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Ocak T, İldemir Ekizoğlu S, Yağız B, Coşkun BN, Dalkılıç E, Pehlivan Y. Vaccination Rates and Influencing Factors in Patients with Axial Spondyloarthritis and Immunosuppressive Treatment-A Survey-Based Cross-Sectional Study. Vaccines (Basel) 2024; 12:756. [PMID: 39066394 PMCID: PMC11281498 DOI: 10.3390/vaccines12070756] [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: 06/01/2024] [Revised: 07/06/2024] [Accepted: 07/06/2024] [Indexed: 07/28/2024] Open
Abstract
Patients with axial spondyloarthritis (axSpA) who receive immunosuppressive therapy are at risk of infection due to impaired immune function and immunosuppressive medication. Vaccination plays a crucial role in preventing infections in this population. However, vaccination rates and factors influencing vaccination uptake in axSpA patients still need to be adequately studied. This study was designed to determine the vaccination rates of vaccines covered by health insurance in this particular group in Turkey and attitudes towards vaccines and infections. This survey included 199 patients with axSpA who visited our outpatient clinic in June, July, and August 2023 and received biologic and targeted synthetic disease-modifying antirheumatic drugs. The mean age of the participants was 43.7 ± 0.7 years, and the majority were male (66.3%). The majority of the patients were vaccinated against COVID-19 (85.4%), followed by hepatitis B (41.2%), influenza (20.1%), and pneumococcal pneumonia (10.5%). While awareness of COVID-19 vaccination was widespread (100%), knowledge of other vaccines was lower (hepatitis B 80.9%, influenza 70.3%, pneumococcal 60.3%, respectively). Educational interventions targeting patients and healthcare professionals are needed to improve vaccination rates in this population. Our findings emphasize the need for strategies to increase vaccination rates in axSpA patients receiving immunosuppressive therapy. Removing barriers to vaccination and raising awareness of the importance of vaccination are critical to optimizing vaccination practices in this vulnerable population.
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Affiliation(s)
- Tuğba Ocak
- Department of Rheumatology, Faculty of Medicine, Uludag University, Nilüfer 16285, Bursa, Turkey; (B.Y.); (B.N.C.); (E.D.); (Y.P.)
| | - Selin İldemir Ekizoğlu
- Department of Internal Medicine, Faculty of Medicine, Uludag University, Nilüfer 16285, Bursa, Turkey;
| | - Burcu Yağız
- Department of Rheumatology, Faculty of Medicine, Uludag University, Nilüfer 16285, Bursa, Turkey; (B.Y.); (B.N.C.); (E.D.); (Y.P.)
| | - Belkıs Nihan Coşkun
- Department of Rheumatology, Faculty of Medicine, Uludag University, Nilüfer 16285, Bursa, Turkey; (B.Y.); (B.N.C.); (E.D.); (Y.P.)
| | - Ediz Dalkılıç
- Department of Rheumatology, Faculty of Medicine, Uludag University, Nilüfer 16285, Bursa, Turkey; (B.Y.); (B.N.C.); (E.D.); (Y.P.)
| | - Yavuz Pehlivan
- Department of Rheumatology, Faculty of Medicine, Uludag University, Nilüfer 16285, Bursa, Turkey; (B.Y.); (B.N.C.); (E.D.); (Y.P.)
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Zhang S, Peng L, Li Q, Zhao J, Xu D, Zhao J, Wang Q, Li M, Zhang W, Tian X, Su J, Zeng X. Spectrum of Spondyloarthritis Among Chinese Populations. Curr Rheumatol Rep 2022; 24:247-258. [PMID: 35829981 PMCID: PMC9307523 DOI: 10.1007/s11926-022-01079-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review aims to emphasize interesting and important new findings with a focus on the spectrum of spondyloarthritis (SpA) in China. RECENT FINDINGS Over the past decade, significant advances have been made in the investigation of SpA epidemiology, the exploration of genetic and environmental risk factors, the identification of clinical features, and the updating of treatment protocols in the Chinese population. The prevalence of ankylosing spondylitis (AS) in China is 0.20-0.42%, and the prevalence of HLA-B27 in AS patients is 88.8-89.4%. HLA-B*2704 is the most common subtype in Chinese AS patients, followed by HLA-B*2705. HLA-A*01, more precisely HLA-A*01:01, may be associated with psoriatic arthritis (PsA). Tumor necrosis factor inhibitors and IL-17A inhibitors have been shown to be effective and safe for AS patients in China. Juvenile-onset AS is relatively rare, accounting for only 9.1% of the AS population. The prevalence of arthritis related to inflammatory bowel disease is 6.9 to 7.2%. A Chinese study showed that the most frequently prescribed medication was methotrexate (66.4%). Biological agents were prescribed in only16.4% of patients with PsA. This review summarizes the latest research in the epidemiology, pathogenesis, clinical manifestations, and management of SpA among Chinese populations. Multiple HLA associations with SpA have also been described, and it is hoped that discoveries of such ethnic-specific risk factor(s) and understanding of their pathological mechanisms may potentially lead to newer targeted therapies for the Chinese populations worldwide.
