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Xie W, Huang H, Zhang Z. Prediction of flare following glucocorticoids withdrawal in rheumatoid arthritis patients with continuation of csDMARDs: a real-life study. Intern Emerg Med 2023; 18:1759-1767. [PMID: 37418144 DOI: 10.1007/s11739-023-03362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To determine the risk factors for flare after glucocorticoids (GC) withdrawal in rheumatoid arthritis (RA) patients with undergoing conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). METHODS RA patients who discontinued GC with continuation of csDMARD were selected from a longitudinal real-world cohort. Established RA was defined as disease duration over 12 months. Dissatisfied RA control was defined as the proportion of simplified disease activity index (SDAI)-based remission time to total time from GC initiation to discontinuation less than 50%. Logistic regression was used to analyze the independent risk factors for flare after GC discontinuation and results were expressed as odds ratio (OR). RESULTS There were 115 eligible RA patients discounted GC with continuation of csDMARDs (methotrexate: 80%; hydroxychloroquine: 61%; csDMARDs combination: 79%). Of these, 24 patients experienced flare after GC discontinuation. Compared with relapse-free patients, flare patients were more likely to have established RA (75% vs 49%, p = 0.025), higher median cumulative prednisolone dosages (3.3 vs 2.2 g, p = 0.004), and higher proportion of dissatisfied RA control during GC usage (66% vs 33%, p = 0.038). In multivariate analysis, significantly increased flare risk was predicted by established RA (OR 2.93 [1.02-8.43]), cumulative prednisolone dose > 2.5 g (OR 3.69 [1.34-10.19]) and dissatisfied RA control (OR 3.00 [1.09-8.30]). Flare risk was increased with increases in number of risk factors with highest OR of 11.56 in patients with three risk factors (p for trend = 0.002). CONCLUSIONS Flare following GC withdrawal is not common in RA patients with undergoing csDMARDs therapy. Established RA, higher cumulative GC dose and dissatisfied RA control before GC discontinuation are important factors associated with flare after GC withdrawal.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China.
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Xie W, Huang H, Zhang Z. Dynamic Characteristics and Predictive Profile of Glucocorticoids Withdrawal in Rheumatoid Arthritis Patients Commencing Glucocorticoids with csDMARD: A Real-World Experience. Rheumatol Ther 2023; 10:405-419. [PMID: 36609980 PMCID: PMC10011229 DOI: 10.1007/s40744-022-00527-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Glucocorticoids (GC) are currently recommended as a bridging therapy in combination with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) for the treatment of rheumatoid arthritis (RA) and should be tapered as rapidly as clinically feasible. We aimed to explore potential predictors for GC discontinuation in patients commencing GC with concomitant csDMARD. METHODS We used data from a longitudinal real-world cohort. RA patients who newly started GC concomitantly with csDMARD were included. All patients were divided into four groups, according to degree of change in disease activity at 3 months from baseline (group 1: worsening or no decrease; group 2: 0-24.9% decrease; group 3: 25.0-49.9% decrease; group 4: ≥ 50.0% decrease). Cox regression was used to estimate hazard risk (HR) with 95% confidence interval (CI). RESULTS In total, 124 out of 207 RA patients discontinued GC at the rheumatologist's discretion and 79.1% (91/115) of them successfully stopping GC without flare within 6 months after GC withdrawal. Increasing age (HR 0.99, 95% CI 0.98-1.00, p = 0.043) and concomitant nonsteroidal anti-inflammatory drugs use at GC initiation (HR 0.47, 95% CI 0.25-0.88, p = 0.018) were independently associated with GC withdrawal failure. Moreover, the degrees of disease activity improvement at 3 months significantly predicted the possibility of subsequent GC discontinuation (fully adjusted HR 1.35-1.47, p < 0.01), with 2.38-3.59 times higher in group 4 than group 1. Switching the outcome to successfully stopping GC without short-term flare yielded similar findings. CONCLUSIONS The degrees of disease activity improvement at 3 months independently predicted the subsequent GC withdrawal. These findings suggest the importance of dynamic treatment strategies with a closer look at disease activity during GC tapering and discontinuation.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034 China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034 China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034 China
