1
|
Avalos-Salgado FA, Gonzalez-Lopez L, Gonzalez-Vazquez S, Ponce-Guarneros JM, Santiago-Garcia AP, Amaya-Cabrera EL, Arellano-Cervantes R, Gutiérrez-Aceves JA, Alcaraz-Lopez MF, Nava-Valdivia CA, Gonzalez-Ponce F, Rodriguez-Jimenez NA, Macias-Islas MA, Valdivia-Tangarife ER, Saldaña-Cruz AM, Cardona-Muñoz EG, Gamez-Nava JI. Risk Factors Associated with Adverse Events Leading to Methotrexate Withdrawal in Elderly Rheumatoid Arthritis Patients: A Retrospective Cohort Study. J Clin Med 2024; 13:1863. [PMID: 38610627 PMCID: PMC11012848 DOI: 10.3390/jcm13071863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Rheumatoid arthritis (RA) in elderly population represents a challenge for physicians in terms of therapeutic management. Methotrexate (MTX) is the first-line treatment among conventional synthetic-disease-modifying anti-rheumatic drugs (cs-DMARDs); however, it is often associated with adverse events (AEs). Therefore, the objective of this study was to identify the incidence and risk factors of MTX discontinuation due to AEs in elderly patients with RA in a long-term retrospective cohort study. Methods: Clinical sheets from elderly RA patients taking MTX from an outpatient rheumatology consult in a university centre were reviewed. To assess MTX persistence, we used Kaplan-Meir curves and Cox regression models to identify the risk of withdrawing MTX due to adverse events. Results: In total, 198 elderly RA patients who reported using MTX were included. Of them, the rates of definitive suspension of MTX due to AEs were 23.0% at 5 years, 35.6% at 10 years and 51.7% at 15 years. The main organs and system involved were gastrointestinal (15.7%) and mucocutaneous (3.0%). Factors associated with withdrawing MTX due to AEs were MTX dose ≥ 15 mg/wk (adjusted HR: 2.46, 95% CI: 1.22-4.96, p = 0.012); instead, the folic acid supplementation was protective for withdrawal (adjusted HR: 0.28, 95% CI: 0.16-0.49, p < 0.001). Conclusions: Higher doses of MTX increase the risk of withdrawals in elderly RA, while folic acid supplementation reduces the risk. Therefore, physicians working in therapeutic management for elderly patients using MTX must focus on using lower MTX doses together with the concomitant prescription of folic acid.
Collapse
Affiliation(s)
- Felipe Alexis Avalos-Salgado
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | - Laura Gonzalez-Lopez
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Programa de Maestria Salud Publica, Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Sergio Gonzalez-Vazquez
- Hospital General Regional 110, Instituto Mexicano del Seguro Social, Guadalajara 44716, Mexico
| | - Juan Manuel Ponce-Guarneros
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Instituto Mexicano del Seguro Social, Unidad de Medicina Familiar No. 97, Magdalena 46474, Mexico
| | - Aline Priscilla Santiago-Garcia
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | | | - Reynaldo Arellano-Cervantes
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Departamento de Ciencias del Movimiento Humano, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - J. Ahuixotl Gutiérrez-Aceves
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | - Miriam Fabiola Alcaraz-Lopez
- Departamento de Medicina Interna-Reumatología, Hospital General Regional Núm. 46, Instituto Mexicano del Seguro Social, Guadalajara 44910, Mexico
| | - Cesar Arturo Nava-Valdivia
- Departamento de Microbiología y Patología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Fabiola Gonzalez-Ponce
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | - Norma Alejandra Rodriguez-Jimenez
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Miguel Angel Macias-Islas
- Departamento de Neurociencias, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (M.A.M.-I.)
| | - Edgar Ricardo Valdivia-Tangarife
- Departamento de Neurociencias, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (M.A.M.-I.)
| | - Ana Miriam Saldaña-Cruz
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Ernesto German Cardona-Muñoz
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Jorge Ivan Gamez-Nava
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Programa de Maestria Salud Publica, Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| |
Collapse
|
2
|
Katturajan R, Evan Prince S. Zinc and L-carnitine combination with or without methotrexate prevents intestinal toxicity during arthritis treatment via Nrf2/Sirt1/Foxo3 pathways: an In vivo and molecular docking approach. Inflammopharmacology 2023; 31:2599-2614. [PMID: 37405586 DOI: 10.1007/s10787-023-01280-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 06/14/2023] [Indexed: 07/06/2023]
Abstract
Methotrexate (MTX) is an antifolate that is inescapable and widely used to treat autoimmune diseases and is the gold standard medicine for the arthritic condition. Despite its importance, it is more prone to gastrointestinal toxicity, which is most common in arthritis patients during MTX treatment. Combination therapies are required to ensure MTX's antiarthritic activity while providing gastrointestinal protection. Zinc (Zn) and L-carnitine (Lc) are well-known potent antioxidants and anti-inflammatory supplements with promising results in pre-clinical studies. Arthritis was induced in Wistar rat's ankles with Freund's adjuvant and treated with either MTX (2.5 mg/kg b.w per week for two weeks) or Zn (18 mg/kg b.w. per day) Lc (200 mg/kg b.w. per day) individually or in combination (MTX + Zn Lc). The antiarthritic effects were evaluated by body weight, paw volume, ankle tissue, and joint histopathology. At the same time, anti-toxicity/gastrointestinal protective activity was examined by tissue oxidative stress markers, antioxidants, mitochondrial function, inflammatory mediators, and antioxidant signaling proteins and their binding mechanism. Repercussions of MTX intoxication induced upregulation of oxidative stress markers, antioxidant depletion, ATP depletion, decreased expression of Nrf2/Sirt1/Foxo3, and the overexpression of inflammatory mediators attenuated by co-treatment with Zn Lc. Zn Lc markedly mitigated MTX-instigated intestinal injury by activating antioxidant signaling mechanisms Nrf2/Sirt1/Foxo3 signaling and tissue architectural anomalies and exhibited an enhanced antiarthritic effect. In conclusion, we report that Zn Lc and MTX combination could presumably protect the intestine from low-dose MTX which managed arthritis but induced severe intestinal damage with increased inflammation and downregulated Nrf2/Sirt1/Foxo3 pathway.
Collapse
Affiliation(s)
- Ramkumar Katturajan
- Department of Biotechnology, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Sabina Evan Prince
- Department of Biotechnology, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India.
| |
Collapse
|
3
|
Katturajan R, Evan Prince S. L-carnitine and Zinc supplementation impedes intestinal damage in methotrexate-treated adjuvant-induced arthritis rats: Reinstating enterocyte proliferation and trace elements. J Trace Elem Med Biol 2023; 78:127188. [PMID: 37163819 DOI: 10.1016/j.jtemb.2023.127188] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Methotrexate (MTX), a folic acid analogue, is used as a first-line treatment for rheumatoid arthritis (RA) since it has more therapeutic mechanisms than any other drug. Being an undeniable drug for the treatment of arthritis, even low-dose MTX provokes intestinal toxicity as a primary adverse effect and does not revive an anti-inflammatory element. Thus, our study aims to elucidate the anti-arthritic and prophylactic activity of supplements L-carnitine (L) and zinc (Z) against MTX-mediated intestinal damage in arthritis rats. METHODS The rats were assessed for arthritic parameters such as body weight, paw volume, x-ray scan, and serum trace elements level. To analyze the toxic effects of MTX in the rats, intestine pH, mucosal weight, digestive enzymes, myeloperoxidase, histopathological, and immunohistochemical analysis were performed. RESULTS Our study demonstrated that the arthritic parameters have shown that MTX has an ameliorative effect on arthritic rats. Besides, our findings showed that low-dose MTX (2.5 mg/kg b.w.) given once a week for two weeks during arthritis treatment had toxic effects in the rat's intestine, as evidenced by changes in intestine pH and mucosal weight, decreased digestive enzymes, increased MPO, and degenerative changes in histopathological analysis. Concurrent therapy of LZ with MTX, on the other hand, restored the modifications in these parameters. CONCLUSION MTX in combination with LZ effectively manages arthritis than monotherapy and significantly prevents MTX-induced intestinal damage in arthritis rats. Thus, LZ could be used as an improved therapeutic and safety for MTX-instigated intestinal damage during arthritis treatments. Therefore, our combination of L-carnitine and zinc with MTX would be promising prophylactic activity for arthritis patients.
Collapse
Affiliation(s)
- Ramkumar Katturajan
- Department of Biotechnology, School of Bio Sciences and Technology, VIT, Vellore, Tamil Nadu, India
| | - Sabina Evan Prince
- Department of Biotechnology, School of Bio Sciences and Technology, VIT, Vellore, Tamil Nadu, India.
| |
Collapse
|
4
|
Dhir V, Prasad CB, Kumar S, Kaul KK, Dung N, Naidu GSRSNK, Sharma SK, Sharma A, Jain S. Long-term persistence of oral methotrexate and associated factors in rheumatoid arthritis: a retrospective cohort study. Rheumatol Int 2023; 43:867-873. [PMID: 36933068 DOI: 10.1007/s00296-023-05305-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/02/2023] [Indexed: 03/19/2023]
Abstract
There is little data on long-term persistence/continuation of methotrexate among Indian Rheumatoid arthritis patients. We assembled a retrospective single-center cohort consisting of RA patients (fulfilling 1987 ACR criteria) started on methotrexate as part of three academic studies (including two RCTs) from 2011 to 2016. Oral methotrexate was started at 7.5 or 15 mg per week with a target dose of 25 mg per week. Between August and December 2020, all patients were contacted (telephonically) and data were obtained from clinic files to evaluate self-reported continuation/persistence of methotrexate and reasons for discontinuation. Survival analysis using Kaplan-Meier and cox-regression were used to assess methotrexate continuation rates and factors associated with its discontinuation. This study included 317 patients with rheumatoid arthritis, with mean age and disease duration (at enrollment) of 43 years and 2 years; And positive rheumatoid factor and anti-CCP in 69 and 75%. At follow-up, 16 patients (5%) had died, whereas 103 (32.5%) had discontinued methotrexate. On Kaplan-Meier survival analysis, the mean survival (continuation) time for methotrexate was 7.3 years (95% CI 7-7.6 years). The actuarial continuation/persistence of methotrexate at 3, 5 and 9 years was 92, 81 and 51%, respectively. Among those who discontinued methotrexate, common reasons were remission of disease, symptomatic adverse effects (intolerance), perceived lack of efficacy and socioeconomic reasons. On multivariable cox-regression, symptomatic adverse effects during the first 12-24 weeks (Hazard ratio, 95% CI 1.8 (1.2-2.8)) and anti-CCP positivity (Hazard ratio, 95% CI 0.6 (0.3-1.0)) were significantly associated with hazard of discontinuation. Persistence or continuation of methotrexate was found to be good and comparable to reports in other centers world-wide. Apart from remission, the most important cause of methotrexate discontinuation was symptomatic adverse effects (intolerance).
Collapse
Affiliation(s)
- Varun Dhir
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Chandra Bhushan Prasad
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sandeep Kumar
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kavya Kriti Kaul
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Neha Dung
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - G S R S N K Naidu
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shefali K Sharma
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| |
Collapse
|
5
|
Bahceci İ, Tumkaya L, Mercantepe T, Aslan N, Duran ÖF, Soztanaci US, Yazıcı ZA. Inhibition of methotrexate induced toxicity in the adult rat spleen by adalimumab. Drug Chem Toxicol 2023; 46:323-329. [PMID: 35057671 DOI: 10.1080/01480545.2022.2029880] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Methotrexate (MTX) has been in use for the treatment of rheumatoid arthritis (RA), psoriasis, and cancer since 1948. Its toxic side effects on tissues and organs have been well documented but splenotoxicity has not been addressed. This study set out to investigate this issue by examining the effectiveness of anti-TNFα agents against MTX-induced toxicity in T lymphocytes and macrophages via the regulation of CD3, CD68, and CD200R. Twenty-four Sprague Dawley rats were allocated to three groups: control (received saline solution only), MTX (20 mg/kg of single-dose of MTX), and Ada + MTX (single dose of 10 mg/kg Adalimumab before MTX administration). The spleens were removed 5 days after MTX administration. The number of CD3+/mm3cells for the control, MTX and Ada + MTX groups were, respectively, 2.69 ± 0.86, 20.51 ± 2.7, (p = 0.000) and 11.07 ± 2.01 (p = 0.000). The number of CD68+ macrophages/mm3 in the control, MTX and Ada + MTX groups were, respectively, 8.62 ± 1.08, 38.19 ± 1.37 (p = 0.000), and 16.87 ± 12.57 (p = 0.000). The number of macrophages that were CD200R+/mm3 in the control, MTX, and Ada + MTX groups were 3.33 ± 1.66, 25.77 ± 2.37 (p = 0.000), and 8.68 ± 2.66 (p = 0.000), respectively. We also observed that Ada reduced the numerical densities of these cells following MTX administration (p < 0.05). Ada may, therefore, be a promising candidate for the prevention of the deleterious effects on T lymphocytes and macrophages of MTX-induced toxicity.