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Affiliation(s)
- Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Qingyang Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Jinwei Zhao
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, 300191, Tianjin, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China
| | - Jinmei Su
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China.
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education,, No.1 Shuaifuyuan, Dongcheng district, 100730, Beijing, China.
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Tseng JC, Wei JCC, Deodhar A, Martin R, Porter B, McCreddin S, Talloczy Z. Secukinumab Demonstrates Sustained Efficacy and Safety in a Taiwanese Subpopulation With Active Ankylosing Spondylitis: Four-Year Results From a Phase 3 Study, MEASURE 1. Front Immunol 2020; 11:561748. [PMID: 33324394 PMCID: PMC7725874 DOI: 10.3389/fimmu.2020.561748] [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: 05/13/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives To present the long-term (4-year) efficacy and safety of secukinumab in Taiwanese patients with active AS in the MEASURE 1 extension study. Methods This post hoc analysis reports data from Taiwanese patients originally randomized to subcutaneous secukinumab 150 or 75mg or placebo every 4 weeks (following intravenous loading dose) who were invited to enter the 3-year extension study. Assessments at Week 208 included ASAS20/40 responses and other clinically relevant endpoints. Efficacy data are presented as observed. Safety analyses included all patients who received ≥1 dose of secukinumab. Results Of the 57 Taiwanese patients in the core trial, 48 entered the extension study and 87.5% patients (42/48) completed 4 years of treatment. Thirteen Taiwanese patients (including placebo-switchers) were escalated from 75 to 150mg (approved dose) at some point starting from Week 172. ASAS20/40 responses were sustained through 4 years in the Taiwanese patients who were originally randomized to secukinumab 150mg. Clinical responses were improved in those patients who received dose-escalation from 75 to 150mg during the study. No unexpected safety signals were reported. Conclusion Secukinumab 150mg demonstrated sustained efficacy over 4 years in Taiwanese patients with active ankylosing spondylitis. The safety profile of secukinumab was consistent with previous reports. ClinicalTrialsgov identifier NCT01863732.
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Affiliation(s)
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Atul Deodhar
- Oregon Health and Science University, Portland, OR, United States
| | - Ruvie Martin
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Brian Porter
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | - Zsolt Talloczy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
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4
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Huang F, Sun F, Wan WG, Wu LJ, Dong LL, Zhang X, Kim TH, Sengupta R, Šenolt L, Wang Y, Qiu HM, Porter B, Haemmerle S. Secukinumab provided significant and sustained improvement in the signs and symptoms of ankylosing spondylitis: results from the 52-week, Phase III China-centric study, MEASURE 5. Chin Med J (Engl) 2020; 133:2521-2531. [PMID: 32925287 PMCID: PMC7722578 DOI: 10.1097/cm9.0000000000001099] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Secukinumab demonstrated sustained efficacy in patients with ankylosing spondylitis (AS) through 5 years in pivotal Phase III studies. Here, we present efficacy and safety results (52-week) of secukinumab in patients with AS from the MEASURE 5 study. METHODS MEASURE 5 was a 52-week, Phase III, China-centric study. Eligible patients were randomly assigned (2:1) to receive subcutaneous secukinumab 150 mg or placebo weekly for the first five doses and then once every 4 weeks (q4w). All placebo patients switched to secukinumab 150 mg q4w starting at Week 16. Primary endpoint was Assessments of SpondyloArthritis international Society (ASAS) 20 at Week 16. Randomization was stratified by region (China vs. non-China). RESULTS Of 458 patients (secukinumab 150 mg, N = 305; placebo, N = 153) randomized, 327 (71.4%) were from China and 131 (28.6%) were not from China. Of these, 97.7% and 97.4% patients completed Week 16 and 91.1% and 95.3% (placebo-secukinumab) patients completed Week 52 of treatment. The primary endpoint was met; secukinumab significantly improved ASAS20 response at Week 16 vs. placebo (58.4% vs. 36.6%; P < 0.0001); corresponding rate in the Chinese population was 56.0% vs. 38.5% (P < 0.01). All secondary efficacy endpoints significantly improved with secukinumab 150 mg in the overall population at Week 16; responses were maintained with a trend toward increased efficacy from Week 16 to 52. No new or unexpected safety signals were reported up to Week 52. CONCLUSIONS Secukinumab 150 mg demonstrated rapid and significant improvement in signs and symptoms of AS. Secukinumab was well tolerated and the safety profile was consistent with previous reports. Efficacy and safety results were comparable between the overall and Chinese populations. TRIAL REGISTRATION ClinicalTrials.gov, NCT02896127; https://clinicaltrials.gov/ct2/show/NCT02896127?term=NCT02896127&draw=2&rank=1.