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Gamboa-Cárdenas RV, Ugarte-Gil MF, Pimentel-Quiroz V, Reátegui-Sokolova C, Rodríguez-Bellido Z, Zevallos-Miranda F, Medina-Chinchón M, Alfaro-Lozano J, Noriega-Zapata E, Cucho-Venegas JM, Perich-Campos R, Pastor-Asurza C, Alarcón GS. Predictors of Remission and Low Disease Activity in Rheumatoid Arthritis Patients: Results From the Follow-up of a Real-World Peruvian Cohort. J Clin Rheumatol 2022; 28:390-396. [PMID: 35697014 DOI: 10.1097/rhu.0000000000001878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical remission is the goal in rheumatoid arthritis (RA) management; however, this can be difficult to achieve in several parts of the world. Our objective was to determine predictors of remission and remission/low disease activity (LDA) in RA. METHODS A longitudinal real-setting RA cohort was followed up (January 2016-2020). Predictors examined were sex, age at diagnosis, disease duration, socioeconomic status, tobacco use, rheumatoid factor titer, comorbidities (Charlson index), Simple Disease Activity Index (SDAI) score, disability (Multidimensional Disease Health Assessment Questionnaire), health-related quality of life (Short Form-36 questionnaire), glucocorticoid dose, biological/target synthetic disease-modifying antirheumatic drugs, and conventional DMARD (c-DMARD) use. Univariable and multivariable generalized estimating equation models were done to determine predictors of remission (at a given visit) and sustained remission (2 consecutives visits), using the SDAI definition (0 or <3.3). Similarly, remission/LDA (SDAI <11) predictors were examined. RESULTS Five hundred thirty RA patients included the following: 160 patients (30.2%) achieved remission in at least 1 visit, and 126 patients (23.77%) achieved sustained remission. On the multivariable analysis glucocorticoid dose (odds ratio [OR], 1.060; 95% confidence interval [CI], 1.027-1.094; p = 0.004) and current (OR, 2.293; 95% CI, 1.811-2.903; p < 0.001) or past (OR, 1.383; 95% CI, 1.127-1.698; p = 0.002) use of c-DMARDs predicted remission/LDA in at least 1 visit, whereas the SDAI (OR, 0.951; 95% CI, 0.942-0.959; p < 0.001), Multidimensional Disease Health Assessment Questionnaire (OR, 0.648; 95% CI, 0.549-0.764; p < 0.001), and age at diagnosis (OR, 0.994; 95% CI, 0.990-0.998; p = 0.004) were negative predictors. As to sustained remission/LDA, current (OR, 2.012; 95% CI, 1.458-2.776: p < 0.001) or past (OR, 1.517; 95% CI, 1.155-1.993; p = 0.003) use of c-DMARDs, having a better Short Form-36 questionnaire physical component summary (OR, 1.022; 95% CI, 1.014-1.029; p < 0.001), and older age at diagnosis (OR, 1.013; 95% CI, 1.003-1.022; p = 0.008) predicted it, whereas SDAI (OR, 0.949; 95% CI, 0.933-0.965; p < 0.001) and medium low/low socioeconomic status (OR, 0.674; 95% CI, 0.500-0.909; p = 0.010) were negative predictors. CONCLUSION During follow-up of this real-world RA cohort, c-DMARD use predicted remission and remission/LDA. In contrast, disease activity was a negative predictor.
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Affiliation(s)
| | | | | | | | | | | | | | - José Alfaro-Lozano
- Rheumatology Department, Hospital Nacional Guillermo Almenara Irigoyen EsSalud
| | | | | | - Risto Perich-Campos
- Rheumatology Department, Hospital Nacional Guillermo Almenara Irigoyen EsSalud
| | - César Pastor-Asurza
- Rheumatology Department, Hospital Nacional Guillermo Almenara Irigoyen EsSalud
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Brkic A, Łosińska K, Pripp AH, Korkosz M, Haugeberg G. Remission or Not Remission, That's the Question: Shedding Light on Remission and the Impact of Objective and Subjective Measures Reflecting Disease Activity in Rheumatoid Arthritis. Rheumatol Ther 2022; 9:1531-1547. [PMID: 36129667 PMCID: PMC9561477 DOI: 10.1007/s40744-022-00490-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/26/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction The inclusion of certain variables in remission formulas for rheumatoid arthritis (RA) may give rise to discrepancies. An increase in patient global assessment (PGA), a variable showing the patient's self-evaluation of their disease activity, may alone tilt a patient out of remission when using certain remission-assessing methods. This study aimed to explore differences in remission rates among various formulas and the impact of PGA and other clinical variables on the calculation of remission. Methods Data were collected from RA patients monitored during the years 2015–2019 at an outpatient clinic in southern Norway. Linear and logistic regression assessed associations between PGA, other RA-related variables, and remission-assessing methods. Results Remission rates were 23%, 65%, and 73% in 2019 when assessing the same 502 RA patients using Boolean remission, Boolean remission without PGA, and the disease activity score (DAS) with C-reactive peptide [DAS28(3)-CRP] method, respectively. Among the same population that year, 27% reported PGA ≤ 10, 74% had a tender joint count of ≤ 1, 85% had a swollen joint count of ≤ 1, and 86% had CRP ≤ 10. Pain (standardized coefficient β = 0.7, p < 0.001) was most strongly associated with PGA. Pain, fatigue, and morning stiffness were substantially associated with the remission-assessing methods that incorporated PGA. Conclusions Since PGA is strongly associated with the patient’s perception of pain and may not reflect the inflammatory process, our study challenges the application of remission-assessing methods containing PGA when monitoring RA patients in the outpatient clinic. We recommend using measures that are less likely to be associated with noninflammatory pain and psychosocial factors. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-022-00490-5.