Collapse
Affiliation(s)
- İlkay Bahceci
- Department of Microbiology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Levent Tumkaya
- Department of Histology & Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Tolga Mercantepe
- Department of Histology & Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Nuray Aslan
- Department of Microbiology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ömer Faruk Duran
- Department of Microbiology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Umut Serkan Soztanaci
- Department of Anayomy, Hamidiye Faculty of Medicine, University of Health Sciences University, İstanbul, Turkey
| | - Zihni Acar Yazıcı
- Department of Microbiology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| |
Collapse
|
6
|
Failure and multiple failure for disease modifying antirheumatic drugs in rheumatoid arthritis: Real-life evidence from a tertiary referral center in Italy. PLoS One 2023; 18:e0281213. [PMID: 36730337 PMCID: PMC9894489 DOI: 10.1371/journal.pone.0281213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/08/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Rheumatoid Arthritis (RA) is a chronic inflammatory disease with a heterogeneous treatments' clinical response. Goals of treatment are remission and low disease activity, which are not achieved in all patients despite the introduction of early treatment and the treat to target strategy. OBJECTIVE To investigate the causes of disease-modifying antirheumatic drugs (DMARDs) discontinuation and treatment failure and multiple failure for inefficacy, and to identify possible failure predictors' according to RA patient characteristics in a real-world setting. METHODS 718 RA patients were retrospectively evaluated. Conventional synthetic (cs) and biologic (b)DMARDs treatments line/s, effectiveness, and reasons of discontinuations were evaluated. Patients failing to at least two csDMARDs or bDMARDs' drug for inefficacy were defined "csDMARDs multifailure" and "bDMARDs multifailure", respectively. Discontinuation of at least two cs- and bDMARDs was termed "global multifailure". RESULTS In total, 1422 csDMARDs and 714 bDMARDs treatment were analysed. Causes of csDMARDs discontinuation were intolerance (21.8%), inefficacy (20.2%), acute adverse reactions (5.3%) and severe infections (0.6%) while csDMARDs multifailure for inefficacy was observed in 5.7% of cases. Reasons of bDMARDs withdrawal were inefficacy (29%), intolerance (10.0%), acute adverse reaction (6.3%) and severe infections (1.5%). Altogether, 8.4% of patients were bDMARDs multifailure for inefficacy while 16.6% were global multifailure. Longstanding disease (≥ 12 months) and smoke habit, resulted as positive predictor of csDMARDs failure (OR 2.6 and OR 2.7, respectively). Thyreopathy was associated with both csDMARDs failure and global multifailure (OR 2.4 and OR 1.8, respectively). Higher prevalence of failure to at least one bDMARDs and global multifailure was detected in female than male (OR 2.3 and OR 2, respectively). CONCLUSIONS Different causes of drug discontinuation were observed on DMARDs treatments. Demographic and clinical features were identified as possible predictors of both cs- and bDMARDs treatment failure and multiple failure, underlining the need of a more personalized therapeutic approach to achieve treatment targets.
Collapse
|
7
|
Alten R, Burmester GR, Matucci-Cerinic M, Salmon JH, Lopez-Romero P, Fakhouri W, de la Torre I, Zaremba-Pechmann L, Holzkämper T, Fautrel B. The RA-BE-REAL Multinational, Prospective, Observational Study in Patients with Rheumatoid Arthritis Receiving Baricitinib, Targeted Synthetic, or Biologic Disease-Modifying Therapies: a 6-Month Interim Analysis. Rheumatol Ther 2023; 10:73-93. [PMID: 36227530 PMCID: PMC9557042 DOI: 10.1007/s40744-022-00500-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/30/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION RA-BE-REAL has the overall aim of defining a profile of patients with rheumatoid arthritis (RA) starting baricitinib or any other targeted synthetic (ts) or any biologic (b) disease-modifying antirheumatic drug (DMARD) for the first time, and the primary objective of estimating time until discontinuation from any cause (excluding sustained response) of the initial treatment. METHODS RA-BE-REAL is an ongoing, prospective, observational, 36-month study in patients with RA initiating treatment with baricitinib (cohort A) or any other tsDMARD or any bDMARD (cohort B) for the first time. The primary objective is to assess the time until treatment discontinuation from any cause (excluding sustained response) at 24 months, (i.e., the rate of discontinuation of initial baricitinib or ts/bDMARD). Patient profiles of each cohort are described and compared. Post-baseline data are descriptively analyzed. This manuscript presents baseline and interim (6-month) outcomes for European patients with RA participating in the global RA-BE-REAL study. RESULTS Data from 1074 patients (cohort A: 509; cohort B: 565) were analyzed. For cohorts A and B, respectively, the 6-month cumulative incidence (95% confidence interval) of treatment discontinuation was 16.5 (12.9-21.1) and 23.3 (19.1-28.2), and the proportions of patients achieving remission were 25.6% and 18.5%. At baseline, mean patient age was 59.1 and 57.0 years (p = 0.010) and mean disease duration was 10.0 and 8.9 years (p = 0.047), respectively. The proportions of patients exposed to ts/bDMARDs at any time before study entry were 51.9% and 39.1%, and the proportions of patients initiated on monotherapy were 50.9% and 31.2%, respectively. CONCLUSION In real-world settings, patients with RA initiating treatment with baricitinib were older and had longer disease duration than those initiating treatment with any other tsDMARD or any bDMARD. Initial descriptive data regarding treatment discontinuation (including reasons for discontinuation), effectiveness, and treatment patterns will be enriched as the study progresses.
Collapse
Affiliation(s)
- Rieke Alten
- Department of Internal Medicine and Rheumatology, Schlosspark-Klinik, University Medicine Berlin, Berlin, Germany.
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
- Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Jean-Hugues Salmon
- Faculty of Medicine, University of Reims Champagne-Ardenne, UR 3797, 51095, Reims, France
- Rheumatology Department, Maison Blanche Hospital, Reims University Hospitals, 51092, Reims, France
| | | | | | | | | | | | - Bruno Fautrel
- Department of Rheumatology, Pitie Salpetriere Hospital, Sorbonne University-Assistance Publique Hôpitaux de Paris, Paris, France
- PEPITES Team, Pierre Louis Institute of Epidemiology and Public Health, INSERM UMRS, 11376, Paris, France
| |
Collapse
|
8
|
Meng CF, Rajesh DA, Jannat-Khah DP, Jivanelli B, Bykerk VP. Can Patients With Controlled Rheumatoid Arthritis Taper Methotrexate From Targeted Therapy and Sustain Remission? A Systematic Review and Metaanalysis. J Rheumatol 2023; 50:36-47. [PMID: 35970524 DOI: 10.3899/jrheum.220152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the risk of not being able to sustain remission after tapering methotrexate (MTX) from targeted therapy in patients with controlled rheumatoid arthritis (RA). METHODS A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Library for studies reporting remission outcomes after tapering MTX from targeted therapies in RA. Full-text articles and abstracts reported in English were included. Metaanalyses were conducted using random-effects models. Forest and funnel plots were created. RESULTS A total of 10 articles were included. Studies evaluated MTX being tapered from combination treatment with tumor necrosis factor inhibitors, tocilizumab, abatacept, and tofacitinib. A total of 9 studies used a randomized design and 1 was observational. Out of 10 studies, 3 focused on early RA (ie, < 1 yr). The MTX-tapering strategy was gradual in 2 studies and rapid in 8 studies. Follow-up ranged from 3 to 18 months in randomized trials and up to 3 years in the observational study. Our metaanalysis, which included 2000 participants with RA from 10 studies, showed that patients who tapered MTX from targeted therapy had a 10% reduction in the ability to sustain remission and an overall pooled risk ratio of 0.90 (95% CI 0.84-0.97). There was no heterogeneity (I 2 = 0%, P = 0.94). Our funnel plot indicated minimal publication bias. CONCLUSION Patients with controlled RA may taper MTX from targeted therapy with a 10% reduction in the ability to sustain remission for up to 18 months. Longer follow-up studies with attention to radiographic, functional, and patient-reported outcomes are needed. The risk of disease worsening should be discussed with the patient with careful follow-up and prompt retreatment of disease worsening.
Collapse
Affiliation(s)
- Charis F Meng
- C.F. Meng MD, V.P. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery, and Department of Medicine, Weill Cornell Medical College.
| | - Diviya A Rajesh
- D.A. Rajesh, BA, Division of Rheumatology, Hospital for Special Surgery
| | - Deanna P Jannat-Khah
- D.P. Jannat-Khah, DRPH, MSPH, Division of Rheumatology, Epidemiology and Biostatistics CORE, Hospital for Special Surgery, and Department of Medicine, Weill Cornell Medical College
| | - Bridget Jivanelli
- B. Jivanelli, MLIS, Kim Barrett Memorial Library, HSS Education Institute, Hospital for Special Surgery, New York, NY, USA
| | - Vivian P Bykerk
- C.F. Meng MD, V.P. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery, and Department of Medicine, Weill Cornell Medical College
| |
Collapse
|
9
|
Nagafuchi H, Goto Y, Kiyokawa T, Kawahata K. Reasons for discontinuation of methotrexate in the treatment of rheumatoid arthritis and challenges of methotrexate resumption: a single-center, retrospective study. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00162-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
Methotrexate (MTX) is an anchor drug used for the treatment of rheumatoid arthritis (RA); hence, understanding the reasons for MTX discontinuation in RA can help improve its treatment. Therefore, this study aimed to investigate the reasons for MTX discontinuation and to identify future challenges in RA treatment regarding the discontinuation and resumption of MTX treatment.
Results
MTX administration was discontinued in 771 patients with RA. The reasons for MTX discontinuation were as follows: (1) infectious diseases (20.0%), (2) malignancy (14.1%), and (3) respiratory problems (10.2%). Some patients did not resume MTX therapy even after the infections were cured. Liver dysfunction (8.0%) did not improve with MTX discontinuation and was often associated with fatty liver disease. In addition to adverse events, MTX discontinuation was due to patient preference (4.3%), planning for pregnancy (5.1%), invalidity (5.7%), remission (5.6%), remission with biologics (4.7%), old age (2.6%), and poor compliance (1.6%).
Conclusions
This study revealed diverse reasons for the discontinuation of MTX; there are cases in which MTX is discontinued but should be considered for resumption. Furthermore, issues such as the indications for MTX discontinuation should still be debated, and multicenter evidence must be collected and examined in future studies.
Collapse
|
10
|
Ogdie A, Maksabedian Hernandez EJ, Shaw Y, Stolshek B, Michaud K. Side Effects of Methotrexate and Tumor Necrosis Factor Inhibitors: Differences in Tolerability Among Patients With Psoriatic Arthritis and Rheumatoid Arthritis. ACR Open Rheumatol 2022; 4:935-941. [PMID: 35971643 PMCID: PMC9661817 DOI: 10.1002/acr2.11467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To examine the prevalence of side effects with methotrexate (MTX) and tumor necrosis factor inhibitors (TNFi) among patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA). Methods This retrospective analysis, conducted between January 2000 and January 2019, used data from the FORWARD databank. Adult patients enrolled in the registry with self‐reported and physician‐confirmed diagnosis of PsA or RA were included if they had completed at least one questionnaire before initiating and within 12 months following initiation of MTX or a TNFi. The primary outcome was to examine the prevalence of side effects with MTX and TNFi within the year following treatment initiation. Multivariate logistic regression analysis was performed to examine the association between PsA and RA and the reporting of their side effects. Results Overall, 116 patients with PsA and 4247 patients with RA newly initiated MTX, and 124 patients with PsA and 4361 patients with RA newly initiated a TNFi. Patients with PsA were more likely to report MTX‐related side effects than those with RA (44.8% vs. 29.4%), whereas similar proportions of patients with PsA and RA reported TNFi‐related side effects within the first year (24.2% and 22.8%, respectively). Additionally, patients with PsA initiating MTX were more likely to report nausea, vomiting, abdominal pain, depression, and tinnitus than patients with RA initiating MTX or those with PsA or RA initiating a TNFi. Conclusion Patients with PsA reported more side effects than patients with RA, and this difference was more pronounced in those receiving MTX versus TNFi.
Collapse
Affiliation(s)
- Alexis Ogdie
- Hospital of the University of Pennsylvania Philadelphia
| | | | - Yomei Shaw
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, and University of Michigan Ann Arbor
| | | | - Kaleb Michaud
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, and University of Nebraska Medical Center Omaha
| |
Collapse
|
11
|
Cui J, Chasman DI, Raychaudhuri S, Xu C, Ridker PM, Solomon DH, Karlson EW. Genetics are not likely to offer clinically useful predictions for elevated liver enzyme levels in patients using low dose methotrexate. Semin Arthritis Rheum 2022; 55:152036. [PMID: 35671649 PMCID: PMC10782828 DOI: 10.1016/j.semarthrit.2022.152036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine genetic influence on the risk of elevations in liver function tests (AST and ALT) among patients using low-dose methotrexate (LD-MTX). METHODS We examined data from the LD-MTX arm of a randomized double-blind placebo-controlled trial conducted among subjects without rheumatic disease. Genome wide association studies (GWAS) were performed in subjects of European ancestry to test the association between single nucleotide polymorphisms (SNPs) and the log transformed maximum values of AST, ALT, and dichotomized outcome with AST or ALT > 2 times upper limit of normal (ULN). The association between variants in MTX metabolism candidate genes and the outcomes was also tested. Furthermore, associations between a drug induced liver injury (DILI) weighted genetic risk score (wGRS) and the outcomes were tested, combining 10 SNPs and 11 classical HLA alleles associated with DILI. RESULTS In genome-wide genetic analyses among 1,429 subjects of European ancestry who were randomized to receive LD-MTX, two SNPs reached genome wide significance for association with log transformed maximum ALT. We observed associations between established candidate genes in MTX pharmacogenetics and log transformed maximum AST and ALT, as well as in dichotomized outcome with AST or ALT > 2 x ULN. There was no association between DILI wGRS or candidate variants and AST, ALT, or DILI response. CONCLUSIONS Modest evidence was observed that common variants affected AST and ALT levels in subjects of European ancestry on LD-MTX, but this genetic effect is not useful as a clinical predictor of MTX toxicity.