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Affiliation(s)
- Feng Huang
- Department of Rheumatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Fei Sun
- Department of Rheumatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Wei-Guo Wan
- Department of Rheumatology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Li-Jun Wu
- Department of Rheumatology & Immunology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang 830001, China
| | - Ling-Li Dong
- Department of Rheumatology & Immunology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, Hubei 430030, China
| | - Xiao Zhang
- Department of Rheumatology & Immunology, Guangdong General Hospital, Guangzhou, Guangdong 510000, China
| | - Tae-Hwan Kim
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - Raj Sengupta
- Royal National Hospital for Rheumatic Disease, Upper Borough Walls, Bath BA1 1RL, UK
| | | | - Yi Wang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Hao-Min Qiu
- China Novartis Institutes for Biomedical Research, Shanghai 201203, China
| | - Brian Porter
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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5
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McInnes IB, Mease PJ, Kivitz AJ, Nash P, Rahman P, Rech J, Conaghan PG, Kirkham B, Navarra S, Belsare AD, Delicha EM, Pricop L. Long-term efficacy and safety of secukinumab in patients with psoriatic arthritis: 5-year (end-of-study) results from the phase 3 FUTURE 2 study. THE LANCET. RHEUMATOLOGY 2020; 2:e227-e235. [PMID: 38268157 DOI: 10.1016/s2665-9913(20)30036-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Secukinumab is an interleukin-17A inhibitor used in the treatment of patients with active psoriatic arthritis. In the phase 3 FUTURE 2 trial, secukinumab showed sustained improvement in clinical outcomes over 2 years. Because scarce data exists on the long-term treatment with biological therapies in patients with psoriatic arthritis, we aimed to assess and describe the 5-year (end-of-study) results on the efficacy and safety of secukinumab 300 mg and 150 mg doses, as well as dose escalation, from the FUTURE 2 study. METHODS FUTURE 2 is a phase 3, double-blind, placebo-controlled study done at 76 centres in Asia, Australia, Canada, Europe, and the USA. Patients with active psoriatic arthritis aged 18 years or older were randomly assigned to either secukinumab (300 mg, 150 mg, or 75 mg) or placebo weekly from baseline and then every 4 weeks from week 4. Secukinumab dose was escalated from 150 mg to 300 mg and from 75 mg to 150 mg or 300 mg starting at week 128, if active signs of disease were observed in patients, on the basis of the physician's assessment, with the escalated dose maintained thereafter. We assessed key efficacy endpoints at week 260 (5 years) for secukinumab 300 mg and 150 mg, including American College of Rheumatology (ACR) and Psoriasis Area and Severity Index (PASI) responses. The safety analysis included all patients who received one or more doses of secukinumab. We report data as observed. This study is registered with ClinicalTrials.gov, NCT01752634. FINDINGS At randomisation, 65% of patients were naive to tumour necrosis factor inhibitors and 47% were receiving concomitant methotrexate. Of 397 patients randomly assigned in FUTURE 2, 248 (62%) completed 5 years of treatment, including 64 (64%) of 100 patients in the original secukinumab 300 mg group, 65 (65%) of 100 in the 150 mg group, 59 (60%) of 99 in the 75 mg group, and 60 (61%) of 98 in the placebo group. Overall, 127 (52%) of 242 patients required dose escalation during the study. ACR responses at 5 years were 71 (74%; ACR20), 50 (52%; ACR50), and 31 (32%; ACR70) of 96 evaluable patients in the secukinumab 300 mg group, and 67 (70%; ACR20), 41 (43%; ACR50), and 28 (29%; ACR70) of 96 evaluable patients in the secukinumab 150 mg group. From 24 to 32 weeks and from 48 to 84 weeks after dose escalation from secukinumab 150 mg to 300 mg, the proportions of ACR and PASI non-responders decreased, whereas the proportions of ACR and PASI responders increased. During the entire treatment period, the most frequent treatment-emergent serious adverse event was serious infection (exposure-adjusted incidence 1·7, 95% CI 1·1-2·5; n=25) in the any secukinumab group. No new or unexpected safety signals were reported. INTERPRETATION Secukinumab 300 mg and 150 mg provided sustained improvement in the signs and symptoms of psoriatic arthritis, with consistent safety over 5 years. This study supports the clinical benefit and safety of long-term treatment with secukinumab in patients with psoriatic arthritis. FUNDING Novartis.