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Affiliation(s)
- Alen Brkic
- Research Department, Sorlandet Hospital, Kristiansand, Norway. .,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Katarzyna Łosińska
- Division of Rheumatology and Immunology, University Hospital, Krakow, Poland
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Mariusz Korkosz
- Division of Rheumatology and Immunology, University Hospital, Krakow, Poland.,Department of Rheumatology and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Glenn Haugeberg
- Research Department, Sorlandet Hospital, Kristiansand, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Division of Rheumatology, Department of Internal Medicine, Sorlandet Hospital, Kristiansand, Norway
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Xie W, Huang H, Li G, Hao Y, Gui Y, Wang Y, Deng X, Zhao J, Geng Y, Ji L, Zhang X, Song Z, Zhang Z. Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020. Ann Rheum Dis 2021; 80:997-1003. [PMID: 33811037 DOI: 10.1136/annrheumdis-2021-220112] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To unravel the dynamical trajectory and features of glucocorticoids (GC) tapering and discontinuation in patients with rheumatoid arthritis (RA) commencing GC with concomitant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). METHODS We used data from longitudinal real-world Treat-to-TARget in RA cohort. Patients with RA who started GC and contaminant csDMARDs therapy were included. The changes in GC dose and disease activity were evaluated. GC discontinuation rate was analysed using Kaplan-Meier analysis. The relapse profile within 6 months after GC discontinuation was also analysed. RESULTS A total of 207 patients with RA were included. During a median follow-up of 38.6 months, 124 patients discontinued GC. The median prednisolone dose of 10 (5-10) mg/day at initiation was reduced by 50% in the first 6 months and then more slowly, to zero by 48 months eventually. The cumulative probabilities of GC discontinuation were 9.7%, 26.6%, 48.0% and 58.6% at month 6, years 1, 2 and 3, with calculated median time to GC cessation of 27 months. In 110 DMARD-naïve patients, the corresponding cumulative probabilities of GC discontinuation were, respectively, 12.7%, 30.0%, 50.9% and 60.6%, with calculated median time to GC cessation of 24 months. Of the 124 patients who discontinued GC, adding other csDMARDs or concomitant csDMARDs increment was documented in 28.2% of them. Approximately half of 124 patients were in clinical remission at GC discontinuation. Within 6 months after GC withdrawal, 79.1% (91/115) of patients maintained relapse free. CONCLUSIONS In patients with RA commencing GC besides csDMARDs, GC is feasibly discontinued with favourable control of disease activity in real-life setting, mostly without short-term flare. But the withdrawal time is far from reaching the recommended time frame, indicating the gap between real-world practice and current guidelines.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanni Gui
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Xuerong Deng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Juan Zhao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yan Geng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - LanLan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Xiaohui Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhibo Song
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
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Xie W, Li G, Huang H, Zhang Z. How to Define Boolean Low Disease Activity in Rheumatoid Arthritis: Experience from a Large Real-world Cohort. Rheumatol Ther 2020; 8:289-301. [PMID: 33355913 PMCID: PMC7991037 DOI: 10.1007/s40744-020-00270-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction The aim of this work is to propose Boolean-defined low disease activity (LDA) and to test its utility in rheumatoid arthritis (RA). Methods We used data from a longitudinal academic clinical database of RA in Peking University First Hospital over a decade. The initial proposal of Boolean-defined LDA was proposed with ascending thresholds from 2 to 5 in steps of 1 (referred to as Boolean-LDA2/3/4/5). Agreement and residual swollen joint count (SJC) pattern with the index-based [Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI)] LDA was analyzed. To confirm discovery, we randomly classified RA patients in a 3:2 ratio into either analysis cohort or validation cohort. Results In total, 4881 visits of 672 patients were included in the analysis cohort. Of these visits, the frequencies of achieving LDA were 71.9% (SDAI), 73.6% (CDAI), 52.8% (Boolean-LDA2), 65.2% (Boolean-LDA3), 73.5% (Boolean-LDA4), and 80.7% (Boolean-LDA5). High consistency and similar SJC pattern with SDAI-LDA or CDAI-LDA were observed in Boolean-LDA3 (kappa = 0.796, 0.771). Further analysis found meeting SDAI-LDA but not Boolean-LDA3 was largely attributable to higher patient’s global assessment (PGA) scores (62.9%). In further modification of Boolean-LDA3, better agreement with SDAI-LDA or CDAI-LDA was reached when exclusively increasing PGA cutoffs to 4.0, 4.5 or replacing PGA by evaluator’s global assessment (EGA) with cutoff to 3.0. These findings were further replicated in randomly generated validation cohort of 449 patients with 3306 clinic visits. Conclusions Using cutoff of 3 to Boolean-LDA provides great clinical utility with index-based LDA, especially when exclusively increasing PGA cutoffs to 4.0, 4.5 or replacing PGA by EGA with cutoffs to 3.0. This may deserve being considered in clinical practice. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-020-00270-z.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China.
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Zeng Q, Liu Y. Comment on: Relapse predictors and serologically unstable condition of IgG4-related disease: a large Chinese cohort: reply. Rheumatology (Oxford) 2020; 59:2179-2180. [PMID: 32353876 DOI: 10.1093/rheumatology/keaa173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/15/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Qiaozhu Zeng
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Yanying Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
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