Collapse
Affiliation(s)
- Jing Cui
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA.
| | - Daniel I Chasman
- Division of Preventive Medicine, Brigham and Women's Hospital USA; Division of Genetics, Brigham and Women's Hospital, Boston, MA USA
| | - Soumya Raychaudhuri
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA; Division of Genetics, Brigham and Women's Hospital, Boston, MA USA
| | - Chang Xu
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA
| | - Paul M Ridker
- Division of Preventive Medicine, Brigham and Women's Hospital USA
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA
| | - Elizabeth W Karlson
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA
| |
Collapse
|
12
|
Faria RJ, Cordeiro FJR, dos Santos JBR, Alvares-Teodoro J, Guerra Júnior AA, Acurcio FDA, da Silva MRR. Conventional Synthetic Disease-Modifying Anti-rheumatic Drugs for Psoriatic Arthritis: Findings and Implications From a Patient Centered Longitudinal Study in Brazil. Front Pharmacol 2022; 13:878972. [PMID: 35559237 PMCID: PMC9086188 DOI: 10.3389/fphar.2022.878972] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/24/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Conventional synthetic disease-modifying antirheumatic drugs are the first-line treatment to inhibit the progression of psoriatic arthritis. Despite their widespread clinical use, few studies have been conducted to compare these drugs for psoriatic arthritis. Methods: a longitudinal study was carried out based on a centered patient national database in Brazil. Market share of drugs, medication persistence, drug costs, and cost per response were evaluated. Results: a total of 1,999 individuals with psoriatic arthritis were included. Methotrexate was the most used drug (44.4%), followed by leflunomide (40.6%), ciclosporin (8.2%), and sulfasalazine (6.8%). Methotrexate and leflunomide had a greater market share than ciclosporin and sulfasalazine over years. Medication persistence was higher for leflunomide (58.9 and 28.2%), followed by methotrexate (51.6 and 25.4%) at six and 12 months, respectively. Leflunomide was deemed the most expensive drug, with an average annual cost of $317.25, followed by sulfasalazine ($106.47), ciclosporin ($97.64), and methotrexate ($40.23). Methotrexate was the drug being the lowest cost per response. Conclusion: Methotrexate had the best cost per response ratio, owing to its lower cost and a slightly lower proportion of persistent patients when compared to leflunomide. Leflunomide had a slightly higher medication persistence than methotrexate, but it was the most expensive drug.
Collapse
Affiliation(s)
- Ronaldo José Faria
- Pharmaceutical Services Graduate Program, Federal University of Espírito Santo, Alegre, Brazil
- Health Assessment, Technology, and Economy Group, Federal University of Espírito Santo, Alegre, Brazil
| | | | - Jéssica Barreto Ribeiro dos Santos
- Pharmaceutical Services Graduate Program, Federal University of Espírito Santo, Alegre, Brazil
- Health Assessment, Technology, and Economy Group, Federal University of Espírito Santo, Alegre, Brazil
| | | | | | | | - Michael Ruberson Ribeiro da Silva
- Pharmaceutical Services Graduate Program, Federal University of Espírito Santo, Alegre, Brazil
- Health Assessment, Technology, and Economy Group, Federal University of Espírito Santo, Alegre, Brazil
| |
Collapse
|
13
|
Felten R, Lambert De Cursay G, Lespessailles E. Is there still a place for methotrexate in severe psoriatic arthritis? Ther Adv Musculoskelet Dis 2022; 14:1759720X221092376. [PMID: 35464810 PMCID: PMC9021512 DOI: 10.1177/1759720x221092376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/17/2022] [Indexed: 11/23/2022] Open
Abstract
The management of psoriatic arthritis (PsA) has long been equated with that of rheumatoid arthritis (RA), particularly because methotrexate (MTX) was found efficient in RA in the 1990s. However, results of collective evidence-based medicine, included and argued in this narrative review, do not currently support the use of MTX as first-line therapy in severe PsA. A recent Cochrane systematic review examining the efficacy of MTX in PsA concluded that low-dose MTX was only slightly more effective than placebo. Questions about a structural effect of MTX in PsA remains non-elucidated. Even if tolerance data on MTX are more consensual and adverse events generally non-severe, subjective side effects such as fatigue might lead to MTX withdrawal based on the patient’s decision. PsA patients with axial disease, radiographic lesions, and extensive and disabling skin or joint involvement should receive early treatment with targeted therapy and no longer with MTX. Finally, the usefulness of MTX combined with targeted therapies is limited. MTX does not affect efficacy but only seems to increase the therapeutic maintenance of monoclonal TNF inhibitors. This narrative review may help clarify the place of MTX in PsA management. It allows for reflection on the evolution of current concepts and practices.
Collapse
Affiliation(s)
- Renaud Felten
- Department of Rheumatology and Centre de Référence National des Maladies Auto-Immunes Systémiques Rares CIC-P Hautepierre, INSERM 1434, University Hospital of Strasbourg, Strasbourg, France
| | - Grégoire Lambert De Cursay
- Department of Internal Medicine, Rheumatology, Infectious and Tropical Diseases, Hospital of Brive, Brive-la-Gaillarde, France
| | - Eric Lespessailles
- Department of Rheumatology, PRIMMO, Regional Hospital of Orleans, 45067 Orleans, France
| |
Collapse
|
14
|
Coates LC, Tillett W, D'Agostino MA, Rahman P, Behrens F, McDearmon-Blondell EL, Bu X, Chen L, Kapoor M, Conaghan PG, Mease P. Comparison between adalimumab introduction and methotrexate dose escalation in patients with inadequately controlled psoriatic arthritis (CONTROL): a randomised, open-label, two-part, phase 4 study. THE LANCET. RHEUMATOLOGY 2022; 4:e262-e273. [PMID: 38288922 DOI: 10.1016/s2665-9913(22)00008-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 02/01/2024]
Abstract
BACKGROUND Many patients with psoriatic arthritis do not reach minimal disease activity (MDA) on methotrexate alone. This phase 4 open-label study aimed to compare attainment of MDA following introduction of adalimumab with methotrexate escalation in patients with psoriatic arthritis who do not reach MDA after an initial methotrexate course (≤15 mg every week). METHODS CONTROL was a phase 4, randomised, two-part, open-label study conducted in 14 countries and 46 sites. We recruited patients with confirmed active psoriatic arthritis, naive to biologic disease-modifying antirheumatic drugs, with an inadequate response to 15 mg or less of methotrexate. In part 1, patients were randomly assigned (1:1) to receive either methotrexate 15 mg (oral or subcutaneous) every week with the addition of adalimumab 40 mg (subcutaneously) every other week (adalimumab plus methotrexate group) or methotrexate (oral or subcutaneous) escalation up to 25 mg every week (escalated methotrexate group). Randomisation was done using Interactive Response Technology and stratified by the duration of methotrexate treatment (≤3 months and >3 months). In this open-label study there was no masking; participants, people giving the interventions, those assessing outcomes, and those analysing the data were aware of group assignment. The primary endpoint was the proportion of patients who reached MDA at 16 weeks. After 16 weeks (part 2), patients who reached MDA (responders) had their current therapy maintained or modified, wheras patients who did not reach MDA (non-responders) had their therapy escalated until 32 weeks. The primary endpoint in part 2 was the proportion of patients who reached MDA at 32 weeks, analysed in all patients who received one or more doses of study drug. The study is registered with ClinicalTrials.gov, NCT02814175. FINDINGS Between Aug 5, 2016, and March 19, 2020, 245 of 287 patients initially assessed were enrolled in the study (50% men and 50% women; 92% of patients were White). 123 patients were randomly assigned to receive adalimumab plus methotrexate and 122 patients to receive escalated methotrexate. All 245 patients were included in the primary analysis, and 227 completed part 1 and entered part 2. A significantly higher proportion of patients reached MDA at 16 weeks in the adalimumab plus methotrexate group (51 [41%] patients) compared with the escalated methotrexate group (16 [13%] patients; p<0·0001). Efficacy was generally maintained through 32 weeks for patients who reached MDA at 16 weeks, with 41 (80%) of 51 adalimumab responders and ten (67%) of 15 methotrexate responders maintaining MDA at 32 weeks. Of adalimumab non-responders, 17 (30%) of 57 patients reached MDA at 32 weeks after adalimumab escalation to every week dosing. Among methotrexate non-responders, 50 (55%) of 91 reached MDA after adalimumab introduction. In part 1, two patients in the adalimumab plus methotrexate group reported serious adverse events; and in part 2, one adalimumab responder, three adalimumab non-responders, and three methotrexate non-responders reported serious adverse events. No new safety signals were identified. INTERPRETATION Results from this novel treatment-strategy trial support the addition of adalimumab over escalating methotrexate in patients with psoriatic arthritis not reaching MDA after an initial methotrexate course. Safety results were consistent with the therapies' known safety profiles. FUNDING AbbVie.
Collapse
Affiliation(s)
- Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - William Tillett
- Royal National Hospital for Rheumatic Diseases, Pharmacy and Pharmacology, University of Bath, Bath, UK
| | | | | | - Frank Behrens
- Rheumatology and Fraunhofer ITMP, Goethe University, Frankfurt, Germany
| | | | | | | | | | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, UK; NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Philip Mease
- Swedish Medical Center/Providence Health, Seattle, WA, USA
| |
Collapse
|
15
|
Patient-Reported Nausea and Fatigue Related to Methotrexate: A Prospective, Self-Controlled Study in the ArthritisPower ® Registry. Rheumatol Ther 2021; 9:207-221. [PMID: 34843092 PMCID: PMC8628141 DOI: 10.1007/s40744-021-00398-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction The magnitude and frequency of temporally related methotrexate (MTX)-associated side effects in rheumatoid arthritis (RA) or psoriatic arthritis (PsA) patients are difficult to quantify using traditional research methods. As proof of concept designed in part to implement digital data collection for remote patient monitoring, we conducted a study implementing self-controlled case series analytic methods to understand MTX-related symptoms in RA or PsA. Methods In study phase 1, adults with RA or PsA from the ArthritisPower® Registry (past or current oral MTX users) participated in a cross-sectional survey. In phase 2, current MTX users participated in a longitudinal study and completed the Patient-Reported Outcomes Measurement Information System (PROMIS®) 1-day nausea/vomiting and fatigue measure. Within-person change in PROMIS scores between risk (6–36 h post-dose) and control (96–144 h post-dose) windows were compared using mixed models. Results The baseline survey was completed by 671 participants (mean age: 54 years, 88% female, 92% white, 79% with RA). Among current MTX users (353/671 [53%]), most reported MTX-associated side effects (216/353 [61%]), most frequently fatigue (161/353 [46%]). Among phase 2 participants with (n = 39) and without (n = 84) baseline nausea, mean increase in PROMIS nausea was 5.1 units (P < 0.0001) and 0.7 units (P = 0.135), respectively; among those with (n = 51) and without (n = 72) baseline fatigue, mean increase in PROMIS fatigue was 3.9 units (P = 0.0003) and 0.4 units (P = 0.554), respectively. Conclusions Digital remote patient monitoring presents an opportunity to detect and address medication tolerability in real time. Using a novel study design to control for between-person confounding, the magnitude of nausea and fatigue experienced by participants with RA and PsA temporally related to weekly MTX use was substantial. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00398-6.
Collapse
|
16
|
Sherbini AA, Sharma SD, Gwinnutt JM, Hyrich KL, Verstappen SMM. Prevalence and predictors of adverse events with methotrexate mono- and combination-therapy for rheumatoid arthritis: a systematic review. Rheumatology (Oxford) 2021; 60:4001-4017. [PMID: 33909898 PMCID: PMC8410011 DOI: 10.1093/rheumatology/keab304] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 03/21/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This systematic review aims to summarize rates of adverse events (AEs) in patients with RA or inflammatory arthritis starting MTX as monotherapy or in combination with other csDMARDs, and to identify reported predictors of AEs. METHODS Three databases were searched for studies reporting AEs in MTX-naïve patients with RA. Randomized controlled trials (RCTs) and observational cohort studies were included. Prevalence rates of AEs were pooled using random effects meta-analysis, stratified by study design. RESULTS Forty-six articles (34 RCTs and 12 observational studies) were identified. The pooled prevalence of total AEs was 80.1% in RCTs (95% CI: 73.5, 85.9), compared with 23.1% in observational studies (95% CI: 12.3, 36.0). The pooled prevalence of serious AEs was 9.5% in RCTs (95% CI: 7.4, 11.7), and 2.1% in observational studies (95% CI: 1.0, 3.4). MTX discontinuation due to AEs was higher in observational studies (15.5%, 95% CI: 9.6, 22.3) compared with RCTs (6.7%, 95% CI: 4.7, 8.9). Gastrointestinal events were the most commonly reported AEs (pooled prevalence: 32.7%, 95% CI: 18.5, 48.7). Five studies examined predictors of AEs. RF status, BMI and HAQ score were associated with MTX discontinuation due to AEs; ACPA negativity, smoking and elevated creatinine were associated with increased risk of elevated liver enzymes. CONCLUSION The review provides an up-to-date overview of the prevalence of AEs associated with MTX in patients with RA. The findings should be communicated to patients to help them make informed choices prior to commencing MTX.