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Affiliation(s)
- Iain B McInnes
- Institute of Infection Immunity and Inflammation, University of Glasgow, Glasgow, UK.
| | - Philip J Mease
- Swedish Medical Centre-Providence St Joseph Health and University of Washington, Seattle, WA, USA
| | - Alan J Kivitz
- Altoona Centre for Clinical Research, Duncansville, PA, USA
| | - Peter Nash
- School of Medicine, Griffith University, QLD, Australia
| | | | - Jürgen Rech
- Friedrich-Alexander-University Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds, UK
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Shimabuco AY, Gonçalves CR, Moraes JCB, Waisberg MG, Ribeiro ACDM, Sampaio-Barros PD, Goldenstein-Schainberg C, Bonfa E, Saad CGS. Factors associated with ASDAS remission in a long-term study of ankylosing spondylitis patients under tumor necrosis factor inhibitors. Adv Rheumatol 2018; 58:40. [PMID: 30657103 DOI: 10.1186/s42358-018-0040-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/23/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To determine the clinical and demographic factors associated with disease remission and drug survival in patients with ankylosing spondylitis (AS) on TNF inhibitors. METHODS Data from a longitudinal electronic database of AS patients under anti-TNF therapy between June/2004 and August/2013. Demographic, clinical parameters, disease activity by ASDAS remission (< 1.3) and inactive/low (< 2.1) were analyzed to characterize reasons for drug survival and switching of anti-TNF. RESULTS Among 117 AS patients, 69 (59%) were prescribed only one anti-TNF, 48 (41%) switched to a second anti-TNF and 13 (11%) to a third anti-TNF. Considering ASDAS-CRP < 1.3, 31 (39%) patients were inactive at the end of the study. Non-switchers (P = 0.04), younger age (P = 0.004), non-smoking (P = 0.016), shorter disease duration (P = 0.047), more frequent use of SSZ (P = 0.037) and lower BASDAI (P = 0.027), BASMI (P = 0.034) and BASFI (P = 0.003) at baseline were associated with remission. In the multivariate analysis younger age (P = 0.016) and lower BASDAI (P = 0.032) remained as remission predictors. CONCLUSION This study supports that ASDAS-CRP remission is an achievable goal not only for non-switchers but also for second anti-TNF, particularly in patients with younger age and lower BASDAI at baseline. Co-medication and non-smoker status seems to have a beneficial effect in anti-TNF response in this population.
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Affiliation(s)
- Andrea Y Shimabuco
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Celio R Gonçalves
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Julio C B Moraes
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Mariana G Waisberg
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Ana Cristina de M Ribeiro
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Percival D Sampaio-Barros
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Claudia Goldenstein-Schainberg
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Eloisa Bonfa
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil
| | - Carla G S Saad
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 3° andar - sala 3131 - Cerqueira César, São Paulo, SP, Cep: 01246-903, Brazil.
