03099668.

Transdermal delivery of fluvastatin sodium via tailored spanlastic nanovesicles: mitigated Freund's adjuvant-induced rheumatoid arthritis in rats through suppressing p38 MAPK signaling pathway

The current study aimed to encapsulate fluvastatin sodium (FVS), a member of the statins family possessing pleiotropic effects in rheumatoid arthritis (RA), into spanlastic nanovesicles (SNVs) for transdermal delivery. This novel delivery could surmount FVS associated oral encumbrances such as apparent first-pass effect, poor bioavailability and short elimination half-life, hence, accomplishing platform for management of RA. To consummate this objective, FVS-loaded SNVs were elaborated by thin film hydration method, utilizing either Span 60 or Span 80, together with Tween 80 or Brij 35 as an edge activator according to full factorial design (2⁴). Applying Design-Expert^® software, the influence of formulation variables on SNVs physicochemical properties and the optimized formulation selection were explored. Additionally, the pharmacokinetic studies were scrutinized in rats. Furthermore, in Freund's adjuvant-induced arthritis, rheumatoid markers, TNF-α, IL-10, p38 MAPK, and antioxidant parameters were measured. The optimum SNVs were nano-scaled spherical vesicles (201.54 ± 9.16 nm), having reasonable entrapment efficiency (71.28 ± 2.05%), appropriate release over 8 h (89.45 ± 3.64%) and adequate permeation characteristics across the skin (402.55 ± 27.48 µg/cm²). The pharmacokinetic study disclosed ameliorated bioavailability of the optimum SNVs gel by 2.79- and 4.59-fold as compared to the oral solution as well as the traditional gel, respectively. Moreover, it elicited a significant suppression of p38 MAPK expression and also significant improvement of all other measured biomarkers. Concisely, the foregoing findings proposed that SNVs can be auspicious for augmenting FVS transdermal delivery for management of RA.

Development of generic core competences of health professionals in rheumatology: a systematic literature review informing the 2018 EULAR recommendations

Objective

To identify generic competences on the desired knowledge, skills and of health professionals in rheumatology (HPRs) to inform the respective EULAR recommendations.

Methods

A systematic literature review was performed on the generic core competences (defined as knowledge, skills or attitudes) of HPRs (nurses, physical therapists (PTs) or occupational therapists (OTs)). Literature was obtained from electronic databases, published EULAR recommendations and via personal communication with representatives of national rheumatology societies and experts in the field. Qualitative, quantitative and mixed methods studies were included, and their methodological quality was scored using appropriate instruments.

Results

From 766 references reviewed, 79 fulfilled the inclusion criteria. Twenty studies addressed competences of multiple HPRs: 15 were of qualitative design, 1 quantitative, 1 mixed-methods, 2 systematic reviews and 1 opinion paper. The methodological quality of most studies was medium to high. Five studies concerned the development of a comprehensive set of competences. Key competences included: basic knowledge of rheumatic diseases, holistic approach to patient management, effective communication with colleagues and patients and provision of education to patients. The proposed competences were confirmed in studies focusing on one or more specific competences, on a rheumatic disease or on a specific profession (nurses, PTs or OTs).

Conclusion

Generic competences were identified for HPRs. Data were mostly derived from qualitative studies. All identified studies varied and were at national level, highlighting the need for the harmonisation of HPR competences across Europe. These findings underpin the development of EULAR recommendations for the core competences of HPRs.

2019 EULAR recommendations for the generic core competences of health professionals in rheumatology

Background/objectives

To maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education.

Methods

The EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0–10 rating scale).

Results

Three overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda.

Conclusion

Evidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.

Effects of off-the-shelf foot orthoses on plantar foot pressures in patients with early rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) often affects feet with progressive pathologic changes to foot morphology and pressure distribution. Studies in RA suggest that reductions in forefoot peak pressures can reduce pain. We investigated the effects of off-the-shelf foot orthoses on plantar foot pressures in patients with early RA.