Collapse
Affiliation(s)
- Ahmad A Sherbini
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
| | - Seema D Sharma
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
| | - James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
17
|
Maassen JM, van Ouwerkerk L, Allaart CF. Tapering of disease-modifying antirheumatic drugs: an overview for daily practice. THE LANCET. RHEUMATOLOGY 2021; 3:e659-e670. [PMID: 38287612 DOI: 10.1016/s2665-9913(21)00224-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/25/2021] [Accepted: 07/08/2021] [Indexed: 01/31/2024]
Abstract
In this Review, we discuss the possibility of drug tapering in patients with rheumatoid arthritis in remission or low disease activity, for glucocorticoids and disease-modifying antirheumatic drugs. We review international guidelines and recommendations, as well as remaining uncertainties, and provide an overview of the current literature. Three strategies of tapering are discussed: (1) tapering by discontinuation of one of the drugs in combination therapy regimens, (2) tapering by reducing the dose of one of the drugs in combination therapy regimens, and (3) tapering by dose reduction of monotherapy with disease-modifying antirheumatic drugs. We discuss the outcomes and robustness of evidence of trials and observational cohorts, and we give a trajectory for further research and drug tapering in daily practice.
Collapse
Affiliation(s)
| | - Lotte van Ouwerkerk
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | | |
Collapse
|
18
|
Generali E, Carrara G, Bortoluzzi A, De Santis M, Ceribelli A, Scirè CA, Selmi C. Non-adherence and discontinuation rate for oral and parenteral methotrexate: A retrospective-cohort study in 8,952 patients with psoriatic arthritis. J Transl Autoimmun 2021; 4:100113. [PMID: 35005587 PMCID: PMC8716656 DOI: 10.1016/j.jtauto.2021.100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/14/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIMS Treatment options for PsA, following non-steroidal anti-inflammatory drugs (NSAIDs), include conventional synthetic disease modifying anti-rheumatic drugs (csDMARDS), particularly methotrexate (MTX). The present study was performed to determine the non-adherence and discontinuation rates of different methotrexate (MTX) formulations in psoriatic arthritis (PsA). APPROACH AND RESULTS We performed a retrospective-cohort study on patients with PsA identified by disease-specific code in the administrative-health-databases of a Northern Italian region (Lombardy) between 2004 and 2015. Subjects were defined as non-adherent if less than 80% of the prescribed MTX dose was taken based on the time between each prescription. Discontinuation rates were calculated using the time between the first and the last MTX prescription over an observation period of 120 months. Among 8952 patients with PsA, 33% were treated with MTX (mean dosage 10 mg/week ± 2.5 mg standard deviation), more frequently (59%) in its parenteral formulation at a 10 mg weekly dosage (35%). Oral glucocorticoids were prescribed to 21% of patients, while non-steroidal anti-inflammatory drugs to 45%. Approximately 37% of patients with PsA were defined as non-adherent to MTX, with the oral formulation associated with an increased risk of non-adherence (hazard ratio 2.08, 95% confidence interval 1.84-2.35, p < 0.001) compared with parenteral 10-15 mg weekly doses. Oral MTX was discontinued in 52% of cases without a significantly increased risk of discontinuation compared to parenteral formulations which, at higher dosages, had a more favorable retention rate. CONCLUSION Oral MTX formulation is associated with a 2-fold risk of non-adherence compared to MTX parenteral route in PsA.
Collapse
Key Words
- Adherence
- HCQ, hydroxychloroquine
- HR, Hazard ratio
- IQR, inter-quartile range
- LEF, leflunomide
- MTX, methotrexate
- Methotrexate
- NSAIDs, non-steroidal anti-inflammatory drugs
- OGC, oral glucocorticoids
- Oral
- Parenteral
- PsA, psoriatic arthritis
- PsO, psoriasis
- Psoriatic arthritis
- Retention rate
- SSZ, sulfasalazine
- TNF, tumor necrosis factor alpha
- list: csDMARDs, conventional synthetic disease modifying anti-rheumatic drugs
Collapse
Affiliation(s)
- Elena Generali
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | | | - Maria De Santis
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Angela Ceribelli
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Carlo A. Scirè
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
- University of Ferrara, Ferrara, Italy
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| |
Collapse
|
19
|
Changes in the use patterns of bDMARDs in patients with rheumatic diseases over the past 13 years. Sci Rep 2021; 11:15051. [PMID: 34302036 PMCID: PMC8302725 DOI: 10.1038/s41598-021-94504-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023] Open
Abstract
The better understanding of the safety of biologic DMARDs (bDMARDs), as well as the emergence of new bDMARDs against different therapeutic targets and biosimilars have likely influenced the use patterns of these compounds over time. The aim of this study is to assess changes in demographic characteristics, disease activity and treatment patterns in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) who started a first- or second-line biologic between 2007 and mid-2020. Patients diagnosed with RA, PsA or AS included in the BIOBADASER registry from January 2007 to July 2020 were included. According to the start date of a first- or second-line biologic therapy, patients were stratified into four time periods: 2007-2009; 2010-2013; 2014-2017; 2018-2020 and analyzed cross-sectionally in each period. Demographic and clinical variables, as well as the type of biologic used, were assessed. Generalized linear models were applied to study the evolution of the variables of interest over time periods, the diagnosis, and the interactions between them. A total of 4543 patients initiated a first biologic during the entire time frame of the study. Over the four time periods, disease evolution at the time of biologic initiation (p < 0.001), disease activity (p < 0.001), retention rate (p < 0.001) and the use of tumor necrosis factor inhibitors as a first-line treatment (p < 0.001) showed a significant tendency to decrease. Conversely, comorbidities, as assessed by the Charlson index (p < 0.001), and the percentage of patients using bDMARDs in monotherapy (p < 0.001), and corticosteroids (p < 0.001) tended to increase over time. Over the entire period of the study's analysis, 3289 patients started a second biologic. The following trends were observed: decreased DAS28 at switching (p < 0.001), lower retention rates (p = 0.004), and incremental changes to the therapeutic target between the first and second biologic (p < 0.001). From 2007 until now rheumatic patients who started a biologic were older, exhibited less clinical activity, presented more comorbidities, and switched to a different biologic more frequently and earlier.
Collapse
|
20
|
Gottlieb AB, Merola JF, Reich K, Behrens F, Nash P, Griffiths CEM, Bao W, Pellet P, Pricop L, McInnes IB. Efficacy of secukinumab and adalimumab in patients with psoriatic arthritis and concomitant moderate-to-severe plaque psoriasis: results from EXCEED, a randomized, double-blind head-to-head monotherapy study. Br J Dermatol 2021; 185:1124-1134. [PMID: 33913511 PMCID: PMC9291158 DOI: 10.1111/bjd.20413] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/28/2022]
Abstract
Background Secukinumab [an interleukin (IL)‐17A inhibitor] has demonstrated significantly higher efficacy vs. etanercept (a tumour necrosis factor inhibitor) and ustekinumab (an IL‐12/23 inhibitor) in patients with moderate‐to‐severe plaque psoriasis. Objectives To report 52‐week results from a prespecified analysis of patients with active psoriatic arthritis (PsA) having concomitant moderate‐to‐severe plaque psoriasis from the head‐to‐head EXCEED monotherapy study comparing secukinumab with adalimumab. Methods Patients were randomized to receive secukinumab 300 mg via subcutaneous injection at baseline, week 1–4, and then every 4 weeks until week 48 or adalimumab 40 mg via subcutaneous injection every 2 weeks from baseline until week 50. Assessments in patients with concomitant moderate‐to‐severe psoriasis, defined as having affected body surface area > 10% or Psoriasis Area and Severity Index (PASI) ≥ 10 at baseline, included musculoskeletal, skin and quality‐of‐life outcomes. Missing data were handled using multiple imputation. Results Of the 853 patients [secukinumab (N = 426), adalimumab (N = 427)], 211 (24·7%) had concomitant moderate‐to‐severe psoriasis [secukinumab (N = 110, 25·8%), adalimumab (N = 101, 23·7%)]. Up to week 50, 5·5% of patients discontinued secukinumab vs.17·8% in the adalimumab group. The proportion of patients who achieved American College of Rheumatology (ACR) 20 response was 76·4% with secukinumab vs. 68·3% with adalimumab (P = 0·175), PASI 100 response was 39·1% vs. 23·8% (P = 0·013), and simultaneous improvement in ACR 50 and PASI 100 response at week 52 was 28·2% vs. 17·7%, respectively (P = 0·06). Secukinumab demonstrated consistently higher responses vs. adalimumab across skin endpoints. Conclusions This prespecified analysis in PsA patients with concomitant moderate‐to‐severe plaque psoriasis in the EXCEED study provides further evidence that IL‐17 inhibitors offer a comprehensive biological treatment to manage the concomitant features of psoriasis and PsA.
What is already known about this topic?
Secukinumab, an interleukin‐17A inhibitor, has previously been reported to have significantly higher efficacy in head‐to‐head trials vs. etanercept and ustekinumab in patients with moderate‐to‐severe plaque psoriasis.
What does this study add?The results of the study provide valuable head‐to‐head data on the efficacy of two biologics with different mechanisms of action (secukinumab and adalimumab) as first‐line biological monotherapy for patients with psoriatic arthritis and concomitant moderate‐to‐severe plaque psoriasis. The findings of this study can further help physicians to make informed and evidence‐based decisions for the treatment of patients with active psoriatic arthritis who have concomitant moderate‐to‐severe plaque psoriasis.
Linked Comment: E. Sbidian and L. Pina‐Vegas. Br J Dermatol 2021; 185:1085.
Collapse
Affiliation(s)
- A B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J F Merola
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - K Reich
- Translational Research in Inflammatory Skin Diseases, Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - F Behrens
- Rheumatology University Hospital and Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Branch for Translational Medicine and Pharmacology TMP and Fraunhofer Cluster of Excellence for Immune-Mediated Diseases CIMD, Goethe University, Frankfurt, Germany
| | - P Nash
- Department of Medicine, Griffith University, Brisbane, QLD, Australia
| | - C E M Griffiths
- The Dermatology Centre, Salford Royal NHS Foundation Trust, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - W Bao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - P Pellet
- Novartis Pharma AG, Basel, Switzerland
| | - L Pricop
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | |
Collapse
|
21
|
Brzezińska O, Kuc A, Kobiałka D, Małecki D, Makowska J. Adherence with methotrexate in polish patients-Survey research results. Int J Clin Pract 2021; 75:e13677. [PMID: 32798326 DOI: 10.1111/ijcp.13677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/12/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Methotrexate (MTX) is the first-line medicine used in most inflammatory joint diseases. It is highly effective but, it's burdened with common side effects and the result of treatment is not immediately visible. This fact significantly increases the risk of unsatisfying patients' compliance. It may lead to difficulties in achieving disease remission and unjustified escalation of treatment. PURPOSE The aim of the study was to evaluate the methotrexate treatment schemes and to assess the patients' compliance with the treatment. MATERIALS AND METHODS The study was based on an online questionnaire distributed to rheumatic patients treated with MTX. The questions about MTX therapy, treatment monitoring, patients' compliance and causing of skipping drug doses were asked. RESULTS The questionnaire was filled up by 415 patients (21 men, 394 women and average age 36 ± 12.3). In 238 cases the MTX therapy was discontinued, in 148 the decision was taken by the physician, the others discontinued treatment on their own (90 subjects). From the group of patients who stopped taking MTX, 140 returned to the previous treatment. The most common cause of stopping treatment was gastrointestinal (GI) side effects. Self-discontinuation was more often explained by unbearable side-effects (63.33% vs 44.59%; P = .005) such as GI complaints, headaches and bad mood. The doctor's decision to stop treatment was more often caused by the occurrence of liver damage and the improvement of the patient's condition. Good compliance was declared by 346 patients. Most of them (61.69%) admit to skipping MTX doses. The most common reasons for missing a dose were: infectious disease and forgetfulness. The group of patients with good adherence to therapy was significantly older with longer disease duration. CONCLUSION High adherence with prescribed MTX is associated with good treatment tolerance, while the occurrence of side effects significantly increases the risk of discontinuation, often without consulting the physician.
Collapse
Affiliation(s)
- Olga Brzezińska
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
| | - Anita Kuc
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
| | - Diana Kobiałka
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
| | - Dawid Małecki
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
| | - Joanna Makowska
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
| |
Collapse
|
22
|
Choi SJ. Biologic therapies for the treatment of rheumatoid arthritis. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.2.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects the synovial joints. If left untreated, persistent synovial inflammation can lead to cartilage and bone destruction, ultimately causing significant longterm disability and mortality. However, since the late 1990s, the combined use of methotrexate, a synthetic diseasemodifying antirheumatic drug (DMARD), and a biological DMARD has revolutionized the treatment of RA. As of 2021, the Korea Food and Drug Administration has approved seven biological DMARDs for RA treatment: four tumor necrosis factor-alpha inhibitors (infliximab, etanercept, adalimumab, and golimumab) and three non-tumor necrosis factor biological products (abatacept, rituximab, and tocilizumab). Although the use of biological products has allowed significant advances in the treatment of RA, there are certain drawbacks, such as high cost, increased infection risk, and the necessity for parenteral route product administration. Therefore, discontinuation of biological DMARD use without a resulting disease flare is the next treatment goal and a desirable result from the standpoint of risk reduction and cost-effectiveness, especially for patients with clinical remission. It is still unclear which biological product is the best. Clinicians must, therefore, personalize the sequence and strategy of treatment by considering patient characteristics, disease activity, comorbidity, and economic condition
Collapse
|
23
|
Serban T, Allara R, Azzolini V, Bellintani C, Belloli L, Belai Beyene N, Bucci R, Caporali R, Cappelli A, Corbelli V, DE Gennaro F, Fusaro E, Giusti A, Govoni M, Magnani L, Manzo C, Romano C, Rossini M, Santilli D, Saviola G, Sinigaglia L, Bianchi G. Long-term methotrexate use in rheumatoid arthritis patients: real-world data from the MARTE study. Minerva Med 2021; 112:246-254. [PMID: 33555152 DOI: 10.23736/s0026-4806.21.06902-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The MARTE study investigated the demographic, clinical, and therapeutic characteristics of rheumatoid arthritis (RA) patients ongoing methotrexate (MTX) treatment for longer than 8 years. METHODS This cross-sectional, observational study considered 587 RA patients from 67 Rheumatology Units across Italy. Data collected included demographic, clinical, and therapeutic characteristics, focusing on MTX prescription patterns (route of administration, dosing regimens, treatment duration, and discontinuation). RESULTS As initial therapy, 90.6% of patients received one conventional synthetic Disease Modifying Anti Rheumatic Drug (csDMARD), with treatment started within the first 3 months from diagnosis in half of the patients. MTX was the first csDMARD in 46.2% of patients. The prevalent route of administration at diagnosis was the intramuscular (60.5%), while at study entry (baseline) 57.6% were receiving subcutaneous MTX. Patients who required a higher MTX dose at study entry were those who received a significantly lower starting MTX dose (P<0.001). Significantly higher MTX doses were currently required in men (P<0.001), current smokers (P=0.013), and overweight patients (P=0.028), whereas patients on oral therapy received significantly lower doses of MTX (P<0.001). CONCLUSIONS The MARTE study confirms once again the potential of the proper use of MTX in the treatment of RA. Data from our study suggest that a higher dose of MTX should be used since the first stages in overweight patients, men, and smokers.