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Wroński J, Fiedor P. The Safety Profile of Tumor Necrosis Factor Inhibitors in Ankylosing Spondylitis: Are TNF Inhibitors Safer Than We Thought? J Clin Pharmacol 2018; 59:445-462. [PMID: 30476367 DOI: 10.1002/jcph.1348] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/27/2018] [Indexed: 12/12/2022]
Abstract
Tumor necrosis factor (TNF) inhibitors significantly improved the treatment options for patients with ankylosing spondylitis. Unfortunately, currently, there is no strategy for sustaining remission of the disease with TNF inhibitors; after discontinuation, a high percentage of patients experience flares in a short time. Therefore, up-to-date, long-term use of TNF inhibitors in patients with ankylosing spondylitis remains necessary. For this reason, the issue of the long-term safety of TNF inhibitors in patients with ankylosing spondylitis raises concerns. Although TNF inhibitors are well established in ankylosing spondylitis treatment, the majority of studies on TNF inhibitors' safety have been performed in patients with rheumatoid arthritis. Until recently, there were very few studies of TNF inhibitors' safety in ankylosing spondylitis. Meanwhile, TNF inhibitors appear to have different safety profiles in ankylosing spondylitis and rheumatoid arthritis. In this review, we describe available data on the occurrence of adverse events associated with TNF inhibitor treatment in ankylosing spondylitis, including serious adverse events, infections, serious infections, tuberculosis, opportunistic infections, hepatitis B reactivation, malignancies, laboratory test abnormalities, autoimmune diseases, paradoxical adverse events, and heart failure.
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Affiliation(s)
- Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland.,Department of Disaster Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Fiedor
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Pierrot A, Combe C, Lepelley M, Brucker M, Constant E. Maladie de Berger au cours d’une Polyarthrite Rhumatoïde traitée par Adalimumab. ANNALES PHARMACEUTIQUES FRANÇAISES 2018; 76:499-503. [DOI: 10.1016/j.pharma.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
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9
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van Bentum RE, Heslinga SC, Nurmohamed MT, Gerards AH, Griep EN, Koehorst CB, Kok MR, Schilder AM, Verhoef M, van der Horst-Bruinsma IE. Reduced Occurrence Rate of Acute Anterior Uveitis in Ankylosing Spondylitis Treated with Golimumab — The GO-EASY Study. J Rheumatol 2018; 46:153-159. [DOI: 10.3899/jrheum.180312] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2018] [Indexed: 01/24/2023]
Abstract
Objective.Acute anterior uveitis (AAU) is common in ankylosing spondylitis (AS). Golimumab (GOL), a tumor necrosis factor-α inhibitor (TNFi), has proven to be effective in the treatment of AS. To date, the effect of GOL on the incidence of AAU in AS is unknown. The objective was to study the AAU occurrence rate in patients with AS during GOL treatment and secondarily, the efficacy of GOL in daily clinical practice.Methods.The study was a multicenter prospective study in a real-world setting in patients with AS who were treated with GOL for 12 months. The occurrence of AAU was assessed in the year before the initial TNFi treatment and during GOL treatment and calculated for the period at risk for a new AAU. Measures for disease activity [Ankylosing Spondylitis Disease Activity Score (ASDAS)] and treatment response [Assessment of Spondyloarthritis international Society (ASAS20 score)] were collected.Results.In total, 93 patients (65% male, 55% TNFi-naive, 27% history of AAU) were included, with a median disease duration of 7 years and ASDAS score of 3.1. During GOL treatment, the AAU occurrence rate was reduced from 11.1 to 2.2 per 100 patient-years (rate-ratio 0.20, 95% CI 0.04–0.91). After 3 months of treatment, 41% of the patients experienced a clinically important improvement of the ASDAS score (p < 0.001) and 36% an ASDAS20 response (p < 0.001). At month 12, 49% had achieved an ASAS20 response (p < 0.001).Conclusion.In AS, the AAU occurrence rate and disease activity decreased significantly during GOL treatment. Therefore, GOL can be considered a good choice in patients with AS who need a TNFi, especially in cases of recurrent AAU. (EudraCT number: 2012-002458-21)
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10
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Bojinca VC, Bojinca M, Gheorghe M, Birceanu A, Iosif CI, Balanescu SM, Balanescu AR. Stevens-Johnsons syndrome or drug-induced lupus - a clinical dilemma: A case report and review of the literature. Biomed Rep 2018; 9:37-41. [PMID: 29930803 PMCID: PMC6007037 DOI: 10.3892/br.2018.1098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022] Open
Abstract
Tumor necrosis factor inhibitors are the first biological agents used in the treatment of rheumatoid arthritis (RA) to have yielded satisfactory results in terms of clinical improvement and radiologic progression, but they are also associated with the possibility of occurrence of a number of autoimmune systemic events [drug-induced lupus (DIL), vasculitis, sarcoidosis] and localized adverse events [uveitis, psoriasis, interstitial lung disease, erythema multiforme including the major form Stevens-Johnson syndrome (SJS)]. During treatment with TNF inhibitors, many patients develop positivity for antinuclear, antihistone and anti-double stranded DNA antibodies, though only a minority of patients will develop clinical manifestations and approximately less than 1% will fulfill the classification criteria for systemic lupus erythematosus. Mucocutaneous manifestations are the most frequent manifestations of DIL following treatment with TNF inhibitors, and can be severe and occasionally difficult to differentiate from erythema multiforme/SJS. Stopping the causative drug (the TNF inhibitor) and general supportive measures are usually sufficient in mild forms, but in moderate to severe forms, systemic glucocorticoids and sometimes immunosuppressive drugs are required. The present report presents the case of a patient with rheumatoid arthritis who developed severe recurrent cutaneous reactions and positive autoantibodies during TNF inhibitor treatment, with difficulties in differential diagnosis and treatment. A review of the literature is also presented.