METHODS

Thirty-five patients with early RA were recorded walking. Variables measured were forefoot peak plantar pressure (PPPft), forefoot pressure-time integral (PTIft), and hallux and lesser toe and midfoot contact areas. Patients were analyzed while walking barefoot, with shoes, and with shoes and foot orthoses. Measurements were taken at baseline and at 3 and 6 months.

RESULTS

There were significantly increased PPPft values between barefoot and shod and between barefoot and orthoses (P < .01). However, there was a significant reduction in PPPft during the 6 months with orthoses compared with shoes only (P < .01). Foot orthoses significantly reduced PTIft over 6 months (P < .01). Results also demonstrated a significant increase in hallux and lesser toe (P < .01) and midfoot (P < .01) contact areas during the 6 months with foot orthoses.

CONCLUSIONS

In patients with early RA, off-the-shelf foot orthoses cause a significant reduction of 22% in PPPft and 14% in PTIft as soon as insoles are worn compared with shod. Further reductions for orthoses compared with baseline were found by 3 months (15% in PPPft and 14% in PTIft) and 6 months (33% in PPPft and 33% in PTIft). These findings could contribute to reductions in foot pain.

Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalisation

PURPOSE

To present a systematic literature review on the state of the art of the utilisation of the International Classification of Functioning, Disability and Health (ICF) since its release in 2001.

METHOD

The search was conducted through EMBASE, MEDLINE and PsychInfo covering the period between 2001 and December 2009. Papers were included if ICF was mentioned in title or abstract. Papers focussing on the ICF-CY and clinical research on children and youth only were excluded. Papers were assigned to six different groups covering the wide scenario of ICF application.

RESULTS

A total of 672 papers, coming from 34 countries and 211 different journals, were included in the analysis. The majority of publications (30.8%) were conceptual papers or papers reporting clinical and rehabilitation studies (25.9%). One-third of the papers were published in 2008 and 2009.

CONCLUSIONS

The ICF contributed to the development of research on functioning and on disability in clinical, rehabilitation as well as in several other contexts, such as disability eligibility and employment. Diffusion of ICF research and use in a great variety of fields and scientific journals is a proof that a cultural change and a new conceptualisation of functioning and disability is happening.

Comparison of AIMS2-SF, WOMAC, x-ray and a global physician assessment in order to approach quality of life in patients suffering from osteoarthritis

Background

Chronic diseases like osteoarthritis (OA) substantially affect different dimensions of quality of life (QoL). The aim of the study was to reveal possible factors which mainly influence general practitioners (GPs) assessment of patients' QoL.

Methods

220 primary care patients with OA of the knee or the hip treated by their general practitioner for at least one year were included. All GPs were asked to assess patients' QoL based on the patients' history, actual examination and existing x-rays by means of a visual analog scale (VAS scale), resulting in values ranging from 0 to 10. Patients were asked to complete the McMaster Universities Osteoarthritis Index (WOMAC) and the Arthritis Impact Measurement Scale2 Short Form (AIMS2-SF) questionnaire.

Results

Significant correlations were revealed between "GP assessment" and the AIMS2-SF scales "physical" (rho = 0.495) and "symptom" (rho = 0.598) as well as to the "pain" scale of the WOMAC (rho = 0.557). A multivariate ordinal regression analysis revealed only the AIMS2-SF "symptom" scale (coefficient beta = 0.2588; p = 0.0267) and the x-ray grading according to Kellgren and Lawrence as significant influence variables (beta = 0.6395; p = 0.0004).

Conclusion

The results of the present study suggest that physicians' assessment of patients' QoL is mainly dominated by physical factors, namely pain and severity of x-ray findings. Our results suggest that socioeconomic and psychosocial factors, which are known to have substantial impact on QoL, are underestimated or missed. Moreover, the overestimation of x-ray findings, which are known to be less correlated to QoL, may cause over-treatment while important and promising targets to increase patients' QoL are missed.