Collapse
Affiliation(s)
- Teodora Serban
- S.C. Rheumatology, Department of Locomotor System, ASL3 Genovese, Genoa, Italy -
| | | | | | | | - Laura Belloli
- S.C. Rheumatology, Polyspecialist Medical Department, Niguarda Hospital, Milan, Italy
| | | | - Romano Bucci
- SSD Rheumatology, University Hospital OO. RR. of Foggia, Foggia, Italy
| | | | - Antonella Cappelli
- SS Rheumatology, ASST Settelaghi, Circolo Hospital and Macchi Foundation, Varese, Italy
| | - Vincenzo Corbelli
- Unit of Medicine, ASST Lariana, S. Anna Hospital, San Fermo della Battaglia, Como, Italy
| | - Fabio DE Gennaro
- US Rheumatology, Hospital of Cremona, ASST of Cremona, Cremona, Italy
| | - Enrico Fusaro
- SC Rheumatology, Città della Salute e della Scienza, Turin, Italy
| | - Andrea Giusti
- S.C. Rheumatology, Department of Locomotor System, ASL3 Genovese, Genoa, Italy
| | - Marcello Govoni
- University of Ferrara, S. Anna University Hospital, Ferrara, Italy
| | - Luca Magnani
- S.C. Rheumatology, IRCCS Arcispedale Santa Maria Nuova Hospital, Reggio Emilia, Italy
| | - Ciro Manzo
- ASL Napoli 3 Sud, Ambulatory of Rheumatology - Sanitary District 59, Sant'Agnello, Naples, Italy
| | - Ciro Romano
- Division of Internal Medicine and Immuno-allergology, SUN University Hospital, Naples, Italy
| | - Maurizio Rossini
- Section of Rheumatology, Department of Medicine, University Hospital of Borgo Trento, Verona, Italy
| | - Daniele Santilli
- S.S.D. Internal Medicine and Rheumatology, University Hospital of Parma, Parma, Italy
| | - Gianantonio Saviola
- Unit of Rheumatology and Rehabilitation, Institute of Castel Goffredo, IRCCS Maugeri Clinical Scientific Institutes, Mantua, Italy
| | - Luigi Sinigaglia
- Day Hospital of Rheumatology, G. Pini Orthopedic Institute, Milan, Italy
| | - Gerolamo Bianchi
- S.C. Rheumatology, Department of Locomotor System, ASL3 Genovese, Genoa, Italy
| | | |
Collapse
|
24
|
Sagdeo A, Askari A, Morrissey H, Ball PA. Baricitinib in Rheumatoid Arthritis – Real World Cross-Sectional Study. Open Rheumatol J 2020. [DOI: 10.2174/1874312902014010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction:
Rheumatoid Arthritis (RA) is the most common cause of inflammatory polyarthritis. In RA, increased circulating levels of pro-inflammatory cytokines contribute to the overall symptomatology of fatigue, pain, and joint stiffness. Baricitinib is an orally administered biologic DMARD, used in RA patients, inhibiting signaling via JAK1/JAK2 inhibition, reducing the release of pro-inflammatory cytokines.
Objective:
To explore the efficacy and tolerability for baricitinib in a local population.
Methods:
A cross-sectional study was carried out to review data of RA patients on Baricitinib from the researchers’ own clinic, since its approval in August 2017. The data was collected from an anonymized electronic patient records report. The clinical response was then classified into mild, moderate, and significant improvement.
Results and Discussion:
Overall, 27 out of 37 patients (72.9%) showed clinical improvement with baricitinib. In 9(24.3%) out of 37 patients, the dose had to be reduced to either 2mg/day or 2mg/day - 4mg/day on alternate days. In four of the 9 patients’ where the dose was reduced due to infections (UTI or sinuses), they subsequently experienced fewer infections while maintaining moderate improvement in their RA.
Conclusion:
There is a need for longer-term and larger studies to evaluate the full side effects profile of baricitinib in the local population.
Collapse
|
25
|
Management of Patients with Psoriatic Arthritis – Analysis and Discussion of the Main Points of the EULAR Recommendations 2019. Fam Med 2020. [DOI: 10.30841/2307-5112.4.2020.217350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
26
|
Favalli EG. Understanding the Role of Interleukin-6 (IL-6) in the Joint and Beyond: A Comprehensive Review of IL-6 Inhibition for the Management of Rheumatoid Arthritis. Rheumatol Ther 2020; 7:473-516. [PMID: 32734482 PMCID: PMC7410942 DOI: 10.1007/s40744-020-00219-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, debilitating autoimmune disorder involving inflammation and progressive destruction of the joints, affecting up to 1% of the population. The majority of patients with RA have one or more comorbid conditions, the most common being cardiovascular disease, osteoporosis, and depression, the presence of which are associated with poorer clinical outcomes and lower health-related quality of life. RA pathogenesis is driven by a complex network of proinflammatory cells and cytokines, and of these, interleukin-6 (IL-6) plays a key role in the chronic inflammation associated with RA. Through cell signaling that can be initiated by both membrane-bound and soluble forms of its receptor, IL-6 acts both locally to promote joint inflammation and destruction, and in the circulation to mediate extra-articular manifestations of RA, including pain, fatigue, morning stiffness, anemia, and weight loss. This narrative review describes the role of IL-6 in the pathogenesis of RA, its comorbidities, and extra-articular systemic manifestations, and examines the effects of the IL-6 receptor inhibitors sarilumab and tocilizumab on clinical endpoints of RA, patient-reported outcomes, and common comorbidities and extra-articular manifestations.
Collapse
Affiliation(s)
- Ennio G Favalli
- Department of Rheumatology, ASST Gaetano Pini-CTO Institute, University of Milan, Milan, Italy.
| |
Collapse
|
27
|
Pery N, Rizvi NB, Shafiq MI. Development of piperidinyl dipyrrrolopyridine-based dual inhibitors of Janus kinase and Bruton’s tyrosine kinase: a potential therapeutic probability to deal with rheumatoid arthritis. J Mol Model 2020; 26:235. [DOI: 10.1007/s00894-020-04512-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023]
|
28
|
Fleischmann R, Takeuchi T, Schiff M, Schlichting D, Xie L, Issa M, Stoykov I, Lisse J, Martinez‐Osuna P, Rooney T, Zerbini CAF. Efficacy and Safety of Long‐Term Baricitinib With and Without Methotrexate for the Treatment of Rheumatoid Arthritis: Experience With Baricitinib Monotherapy Continuation or After Switching From Methotrexate Monotherapy or Baricitinib Plus Methotrexate. Arthritis Care Res (Hoboken) 2020; 72:1112-1121. [DOI: 10.1002/acr.24007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 06/11/2019] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - Li Xie
- Eli Lilly and Company Indianapolis Indiana
| | - Maher Issa
- Eli Lilly and Company Indianapolis Indiana
| | | | | | | | | | | |
Collapse
|
29
|
Mease PJ, Gladman DD, Gomez-Reino JJ, Hall S, Kavanaugh A, Lespessailles E, Schett G, Paris M, Delev N, Teng L, Wollenhaupt J. Long-Term Safety and Tolerability of Apremilast Versus Placebo in Psoriatic Arthritis: A Pooled Safety Analysis of Three Phase III, Randomized, Controlled Trials. ACR Open Rheumatol 2020; 2:459-470. [PMID: 32710493 PMCID: PMC7437129 DOI: 10.1002/acr2.11156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 03/23/2020] [Indexed: 01/05/2023] Open
Abstract
Objective Psoriatic arthritis (PsA) requires long‐term treatment, yet safety concerns and monitoring requirements make maintenance a challenge. This analysis of pooled Psoriatic Arthritis Long‐term Assessment of Clinical Efficacy (PALACE) 1, 2, and 3 data describes 3‐year apremilast safety and tolerability in PsA. Methods Patients with active PsA were randomized (1:1:1) to placebo, apremilast 30 mg twice daily, or apremilast 20 mg twice daily. Placebo patients were re‐randomized to apremilast 30 mg twice daily or 20 mg twice daily at week 16 (early escape) or 24. Double‐blind treatment continued to week 52; patients could continue apremilast during an open‐label, long‐term treatment phase. Results In total, 1493 patients received at least one dose of study medication and were included in the safety population (placebo: n = 495; apremilast 30 mg: n = 497; apremilast 20 mg: n = 501). Among patients receiving apremilast, 53.2% (767/1441) completed 3 years of treatment. Greater rates of adverse events (AEs) were reported with apremilast (61.1%; exposure‐adjusted incidence rate [EAIR]/100 patient‐years, 265.1) versus placebo (47.5%; EAIR/100 patient‐years, 200.7) in the placebo‐controlled period. During weeks 0 to ≤52, the most common AEs occurring in apremilast‐exposed patients were diarrhea (13.9%; EAIR/100 patient‐years, 18.6), nausea (12.3%; EAIR/100 patient‐years, 16.0), headache (9.4%; EAIR/100 patient‐years, 12.1), upper respiratory tract infection (9.1%; EAIR/100 patient‐years, 11.5), and nasopharyngitis (6.2%; EAIR/100 patient‐years, 7.7). Most AEs were mild/moderate with apremilast exposure ≤156 weeks. Rates of depression remained low (EAIR/100 patient‐years, 1.8). Major adverse cardiac events (EAIR/100 patient‐years, 0.5), malignancies (EAIR/100 patient‐years, 0.9), and serious opportunistic infections (EAIR/100 patient‐years, 0.0) were infrequent over the 3‐year exposure period. Discontinuation rates due to AEs were low (<7.5%) across all apremilast‐exposure periods. Incidences of clinically meaningful abnormalities in postbaseline laboratory values was low; most values returned to baseline levels with continued treatment and without intervention. Conclusion Apremilast demonstrated a favorable safety profile and was well tolerated up to 156 weeks.
Collapse
Affiliation(s)
- Philip J Mease
- Swedish Medical Center/Providence St. Joseph Health, Seattle, Washington and University of Washington School of Medicine, Seattle
| | - Dafna D Gladman
- Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Stephen Hall
- Monash University, Cabrini Health, Melbourne, Australia
| | | | | | - Georg Schett
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany und Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | | | |
Collapse
|
30
|
Gossec L, Baraliakos X, Kerschbaumer A, de Wit M, McInnes I, Dougados M, Primdahl J, McGonagle DG, Aletaha D, Balanescu A, Balint PV, Bertheussen H, Boehncke WH, Burmester GR, Canete JD, Damjanov NS, Kragstrup TW, Kvien TK, Landewé RBM, Lories RJU, Marzo-Ortega H, Poddubnyy D, Rodrigues Manica SA, Schett G, Veale DJ, Van den Bosch FE, van der Heijde D, Smolen JS. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis 2020; 79:700-712. [PMID: 32434812 PMCID: PMC7286048 DOI: 10.1136/annrheumdis-2020-217159] [Citation(s) in RCA: 527] [Impact Index Per Article: 131.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To update the European League Against Rheumatism (EULAR) recommendations for the pharmacological treatment of psoriatic arthritis (PsA). METHODS According to the EULAR standardised operating procedures, a systematic literature review was followed by a consensus meeting to develop this update involving 28 international taskforce members in May 2019. Levels of evidence and strengths of recommendations were determined. RESULTS The updated recommendations comprise 6 overarching principles and 12 recommendations. The overarching principles address the nature of PsA and diversity of both musculoskeletal and non-musculoskeletal manifestations; the need for collaborative management and shared decision-making is highlighted. The recommendations provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs and local glucocorticoid injections are proposed as initial therapy; for patients with arthritis and poor prognostic factors, such as polyarthritis or monoarthritis/oligoarthritis accompanied by factors such as dactylitis or joint damage, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drugs (bDMARDs) targeting tumour necrosis factor (TNF), interleukin (IL)-17A or IL-12/23 should be initiated, taking into account skin involvement if relevant. If axial disease predominates, a TNF inhibitor or IL-17A inhibitor should be started as first-line disease-modifying antirheumatic drug. Use of Janus kinase inhibitors is addressed primarily after bDMARD failure. Phosphodiesterase-4 inhibition is proposed for patients in whom these other drugs are inappropriate, generally in the context of mild disease. Drug switches and tapering in sustained remission are addressed. CONCLUSION These recommendations provide stakeholders with an updated consensus on the pharmacological management of PsA, based on a combination of evidence and expert opinion.