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Affiliation(s)
- Violeta Claudia Bojinca
- Department of Internal Medicine and Rheumatology, 'Sfanta Maria' Hospital, 011172 Bucharest, Romania.,Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania
| | - Mihai Bojinca
- Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania.,Department of Internal Medicine and Rheumatology, 'Dr Ion Cantacuzino' Hospital, 020475 Bucharest, Romania
| | - Madalina Gheorghe
- Department of Internal Medicine and Rheumatology, 'Sfanta Maria' Hospital, 011172 Bucharest, Romania
| | - Adelina Birceanu
- Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania.,Department of Pathology 'Sfanta Maria' Hospital, 011172 Bucharest, Romania
| | | | - Serban Mihai Balanescu
- Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania.,Department of Cardiology, 'Elias' Hospital, 011461 Bucharest, Romania
| | - Andra Rodica Balanescu
- Department of Internal Medicine and Rheumatology, 'Sfanta Maria' Hospital, 011172 Bucharest, Romania.,Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania
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11
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Pulmonary Sarcoidosis Induced by Anti-Tumor Necrosis Factor Therapy: A Paradoxical Effect. J Clin Rheumatol 2018; 26:23-24. [PMID: 29667945 DOI: 10.1097/rhu.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Risk of serious infections in biological treatment of patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a meta-analysis. Clin Rheumatol 2017; 37:439-450. [PMID: 29290076 DOI: 10.1007/s10067-017-3966-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/24/2017] [Accepted: 12/18/2017] [Indexed: 12/19/2022]
Abstract
The objective of the study is to quantitatively assess the risk of serious infections in patients with axial spondyloarthritis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) treated by biologics enrolled in randomized controlled trials (RCTs). A systematic literature searches of MEDLINE (via PubMed), EMBASE, the Cochrane Library and abstracts archives of the annual scientific meetings of both the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) was conducted through October 2015. The RCTs that compared the safety of any biologics treatment for AS or nr-axSpA with placebo and/or non-steroidal anti-inflammatory drugs (NSAIDs) and/or conventional disease modifying antirheumatic drugs (DMARDs) with a minimum of 12 weeks of follow-up were selected independently by 2 reviewers. Twenty-five RCTs with data from 2403 patients were analyzed in the analysis. Patients included active AS in 21 studies and nr-axSpA in 4 studies were treated by 5 TNF inhibitors (adalimumab, certolizumab, etanercept, golimumab and infliximab) and 3 non-TNF inhibitors (sarilumab, tocilizumab, secukinumab). The risk of serious infections has no difference and numerically was only slightly increased in patients with AS and nr-axSpA treated by biologics compared with controls (OR = 1.42; 95%CI 0.58-3.47). Stratified analysis yielded the pooled risk differences (RDs) of 0.00 (95%CI, - 0.01 to 0.01), 0.01 (95%CI - 0.01 to 0.03), - 0.00 (95%CI -0.01 to 0.01), 0.00 (95%CI - 0.02 to 0.02), 0.01 (95%CI -0.01 to 0.03) and 0.01 (95%CI -0.02 to 0.04) for adalimumab, certolizumab, etanercept, golimumab, infliximab and non-TNF inhibitors respectively. There are also no significant effect of biologics on serious infections was observed compared with controls in patients with AS (p = 0.29) and nr-axSpA (p = 0.89). The use of biologics among patients with AS and nr-axSpA included in RCTs was not significantly associated with an increased risk of serious infections compared with placebo or NSAIDs or DMARDs.