Collapse
Affiliation(s)
- Laure Gossec
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France
- APHP.Sorbonne Universite, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
| | | | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3; 2nd Department of Medicine, Hietzing Hospital, Medical University of Vienna, Vienna, Austria
| | | | - Iain McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Maxime Dougados
- Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
| | - Jette Primdahl
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dennis G McGonagle
- LTHT, Leeds NIHR Biomedical Research Centre, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Andra Balanescu
- Research Center of Rheumatic Diseases, Sf Maria Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Peter V Balint
- 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | | | | | - Gerd R Burmester
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Juan D Canete
- Arthritis Unit, Department of Rheumatology and IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Nemanja S Damjanov
- Institute of Rheumatology, Belgrade University School of Medicine, Belgrade, Serbia
| | - Tue Wenzel Kragstrup
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark
- Department of Rheumatology, Aarhus Universitetshospital, Aarhus, Denmark
| | - Tore K Kvien
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands
- Rheumatology, Zuyderland MC, Heerlen, The Netherlands
| | - Rik Jozef Urbain Lories
- Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Helena Marzo-Ortega
- LTHT, Leeds NIHR Biomedical Research Centre, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Denis Poddubnyy
- Department of Rheumatology, Infectious Diseases and Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Epidemiology, German Rheumatism Research Center Berlin, Berlin, Germany
| | - Santiago Andres Rodrigues Manica
- Rheumatology, Hospital de Egas Moniz, Lisboa, Portugal
- Universidade Nova de Lisboa Centro de Estudos de Doencas Cronicas, Lisboa, Portugal
| | - Georg Schett
- Internal Medicine, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Douglas J Veale
- Centre for Arthritis and Rheumatic Disease, Dublin Academic Medical Centre, St Vincent's University Hospital, Dublin, Ireland
| | - Filip E Van den Bosch
- Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Gent, Belgium
| | - Désirée van der Heijde
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Wien, Austria
- 2nd Department of Medicine, Hietzing Hospital, Vienna, Wien, Austria
| |
Collapse
|
31
|
Li CKH, Baker K, Jones T, Coulson E, Roberts A, Birrell F. Safety and Tolerability of Subcutaneous Methotrexate in Routine Clinical Practice. Arthritis Care Res (Hoboken) 2020; 73:1306-1311. [PMID: 32475009 DOI: 10.1002/acr.24334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/19/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To show the safety and efficacy of subcutaneous (SC) methotrexate (MTX) compared to oral MTX, alternative disease-modifying antirheumatic drugs (DMARDs) monotherapy, biologic monotherapy, and combinations (conventional and biologic combination groups) in routine clinical practice. METHODS Clinical and laboratory data were retrospectively analyzed for rheumatology clinic attendances at a large Northeast England hospital trust between January 2014 and January 2018. Rates of adverse events and stop events (transaminitis [serum alanine aminotransferase level of >80 units/liter] or neutropenia [neutrophil count of <2.0 × 109 /liter]) were calculated, with adjustment for duration of DMARD exposure. RESULTS In the present study, 8,394 patients received DMARDs, with 2,093 patients receiving oral MTX and 949 patients receiving SC MTX. The median dose was 15 mg (interquartile range [IQR] 10-20 mg) for oral MTX, and 20 mg (IQR 15-25 mg) for SC MTX (P < 0.0001). Continuation rates were higher for SC MTX therapy when adjusted for follow-up duration, with a rate ratio (RR) of 1.54 (95% confidence interval [95% CI] 1.40-1.70) (P < 0.0001). For the time period assessed, 2,382 patients experienced 4,358 adverse events, with 1,711 incidents of transaminitis and 2,647 incidents of neutropenia recorded. Significantly fewer adverse events were observed in patients who received SC MTX monotherapy versus those who received biologic and combination DMARD therapies (P < 0.01). Compared to oral MTX, SC MTX was associated with a nonsignificant trend toward lower rates of neutropenia, but only a slightly higher rate of transaminitis (RR 1.26 [95% CI 1.07-1.48]) (P = 0.006), despite significantly higher doses of MTX. CONCLUSION Subcutaneous MTX is safe in routine clinical practice. This is the largest study yet reported on SC MTX and provides observational data that SC MTX is continued longer and better tolerated in patients compared to other therapy groups, especially oral MTX.
Collapse
Affiliation(s)
- Christien K H Li
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Kenneth Baker
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Tania Jones
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Elizabeth Coulson
- Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Fraser Birrell
- Translational and Clinical Research Institute, Newcastle University and Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| |
Collapse
|
32
|
McInnes IB, Behrens F, Mease PJ, Kavanaugh A, Ritchlin C, Nash P, Masmitja JG, Goupille P, Korotaeva T, Gottlieb AB, Martin R, Ding K, Pellet P, Mpofu S, Pricop L. Secukinumab versus adalimumab for treatment of active psoriatic arthritis (EXCEED): a double-blind, parallel-group, randomised, active-controlled, phase 3b trial. Lancet 2020; 395:1496-1505. [PMID: 32386593 DOI: 10.1016/s0140-6736(20)30564-x] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Head-to-head trials in psoriatic arthritis are helpful in guiding clinical decision making. The EXCEED study evaluated the efficacy and safety of secukinumab versus adalimumab as first-line biological monotherapy for 52 weeks in patients with active psoriatic arthritis, with a musculoskeletal primary endpoint of American College of Rheumatology (ACR) 20 response. METHODS This parallel-group, double-blind, active-controlled, phase-3b, multicentre (168 sites in 26 countries) trial enrolled patients aged at least 18 years with active psoriatic arthritis. Eligible patients were randomly assigned (1:1) by means of interactive response technology to receive secukinumab or adalimumab. Patients, investigators, site personnel, and those doing the assessments (except independent study drug administrators) were masked to study assignment. 300 mg secukinumab was administered subcutaneously at baseline, weeks 1, 2, 3, and 4, and then every 4 weeks until week 48 as a pre-filled syringe. Adalimumab was administered every 2 weeks from baseline until week 50 as 40 mg per 0·4 mL citrate free subcutaneous injection. The primary outcome was the proportion of patients with at least 20% improvement in the ACR response criteria (ACR20) at week 52. Patients were analysed according to the treatment to which they were randomly assigned. Safety analyses included all safety data reported up to and including the week 52 visit for each patient who received at least one dose of study drug. The trial is registered at ClinicalTrials.gov, NCT02745080. FINDINGS Between April 3, 2017 and Aug 23, 2018, we randomly assigned 853 patients to receive secukinumab (n=426) or adalimumab (n=427). 709 (83%) of 853 patients completed week 52 of the study, of whom 691 (81%) received the last study treatment at week 50. 61 (14%) of 426 patients in the secukinumab group discontinued treatment by week 52 versus 101 (24%) of 427 patients in the adalimumab group. The primary endpoint of superiority of secukinumab versus adalimumab for ACR20 response at week 52 was not met. 67% of patients in the secukinumab group achieved an ACR20 response at week 52 versus 62% of patients in the adalimumab group (OR 1·30, 95% CI 0·98-1·72; p=0·0719). The safety profiles of secukinumab and adalimumab were consistent with previous reports. Seven (2%) of 426 patients in the secukinumab group and six (1%) of 427 patients in the adalimumab group had serious infections. One death was reported in the secukinumab group due to colon cancer and was assessed as not related to the study drug by the investigator. INTERPRETATION Secukinumab did not meet statistical significance for superiority versus adalimumab in the primary endpoint of ACR20 response at week 52. However, secukinumab was associated with a higher treatment retention rate than adalimumab. This study provides comparative data on two biological agents with different mechanisms of action, which could help guide clinical decision making in the management of patients with psoriatic arthritis. FUNDING Novartis Pharma.
Collapse
Affiliation(s)
- Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Frank Behrens
- Rheumatology University Hospital and Fraunhofer Institute for Molecular Biology and Applied Ecology, Branch for Translational Medicine and Pharmacology and Fraunhofer Cluster of Excellence for Immune-Mediated Diseases, Goethe University, Frankfurt, Germany
| | - Philip J Mease
- Swedish Medical Centre, Providence St Joseph Health and University of Washington, Seattle, WA, USA
| | - Arthur Kavanaugh
- Rheumatology, Allergy, Immunology Division, University of California San Diego, School of Medicine, La Jolla, CA, USA
| | - Christopher Ritchlin
- Allergy, Immunology and Rheumatology Division, University of Rochester, Rochester, NY, USA
| | - Peter Nash
- Department of Medicine, Griffith University, Brisbane, QLD, Australia
| | - Jordi Gratacós Masmitja
- Rheumatology Department, University Hospital Parc Taulí, Sabadell, Universitat Autònoma de Barcelona, Spain
| | - Philippe Goupille
- Department of Rheumatology and INSERM-CIC1415, University Hospital of Tours, EA 7501 GICC, University of Tours, Tours, France
| | - Tatiana Korotaeva
- Research Institute of Rheumatology n.a. V A Nasonova, Moscow, Russia
| | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Kevin Ding
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | | | | | | |
Collapse
|
33
|
Taylor PC, Law ST. When the first visit to the rheumatologist is established rheumatoid arthritis. Best Pract Res Clin Rheumatol 2020; 33:101479. [PMID: 32001168 DOI: 10.1016/j.berh.2019.101479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The outlook for people living with rheumatoid arthritis (RA) has improved tremendously in a generation. Major contributions to this include recognition of the importance of early treatment initiation, improved understanding of the pathobiology, the identification of therapeutic targets and their subsequent validation in clinic trials and the realisation of the importance of 'tight control' of inflammatory responses. Despite these advances, many patients meeting classification criteria present for the first time to a rheumatologist with longstanding symptoms. There is no definition as to when RA becomes 'established'. But there is evidence that a 'window of opportunity' exists over about 12-16 weeks symptom duration, during which treatment intervention gives rise to the most optimal outcomes. This review addresses issues regarding the management of patients presenting outside the window of opportunity in terms of heterogeneity of presentation, assessment, therapeutic goals and treatment options as well as the importance of a multidisciplinary approach to holistic care.
Collapse
|
34
|
Law ST, Taylor PC. Role of biological agents in treatment of rheumatoid arthritis. Pharmacol Res 2019; 150:104497. [PMID: 31629903 DOI: 10.1016/j.phrs.2019.104497] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/26/2019] [Accepted: 10/14/2019] [Indexed: 12/20/2022]
Abstract
Advances in understanding of the pathophysiology of rheumatoid arthritis with concurrent advances in protein engineering led to the development of biological disease-modifying antirheumatic drugs which have dramatically revolutionized the treatment of this condition. This review article focuses on the role of biological agents currently employed in the treatment of rheumatoid arthritis, as well as novel biological agents in development.
Collapse
Affiliation(s)
- Shing T Law
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK.
| |
Collapse
|
35
|
Lucas CJ, Dimmitt SB, Martin JH. Optimising low-dose methotrexate for rheumatoid arthritis-A review. Br J Clin Pharmacol 2019; 85:2228-2234. [PMID: 31276602 DOI: 10.1111/bcp.14057] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
Methotrexate at low doses (5-25 mg/week) is first-line therapy for rheumatoid arthritis. However, there is inter- and intrapatient variability in response, with contribution of variability in concentrations of active polyglutamate metabolites, associated with clinical efficacy and toxicity. Prescribing remains heterogeneous across population groups, disease states and regimens. This review examines current knowledge of dose-response of oral methotrexate in the setting of rheumatoid arthritis, and how this could help inform dosage regimens.
Collapse
Affiliation(s)
- Catherine J Lucas
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Simon B Dimmitt
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Internal Medicine, Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Western Australia, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Hunter New England Local Health District, Newcastle, New South Wales, Australia
| |
Collapse
|
36
|
Impact of Adverse Events Associated With Medications in the Treatment and Prevention of Rheumatoid Arthritis. Clin Ther 2019; 41:1376-1396. [DOI: 10.1016/j.clinthera.2019.04.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/28/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
|
37
|
Smolen JS, Pangan AL, Emery P, Rigby W, Tanaka Y, Vargas JI, Zhang Y, Damjanov N, Friedman A, Othman AA, Camp HS, Cohen S. Upadacitinib as monotherapy in patients with active rheumatoid arthritis and inadequate response to methotrexate (SELECT-MONOTHERAPY): a randomised, placebo-controlled, double-blind phase 3 study. Lancet 2019; 393:2303-2311. [PMID: 31130260 DOI: 10.1016/s0140-6736(19)30419-2] [Citation(s) in RCA: 217] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/12/2019] [Accepted: 02/19/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Upadacitinib, an oral Janus kinase (JAK)1-selective inhibitor, showed efficacy in combination with stable background conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) in patients with rheumatoid arthritis who had an inadequate response to DMARDs. We aimed to evaluate the safety and efficacy of upadacitinib monotherapy after switching from methotrexate versus continuing methotrexate in patients with inadequate response to methotrexate. METHODS SELECT-MONOTHERAPY was conducted at 138 sites in 24 countries. The study enrolled adults (≥18 years) who fulfilled the 2010 American College of Rheumatology (ACR)-European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis. Patients with active rheumatoid arthritis despite stable methotrexate were randomly assigned 2:2:1:1 to switch to once-daily monotherapy of of upadacitinib or to continue methotrexate at their existing dose as blinded study drug; starting from week 14, patients assigned to continue methotrexate were switched to 15 mg or 30 mg once-daily upadacitinib per prespecified random assignment at baseline. The primary endpoints in this report are proportion of patients achieving 20% improvement in the ACR criteria (ACR20) at week 14, and proportion achieving low disease activity defined as 28-joint Disease Activity Score using C-reactive protein (DAS28[CRP]) of 3·2 or lower, both with non-responder imputation at week 14. Outcomes were assessed in patients who received at least one dose of study drug. This study is active but not recruiting and is registered with ClinicalTrials.gov, number NCT02706951. FINDINGS Patients were screened between Feb 23, 2016, and May 19, 2017 and 648 were randomly assigned to treatment. 598 (92%) completed week 14. At week 14, an ACR20 response was achieved by 89 (41%) of 216 patients (95% CI 35-48) in the continued methotrexate group, 147 (68%) of 217 patients (62-74) receiving upadacitinib 15 mg, and 153 (71%) of 215 patients (65-77) receiving upadacitinib 30 mg (p<0·0001 for both doses vs continued methotrexate). DAS28(CRP) 3·2 or lower was met by 42 (19%) of 216 (95% CI 14-25) in the continued methotrexate group, 97 (45%) of 217 (38-51) receiving upadacitinib 15 mg, and 114 (53%) of 215 (46-60) receiving upadacitinib 30 mg (p<0·0001 for both doses vs continued methotrexate). Adverse events were reported in 102 patients (47%) on continued methotrexate, 103 (47%) on upadacitinib 15 mg, and 105 (49%) on upadacitinib 30 mg. Herpes zoster was reported by one (<1%) patient on continued methotrexate, three (1%) on upadacitinib 15 mg, and six (3%) on upadacitinib 30 mg. Three malignancies (one [<1%] on continued methotrexate, two [1%] on upadacitinib 15 mg), three adjudicated major adverse cardiovascular events (one [<1%] on upadacitinib 15 mg, two [<1%] on upadacitinib 30 mg), one adjudicated pulmonary embolism (<1%; upadacitinib 15 mg), and one death (<1%; upadacitinib 15 mg, haemorrhagic stroke [ruptured aneurysm]) were reported in the study. INTERPRETATION Upadacitinib monotherapy showed statistically significant improvements in clinical and functional outcomes versus continuing methotrexate in this methotrexate inadequate-responder population. Safety observations were similar to those in previous upadacitinib rheumatoid arthritis studies. FUNDING AbbVie Inc, USA.
Collapse
Affiliation(s)
| | | | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds NIHR BRC, Leeds, UK
| | | | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | | | | | - Nemanja Damjanov
- University of Belgrade School of Medicine, Institute of Rheumatology, Belgrade, Serbia
| | | | | | | | | |
Collapse
|
38
|
Abstract
Methotrexate (MTX) is widely used in the treatment of psoriatic arthritis (PsA), despite the evidence base for this being limited. This narrative review summarizes the evidence to date of using MTX within different domains of psoriatic disease, including peripheral arthritis, axial disease, dactylitis, enthesitis, psoriasis, and nail disease. We also explore the role of MTX in combination therapy with tumor necrosis factor inhibitors, in addition to its safety and tolerability, to answer the question: should methotrexate have any place in the treatment of psoriatic arthritis?
Collapse
|
39
|
Lomholt S, Mellemkjaer A, Iversen MB, Pedersen SB, Kragstrup TW. Resveratrol displays anti-inflammatory properties in an ex vivo model of immune mediated inflammatory arthritis. BMC Rheumatol 2018; 2:27. [PMID: 30886977 PMCID: PMC6390607 DOI: 10.1186/s41927-018-0036-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/29/2018] [Indexed: 12/18/2022] Open
Abstract
Background Resveratrol is a natural polyphenol found in berries, roots and wine that is well known to have anti-inflammatory and anti-oxidative properties. The anti-inflammatory effect has been reported for both immune cells and connective tissues, but only few studies have investigated effects on immune mediated inflammatory arthritis. None of which have studied this effect when combining resveratrol with methotrexate or adalimumab, two major drugs in the treatment of immune mediated inflammatory arthritis. We therefore aimed to investigate the anti-inflammatory effect of resveratrol alone and in combination with methotrexate or adalimumab in ex vivo models of immune mediated inflammatory arthritis. We furthermore aimed to describe any variations in this effect based on disease activity and cellular composition of the synovial fluid infiltrate. Methods Synovial fluid mononuclear cells from patients with rheumatoid arthritis (n = 7) and spondyloarthritis (n = 7) were cultured for either 48 h or 21 days. In both models, synovial fluid mononuclear cells were treated with resveratrol alone or in combination with methotrexate or adalimumab. Monocyte chemoattractant protein 1, matrix metalloproteinase 3 and tartrate resistant acidic phosphatase were measured to quantify inflammation, enzymatic degradation and osteoclast differentiation, respectively. Results Resveratrol reduced monocyte chemoattractant protein 1 production by synovial fluid mononuclear cells significantly (p = 0.005) compared to untreated controls. The effect of resveratrol was greatest in cultures from patients with low disease activity, i.e. DAS28CRP ≤ 3.2 (p = 0.022), and in cultures dominated by lymphocytes (p = 0.03). Further, the combination of methotrexate and resveratrol significantly reduced monocyte chemoattractant protein 1 levels compared with methotrexate alone in cultures from patients with low disease activity (p = 0.016), and in cultures with high lymphocyte count (p = 0.011). Resveratrol did not significantly affect matrix metalloproteinase 3 and tartrate resistant acidic phosphatase production. Conclusion Resveratrol has anti-inflammatory properties in our ex vivo model of immune mediated inflammatory arthritis. Results show an additive effect of resveratrol, when combined with methotrexate in samples dominated by lymphocytes and samples from patients with low disease activity. This suggests further investigations in vitro and whether this effect may also be present in a clinical setting. Electronic supplementary material The online version of this article (10.1186/s41927-018-0036-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- S Lomholt
- 1Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - A Mellemkjaer
- 1Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - M B Iversen
- 1Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - S B Pedersen
- 2Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - T W Kragstrup
- 1Department of Biomedicine, Aarhus University, Aarhus, Denmark.,3Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,4Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| |
Collapse
|
40
|
Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review. Eur J Med Chem 2018; 158:502-516. [PMID: 30243154 DOI: 10.1016/j.ejmech.2018.09.027] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022]
Abstract
Methotrexate (MTX) is used as an anchor disease-modifying anti-rheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA) because of its potent efficacy and tolerability. MTX benefits a large number of RA patients but partially suffered from side effects. A variety of side effects can be associated with MTX when treating RA patients, from mild to severe or discontinuation of the treatment. In this report, we reviewed the possible side effects that MTX might cause from the most common gastrointestinal toxicity effects to less frequent malignant diseases. In order to achieve regimen with less side effects, the administration of MTX with appropriate dose and a careful pretreatment inspection is necessary. Further investigations are required when combining MTX with other drugs so as to enhance the efficacy and reduce side effects at the same time. The management of MTX treatment is also discussed to provide strategies for occurred side effects. Thus, this review will provide scholars with a comprehensive understanding the side effects of MTX administration by RA patients.
Collapse
|
41
|
Kucharz EJ, Stajszczyk M, Kotulska-Kucharz A, Batko B, Brzosko M, Jeka S, Leszczyński P, Majdan M, Olesińska M, Samborski W, Wiland P. Tofacitinib in the treatment of patients with rheumatoid arthritis: position statement of experts of the Polish Society for Rheumatology. Reumatologia 2018; 56:203-211. [PMID: 30237624 PMCID: PMC6142023 DOI: 10.5114/reum.2018.77971] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 12/30/2022] Open
Abstract
Tofacitinib is a newly approved small-molecule targeted synthetic disease-modifying antirheumatic drug. The drug was designed as a selective and specific inhibitor of pro-inflammatory receptor signalling. Tofacitinib inhibits the process of intracellular signalling from the receptor to the cellular nucleus and inhibits the inflammation process via a new pathway (inhibition of the Janus kinases), which is unavailable to biological medicines. Tofacitinib has been approved for use in the treatment of patients with moderate to severe active RA. The drug may be used in combination with methotrexate or another conventional synthetic disease-modifying antirheumatic drug or in monotherapy. The efficacy of tofacitinib has been confirmed in several clinical trials. The drug inhibits radiographic progression of the disease. The innovative mechanism of action of tofacitinib is a noteworthy feature because it offers hope of effective treatment for patients who fail to respond to other drugs. The presented article discusses the mechanism of action and the clinical application of tofacitinib. Tofacitinib represents a new group of disease-modifying antirheumatic drugs that can be placed on an equal footing with biological drugs already available.
Collapse
Affiliation(s)
- Eugeniusz J. Kucharz
- Department of Internal Medicine, Rheumatology, and Clinical Immunology, Medical University of Silesia in Katowice, Poland
| | - Marcin Stajszczyk
- Department of Rheumatology and Autoimmune Diseases, Silesian Centre for Rheumatology, Rehabilitation, and Disability Prevention in Ustroń, Poland
| | - Anna Kotulska-Kucharz
- Department of Internal Medicine, Rheumatology, and Clinical Immunology, Medical University of Silesia in Katowice, Poland
| | - Bogdan Batko
- Department of Rheumatology, J. Dietl Memorial Specialist Hospital in Kraków, Poland
| | - Marek Brzosko
- Department of Rheumatology, Internal Medicine, and Geriatrics, Pomeranian Medical University in Szczecin, Poland
| | - Sławomir Jeka
- Department of Rheumatology and Systemic Connective Tissue Disorders, Jan Biziel University Hospital No. 2 in Bydgoszcz, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
| | - Piotr Leszczyński
- Department of Rheumatology and Rehabilitation, Poznań University of Medical Sciences, Poland
- Department of Rheumatology and Osteoporosis, J. Struś Memorial Multidisciplinary Municipal Hospital in Poznań, Poland
| | - Maria Majdan
- Department of Rheumatology and Systemic Connective Tissue Disorders, Medical University of Lublin, Poland
| | - Marzena Olesińska
- Clinic of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Włodzimierz Samborski
- Department of Rheumatology and Rehabilitation, Poznań University of Medical Sciences, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wrocław Medical University, Poland
| |
Collapse
|
42
|
Strand V, Gossec L, Proudfoot CWJ, Chen CI, Reaney M, Guillonneau S, Kimura T, van Adelsberg J, Lin Y, Mangan EK, van Hoogstraten H, Burmester GR. Patient-reported outcomes from a randomized phase III trial of sarilumab monotherapy versus adalimumab monotherapy in patients with rheumatoid arthritis. Arthritis Res Ther 2018; 20:129. [PMID: 29921318 PMCID: PMC6009058 DOI: 10.1186/s13075-018-1614-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 04/30/2018] [Indexed: 01/14/2023] Open
Abstract
Background The phase III MONARCH randomized controlled trial (NCT02332590) demonstrated that in patients with rheumatoid arthritis (RA), sarilumab (anti-interleukin-6 receptor monoclonal antibody) monotherapy is superior to adalimumab monotherapy in reducing disease activity and signs and symptoms of RA, as well as in improving physical function, with similar rates of adverse and serious adverse events. We report the effects of sarilumab versus adalimumab on patient-reported outcomes (PROs). Methods Patients with active RA intolerant of, or inadequate responders to, methotrexate were randomized to sarilumab 200 mg plus placebo every 2 weeks (q2w; n = 184) or adalimumab 40 mg plus placebo q2w (n = 185). Dose escalation to weekly administration of adalimumab or matching placebo was permitted at week 16. PROs assessed at baseline and weeks 12 and 24 included patient global assessment of disease activity (PtGA), pain and morning stiffness visual analogue scales (VASs), Health Assessment Questionnaire Disability Index (HAQ-DI), 36-item Short Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F), Rheumatoid Arthritis Impact of Disease (RAID), and rheumatoid arthritis-specific Work Productivity Survey (WPS-RA). Between-group differences in least-squares mean (LSM) changes from baseline were analyzed. p < 0.05 was considered significant for PROs in a predefined hierarchy. For PROs not in the hierarchy, nominal p values are provided. Proportions of patients reporting improvements greater than or equal to the minimal clinically important difference (MCID) and achieving normative values were assessed. Results At week 24, sarilumab treatment resulted in significantly greater LSM changes from baseline than adalimumab monotherapy in HAQ-DI (p < 0.005), PtGA (p < 0.001), pain VAS (p < 0.001), and SF-36 Physical Component Summary (PCS) (p < 0.001). Greater LSM changes were reported for sarilumab than for adalimumab in RAID (nominal p < 0.001), morning stiffness VAS (nominal p < 0.05), and WPS-RA (nominal p < 0.005). Between-group differences in FACIT-F and SF-36 Mental Component Summary (MCS) were not significant. More patients reported improvements greater than or equal to the MCID in HAQ-DI (nominal p < 0.01), RAID (nominal p < 0.01), SF-36 PCS (nominal p < 0.005), and morning stiffness (nominal p < 0.05), as well as greater than or equal to the normative values in HAQ-DI (p < 0.05), with sarilumab versus adalimumab. Conclusions In parallel with the clinical efficacy profile previously reported, sarilumab monotherapy resulted in greater improvements across multiple PROs than adalimumab monotherapy. Trial registration ClinicalTrials.gov, NCT02332590. Registered on 5 January 2015. Electronic supplementary material The online version of this article (10.1186/s13075-018-1614-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Laure Gossec
- Sorbonne Universités, UPMC Université Paris 6, GRC-UPMC 08 (EEMOIS), Paris, France.,Department of Rheumatology, Assistance publique - Hôpitaux de Paris, Pitié Salpêtrière Hospital, Paris, France
| | | | - Chieh-I Chen
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY, 10591-6707, USA.