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13
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Xu Z, Xu P, Fan W, Yang G, Wang J, Cheng Q, Yu M. Risk of infection in patients with spondyloarthritis and ankylosing spondylitis receiving antitumor necrosis factor therapy: A meta-analysis of randomized controlled trials. Exp Ther Med 2017; 14:3491-3500. [PMID: 29042938 PMCID: PMC5639314 DOI: 10.3892/etm.2017.5003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 06/02/2017] [Indexed: 12/17/2022] Open
Abstract
Antitumor necrosis factor (TNF) agents have been widely used for the treatment of spondyloarthritis (SpA) and ankylosing spondylitis (AS). However, these agents may increase the risk of infection due to suppressing the immune response. The present meta-analysis was performed to systematically investigate the risk of overall infection, serious infection and tuberculosis in patients with SpA and AS treated with anti-TNF agents. Medline, Embase and the Cochrane library were searched for randomized controlled trials (RCTs) published between January 1998 and December 2015 about infection in patients with SpA receiving anti-TNF therapy. Data were pooled to obtain relative risks (RRs) along with their 95% confidence intervals (CIs). A total of 25 RCTs investigating SpA, including 12 investigating AS specifically, were eligible for the meta-analysis. Similar risks of overall infection were reported in patients with SpA (RR, 1.03; 95% CI, 0.92–1.15) and AS (RR, 1.06; 95% CI, 0.91–1.24) treated with anti-TNF agents. The RR of serious infection for patients with SpA or AS receiving anti-TNF therapy compared with a placebo was 1.27 (95% CI, 0.67–2.38) and 1.57 (95% CI, 0.63–3.91), respectively. In addition, 4 RCTs with outcomes of tuberculosis in patients with SpA receiving anti-TNF agents were identified, all in infliximab-treated patients (RR, 2.52; 95% CI, 0.53–12.09). However, due to the limited number of RCTs, this finding should be interpreted with caution. The present meta-analysis did not find any significantly increased risk of infection associated with anti-TNF therapy in patients with SpA or AS. However, due to short duration of follow-up in the RCTs and the rarity of serious infections and tuberculosis, patients treated with anti-TNF agents still should be closely monitored in clinical practice.
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Affiliation(s)
- Zhigao Xu
- Department of Pathology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Peipei Xu
- Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Wei Fan
- Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Gui Yang
- Department of Clinical Laboratory, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - June Wang
- Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Qingyuan Cheng
- Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Mingxia Yu
- Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China.,Department of Clinical Laboratory, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
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Wei JCC, Baeten D, Sieper J, Deodhar A, Bhosekar V, Martin R, Porter B. Efficacy and safety of secukinumab in Asian patients with active ankylosing spondylitis: 52-week pooled results from two phase 3 studies. Int J Rheum Dis 2017; 20:589-596. [DOI: 10.1111/1756-185x.13094] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- James C.-C. Wei
- Division of Allergy, Immunology and Rheumatology; Chung Shan Medical University Hospital; Institute of Medicine; Chung Shan Medical University; Graduate Institute of Integrated Medicine; China Medical University; Taichung Taiwan
| | | | | | - Atul Deodhar
- Oregon Health & Science University; Portland Oregon USA
| | | | - Ruvie Martin
- Novartis Pharmaceuticals Corporation; East Hanover New Hampshire USA
| | - Brian Porter
- Novartis Pharmaceuticals Corporation; East Hanover New Hampshire USA
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15
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A Rare Adverse Effect of Anti-Tumor Necrosis Factor Alpha Therapy: Sarcoidosis. Arch Rheumatol 2017; 32:67-70. [PMID: 30375550 DOI: 10.5606/archrheumatol.2017.6055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 07/04/2016] [Indexed: 12/17/2022] Open
Abstract
Anti-tumor necrosis factor alpha (anti-TNF-a) therapy has been widely used for the management of rheumatologic diseases. The most frequent adverse effects of anti-TNF-a therapy are infections and malignancies while sarcoidosis is a rare condition. On the other hand, anti-TNF-a therapy has been used in the treatment of sarcoidosis. Elucidation of this paradoxical issue is unclear. In this article, we report an ankylosing spondylitis patient who was diagnosed as sarcoidosis during the period of etanercept usage. Sarcoidosis as a possible adverse effect should be kept in mind during anti-TNF-a therapy.