| | | | | | - Toshio Kimura
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY, 10591-6707, USA
| | - Janet van Adelsberg
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY, 10591-6707, USA.,Present Address: Celgene, Summit, NJ, USA
| | | | - Erin K Mangan
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY, 10591-6707, USA
| | | | | |
Collapse
|
43
|
Favalli EG, Becciolini A, Biggioggero M, Bertoldi I, Crotti C, Raimondo MG, Marchesoni A. The role of concomitant methotrexate dosage and maintenance over time in the therapy of rheumatoid arthritis patients treated with adalimumab or etanercept: retrospective analysis of a local registry. Drug Des Devel Ther 2018; 12:1421-1429. [PMID: 29872265 PMCID: PMC5973379 DOI: 10.2147/dddt.s162286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the pattern of prescription and maintenance over time of concomitant methotrexate (MTX), and its impact on a 2-year clinical response in a cohort of rheumatoid arthritis (RA) patients treated with a first-line tumor necrosis factor alpha inhibitor (TNFi). PATIENTS AND METHODS The study population included all RA patients receiving adalimumab or etanercept a as first-line biologic drug, extracted from a local registry. Enrolled patients were stratified into 3 subgroups according to baseline concomitant MTX: no MTX, low-dose MTX (≤10 mg/wk), and high-dose MTX (≥12.5 mg/wk). The 2-year persistence of the initial MTX regimen was computed by the Kaplan-Meier method, and a Cox proportional hazard model was developed to examine potential predictors of MTX withdrawal/change of dosage. European League Against Rheumatism remission and good-to-moderate response were evaluated according to baseline MTX regimen and MTX maintenance over time. RESULTS A total of 330 patients (163 treated with adalimumab and 167 with etanercept) were included; 141 were prescribed TNFi without MTX and 112 received low-dose and 77 high-dose concomitant MTX. Male sex, younger age, and shorter mean disease duration were predictors of high-dose MTX use. Among MTX users (76.2% parenteral and 23.8% oral), initial MTX dose persisted over time in 79.9% at 1 year and 70.2% at 2 years. Fifty-one patients (27%) underwent MTX dose de-escalation/discontinuation because of intolerance/adverse events. The 2-year EULAR remission rate was higher in the patients receiving and maintaining high-dose MTX than in those receiving low-dose or no MTX (46.2% vs 29.5% and 23.4%, respectively; p=0.009). The same was true for good-to-moderate response rate (71.2% vs 52.6% and 50.4%, respectively; p=0.031). CONCLUSION In a real-life setting, about one-third of RA patients treated with TNFis experienced dose reduction/discontinuation of concomitant MTX because of intolerance/adverse events over a 2-year follow-up period. Initial high-dose MTX and its maintenance over time are associated with better 2-year clinical response.
Collapse
Affiliation(s)
| | | | - Martina Biggioggero
- Department of Clinical Sciences and Health Community, University of Milan, Division of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | | | - Chiara Crotti
- Department of Clinical Sciences and Health Community, University of Milan, Division of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - Maria Gabriella Raimondo
- Department of Clinical Sciences and Health Community, University of Milan, Division of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | | |
Collapse
|
44
|
Lauper K, Nordström DC, Pavelka K, Hernández MV, Kvien TK, Kristianslund EK, Santos MJ, Rotar Ž, Iannone F, Codreanu C, Lukina G, Gale SL, Sarsour K, Luder Y, Courvoisier DS, Gabay C. Comparative effectiveness of tocilizumab versus TNF inhibitors as monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis after the use of at least one biologic disease-modifying antirheumatic drug: analyses from the pan-European TOCERRA register collaboration. Ann Rheum Dis 2018; 77:1276-1282. [PMID: 29730637 DOI: 10.1136/annrheumdis-2017-212845] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/24/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare the effectiveness of tocilizumab (TCZ) and tumour necrosis factor (TNF) inhibitors (TNFi) as monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA) after the use of at least one biologic DMARD (bDMARD). METHODS We included patients with RA having used at least one bDMARD from 10 European registries. We compared drug retention using Kaplan-Meier and Cox models and Clinical Disease Activity Index (CDAI) change over time with mixed-effects models for longitudinal data. The proportions of CDAI remission and low disease activity (LDA) at 1 year were compared using LUNDEX correction. RESULTS 771 patients on TCZ as monotherapy (TCZ mono), 1773 in combination therapy (TCZ combo), 1404 on TNFi as monotherapy (TNFi mono) and 4660 in combination therapy (TNFi combo) were retrieved. Crude median retention was higher for TCZ mono (2.31 years, 95% CI 2.07 to 2.61) and TCZ combo (1.98 years, 95% CI 1.83 to 2.11) than TNFi combo (1.37 years, 95% CI 1.30 to 1.45) and TNFi mono (1.31 years, 95% CI 1.18 to 1.47). In a country and year of treatment initiation-stratified, covariate-adjusted analysis, hazards of discontinuation were significantly lower among patients on TCZ mono or combo compared with patients on TNFi mono or combo, and TNFi combo compared with TNFi mono, but similar between TCZ mono and combo. Average adjusted CDAI change was similar between groups. CDAI remission and LDA rates were comparable between groups. CONCLUSION With significantly longer drug retention and similar efficacy to TNFi combo, TCZ mono or combo are reasonable therapeutic options in patients with inadequate response to at least one bDMARD.
Collapse
Affiliation(s)
- Kim Lauper
- Geneva University Hospitals, Geneva, Switzerland.,SCQM Registry, Zurich, Switzerland
| | - Dan C Nordström
- ROB-FIN Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Maria Jose Santos
- Rheumatology Department, Hospital Garcia de Orta, on behalf of Reuma.pt, Almada, Portugal
| | - Žiga Rotar
- BioRx.si, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Galina Lukina
- ARBITER, Institute of Rheumatology, Moscow, Russian Federation
| | - Sara L Gale
- Genentech, South San Francisco, California, USA
| | | | - Yves Luder
- F. Hoffmann-La Roche AG, Basel, Switzerland
| | | | - Cem Gabay
- Geneva University Hospitals, Geneva, Switzerland.,SCQM Registry, Zurich, Switzerland
| |
Collapse
|
45
|
Busger op Vollenbroek FTM, Doggen CJM, Janssens RWA, Bernelot Moens HJ. Dermatological guidelines for monitoring methotrexate treatment reduce drug-survival compared to rheumatological guidelines. PLoS One 2018; 13:e0194401. [PMID: 29570708 PMCID: PMC5865732 DOI: 10.1371/journal.pone.0194401] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 03/04/2018] [Indexed: 01/30/2023] Open
Abstract
Background Methotrexate (MTX) is widely used as disease modifying treatment for psoriasis and psoriatic arthritis (PsA). Rheumatological and dermatological guidelines to prevent MTX-induced adverse events diverge in the number and frequency of blood tests. These differences are not based on evidence indicating a higher risk for patients with psoriasis compared to PsA or rheumatic arthritis (RA). This raises the question if multiple testing increases safety, or results in false positive signals potentially leading to early withdrawal of an effective treatment. Objective Compare the effects of MTX monitoring strategies by rheumatologists and dermatologists regarding drug survival, reasons for withdrawal and safety. Methods Retrospective follow-up of all patients diagnosed with psoriasis by dermatologists or PsA by rheumatologists. Included were consecutive patients who started methotrexate (MTX) between 2006 and 2012 and had a scheduled follow-up by dermatologist or rheumatologist. Exclusions were: drug not started after the first prescription or incomplete availability of lab data. Data were extracted from electronic records: start and stop dates and dosing of MTX; treatment with folic acid and dose; reasons for withdrawal of MTX; numbers of blood sampling and types of laboratory tests performed for MTX safety; number of abnormal tests; occurrence of any serious adverse event (SAE). Results 190 Psoriasis and 196 PsA patients starting methotrexate (MTX) were included. Age and sex were comparable. PsA patients used higher initial and maximum doses of MTX and folic acid, but psoriasis patients had a higher frequency of abnormal laboratory results (0.14 vs 0.03 per treatment month, p<0.001), resulting in a striking difference in withdrawal of MTX for abnormal liver enzymes (15.8% vs 3.6%, p<0.001). In PsA patients MTX was withdrawn less frequently for ineffectiveness (15.8 vs 24.2%, p<0.05) leading to longer drug survival in the first course of treatment (37.4±30 vs 18.8±19.1 months). Repeated courses of MTX were more often prescribed by rheumatologists than by dermatologists. There were no significant differences in the occurrence of SAE (psoriasis 0.0041 vs PsA 0.0038 per treatment month) or death (1.6% vs 2.0%) between these groups. Hospital admissions related to infection were recorded in 6 (3.1%) PsA vs 4 (2.1%) psoriasis patients. Conclusion Strict monitoring by dermatologists resulted in more abnormal findings, which reduced drug survival of MTX. The limited monitoring strategy by rheumatologists was not associated with more SAEs. Further research in other populations is needed to confirm whether reduced intensity of monitoring can optimize the use of MTX with sufficient long-term safety.
Collapse
Affiliation(s)
| | - Carine J. M. Doggen
- Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | | | | |
Collapse
|
46
|
Świerkot J, Batko B, Wiland P, Jędrzejewski M, Stajszczyk M. Methotrexate treatment for rheumatoid arthritis in Poland: Retrospective analysis of patients in routine clinical practice. Reumatologia 2018; 56:3-9. [PMID: 29686436 PMCID: PMC5911651 DOI: 10.5114/reum.2018.74741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 02/21/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate methotrexate (MTX) treatment administered by Polish rheumatologists in everyday practice. MATERIAL AND METHODS The study was based on a retrospective analysis of a cohort of 1957 patients with rheumatoid arthritis (RA). It was conducted among 100 rheumatologists, each of whom received 20 questionnaires and completed them based on the data from their rheumatoid arthritis patients. RESULTS Methotrexate was taken by 91% of patients, and 80% of them continued the treatment either as a monotherapy (65%) or concomitantly with other disease-modifying anti-rheumatic drugs. In 60% of the cases, therapy was initiated within six months of diagnosis. Dose modifications were observed in 76% of cases and were contingent on different factors, e.g. lack of efficacy, presence of adverse events. The most prevalent adverse events were nausea and vomiting, weakness, and elevated liver enzyme activity. The most common initial dose of MTX was 10 or 15 mg/week. An increase in dose to the maximum of 25 mg/week was observed in 36% of cases, with continuation for 27% of patients. Treatment interruption was noted in 21% of patients, predominantly due to MTX intolerance; however, in 13% of cases, it was due to patient choice. CONCLUSIONS Methotrexate is the most common agent used to treat rheumatoid arthritis. Dose modifications are often applied to maximise efficacy and reduce adverse reactions, which could lead to withdrawal. Methotrexate is an effective drug for treatment of RA when used according to current recommendations. To optimise MTX therapy, regular medical visits are required.
Collapse
Affiliation(s)
- Jerzy Świerkot
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | - Bogdan Batko
- Department of Rheumatology, J. Dietl Specialist Hospital, Krakow, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | | | - Marcin Stajszczyk
- Department of Rheumatology and Autoimmune Diseases, Silesian Rheumatology Centre, Ustron, Poland
| |
Collapse
|
47
|
Affiliation(s)
- Maurizio Cutolo
- Research Laboratories and Academic Division of Rheumatology, Department of Internal Medicine, Postgraduate School of Rheumatology, University of Genova, Genova, Italy
| | - Elena Nikiphorou
- Academic Rheumatology Department, King's College London & The Whittington Hospital NHS Trust, London, UK
| |
Collapse
|
48
|
Favalli EG, Raimondo MG, Becciolini A, Crotti C, Biggioggero M, Caporali R. The management of first-line biologic therapy failures in rheumatoid arthritis: Current practice and future perspectives. Autoimmun Rev 2017; 16:1185-1195. [DOI: 10.1016/j.autrev.2017.10.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/31/2017] [Indexed: 12/20/2022]
|
49
|
Edwards CJ, Östör AJK, Naisbett-Groet B, Kiely P. Tapering versus steady-state methotrexate in combination with tocilizumab for rheumatoid arthritis: a randomized, double-blind trial. Rheumatology (Oxford) 2017; 57:84-91. [DOI: 10.1093/rheumatology/kex358] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Christopher J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Andrew J K Östör
- Cabrini Medical Centre, Wattletree Road, Malvern, Victoria, Australia
| | | | - Patrick Kiely
- St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
50
|
Abstract
Management and therapy of rheumatoid arthritis (RA) has been revolutionized by the development and approval of the first biological disease-modifying antirheumatic drugs (bDMARDs) targeting tumor necrosis factor (TNF) α at the end of the last century. Today, numerous efficacious agents with different modes of action are available and achievement of clinical remission or, at least, low disease activity is the target of therapy. Early therapeutic interventions aiming at a defined goal of therapy (treat to target) are supposed to halt inflammation, improving symptoms and signs, and preserving structural integrity of the joints in RA. Up to now, bDMARDs approved for therapy in RA include agents with five different modes of action: TNF inhibition, T cell co-stimulation blockade, IL-6 receptor inhibition, B cell depletion, and interleukin 1 inhibition. Furthermore, targeted synthetic DMARDs (tsDMARDs) inhibiting Janus kinase (JAK) and biosimilars also are approved for RA. The present review focuses on bDMARDs and tsDMARDS regarding similarities and possible drug-specific advantages in the treatment of RA. Furthermore, compounds not yet approved in RA and biosimilars are discussed. Following the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) recommendations, specific treatment of the disease will be discussed with respect to safety and efficacy. In particular, we discuss the question of favoring specific bDMARDs or tsDMARDs in the two settings of insufficient response to methotrexate and to the first bDMARD, respectively.
Collapse
|