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16
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Different roles of TNF inhibitors in acute anterior uveitis associated with ankylosing spondylitis: state of the art. Clin Rheumatol 2016; 35:2631-2638. [DOI: 10.1007/s10067-016-3426-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 09/18/2016] [Accepted: 09/18/2016] [Indexed: 12/20/2022]
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17
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de Camargo IA, Almeida Barros BC, do Nascimento Silveira MS, Osorio-de-Castro CGS, Guyatt G, Lopes LC. Gap Between Official Guidelines and Clinical Practice for the Treatment of Rheumatoid Arthritis in São Paulo, Brazil. Clin Ther 2016; 38:1122-33. [PMID: 26976223 DOI: 10.1016/j.clinthera.2016.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/17/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Biological agents used for the treatment of rheumatoid arthritis (RA) are associated with serious adverse events. Guidelines provide standards for the prescribing and monitoring of these drugs. In São Paulo, health litigation for access to medicines has fueled the demand for biological therapy. The extent to which biological agents are being appropriately prescribed and patients are being appropriately monitored is uncertain. Our goal was to determine whether RA clinical guidelines are being translated into clinical practice for patients receiving treatment as a result of lawsuits against the government. METHODS We identified patients through records of the State Secretary of Health of São Paulo from 2003 to 2011. We consulted guidelines from 5 countries and chose those recommendations endorsed by all of the guidelines reviewed as standards. Pharmacy records provided data regarding biologic use. The guidelines recommended the use of biological agents only when patients had been receiving treatment with at least 1 disease-modifying antirheumatic drug (DMARD) and recommended annual monitoring of laboratory blood tests. FINDINGS Of the 238 patients identified in the database, 216 patients were interviewed, and 124 (57.4%) patients were still using biological agents at the time of the survey. Of the patients interviewed, 167 patients (77.3%) started biological treatment when using ≥2 DMARDs before, 22 patients (10.2%) were using 1 DMARD before, and 27 patients (12.5%) had never taken a DMARD. Of the 124 patients still taking biological drugs, 117 patients (94.3%) had visited a doctor at least once per year, but 28 patients (22.6%) did not undergo the recommended laboratory blood testing. Only 43 of the 124 patients (34.7%) still taking biological agents met the guideline criteria for both the use of previous agents and the appropriate monitoring. IMPLICATIONS An important gap between clinical practice and the national guidelines exists among treatments prescribed for plaintiffs obtaining medicines for RA in São Paulo. The results suggest the need for intervention by health authorities.
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Affiliation(s)
- Iara Alves de Camargo
- Pharmaceutical Sciences Master Course, University of Sorocaba (UNISO), Sorocaba, Brazil
| | | | | | | | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences Master Course, University of Sorocaba (UNISO), Sorocaba, Brazil.
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Braun J, Kiltz U, Sarholz M, Heldmann F, Regel A, Baraliakos X. Monitoring ankylosing spondylitis: clinically useful markers and prediction of clinical outcomes. Expert Rev Clin Immunol 2015; 11:935-46. [PMID: 26048334 DOI: 10.1586/1744666x.2015.1052795] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Patient assessment in axial spondyloarthritis (axSpA) is multidimensional, and monitoring of disease activity, function and radiographic progression is complex. There is no simple 'gold standard' for measuring disease activity in all individual patients, as disease activity in axSpA is the sum of many different aspects and a complexity that cannot be represented by a single variable. Limited spinal mobility is a cardinal sign of ankylosing spondylitis and loss of spinal mobility has been reported to be a prognostic factor and most often evaluated with the Bath Ankylosing Spondylitis Functional Index. Imaging of the spine and assessment of safety aspects plays an important role in the monitoring of patients with axSpA. The timeframe for collecting information regarding disease activity, function and radiographic progression are recommended on an individual basis.
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Affiliation(s)
- Juergen Braun
- Rheumazentrum Ruhrgebiet, Claudiusstr 45, 44649 Herne Germany
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