1
|
Bergstra SA, Sepriano A, Kerschbaumer A, van der Heijde D, Caporali R, Edwards CJ, Verschueren P, de Souza S, Pope JE, Takeuchi T, Hyrich KL, Winthrop KL, Aletaha D, Stamm TA, Schoones JW, Smolen JS, Landewé RBM. Efficacy, duration of use and safety of glucocorticoids: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2023; 82:81-94. [PMID: 36410794 DOI: 10.1136/ard-2022-223358] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
Abstract
This systematic literature review (SLR) regarding the efficacy, duration of use and safety of glucocorticoids (GCs), was performed to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA). Studies on GC efficacy were identified from a separate search on the efficacy of disease-modifying antirheumatic drugs (DMARDs). A combined search was performed for the duration of use and safety of GCs in RA patients. Dose-defined and time-defined GC treatment of any dose and duration (excluding intra-articular GCs) prescribed in combination with other DMARDs were considered. Results are presented descriptively. Two included studies confirmed the efficacy of GC bridging as initial therapy, with equal efficacy after 2 years of initial doses of 30 mg/day compared with 60 mg/day prednisone. Based on a recently performed SLR, in clinical trials most patients starting initial GC bridging are able to stop GCs within 12 (22% patients continued on GCs) to 24 months (10% patients continued on GCs). The safety search included 12 RCTs and 21 observational studies. Well-known safety risks of GC use were confirmed, including an increased risk of osteoporotic fractures, serious infections, diabetes and mortality. Data on cardiovascular outcomes were Inconsistent. Overall, safety risks increased with increasing dose and/or duration, but evidence on which dose is safe was conflicting. In conclusion, this SLR has confirmed the efficacy of GCs in the treatment of RA. In clinical trials, most patients have shown to be able to stop GCs within 12-24 months. Well-known safety risks of GC use have been confirmed, but with heterogeneity between studies.
Collapse
Affiliation(s)
- Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria
| | | | - Roberto Caporali
- University of Milan, Milan and Department of Rheumatology, ASST PINI-CTO, Milano, Italy
| | - Christopher John Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick Verschueren
- Department of rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Savia de Souza
- EULAR Patient Research Partner Network, Zurich, Switzerland
| | - Janet E Pope
- University of Western Ontario, Schulich School of Medicine, London, Ontario, Canada
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan.,Saitama Medical University, Iruma-gun, Saitama, Japan
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Trust, UK
| | | | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Wien, Austria.,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria.,2nd Department of Medicine, Hietzing Hospital, Wien, Austria
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| |
Collapse
|
2
|
Bredemeier M, Ranza R, Kakehasi AM, Ranzolin A, da Silveira IG, Ribeiro ACM, Titton DC, Hayata ALS, Carvalho HMS, Kahlow BS, Fernandes V, Louzada P, Bértolo MB, Duarte ÂLBP, Macieira JC, Miranda JRS, Pinheiro GRC, Teodoro RB, Pinheiro MM, Valim V, Pereira IA, Sauma MFLC, de Castro GRW, da Rocha LF, Studart SAS, Gazzeta MO, da Silveira LG, Lupo CM, Laurindo IMM. Safety of the Methotrexate-leflunomide Combination in Rheumatoid Arthritis: Results of a Multicentric, Registry-based, Cohort Study (BiobadaBrasil). J Rheumatol 2021; 48:1519-1527. [PMID: 33934077 DOI: 10.3899/jrheum.201248] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the safety of the methotrexate (MTX)-leflunomide (LEF) combination in rheumatoid arthritis (RA), comparing it with other therapeutic schemes involving conventional synthetic (cs-) and biologic (b-) disease-modifying antirheumatic drugs (DMARDs) or Janus kinase inhibitors (JAKi). METHODS Patients with RA starting a treatment course with a csDMARD (without previous use of bDMARD or JAKi) or their first bDMARD/JAKi were followed up in a registry-based, multicentric cohort study in Brazil (BiobadaBrasil). The primary outcome was the incidence of serious adverse events (SAEs); secondary outcomes included serious infections. Multivariate Cox proportional hazards models and propensity score matching analysis (PSMA) were used for statistical comparisons. RESULTS In total, 1671 patients (5349 patient-years [PY]) were enrolled; 452 patients (1537 PY) received MTX + LEF. The overall incidence of SAEs was 5.6 per 100 PY. The hazard of SAEs for MTX + LEF was not higher than for MTX or LEF (adjusted HR [aHR] 1.00, 95% CI 0.76-1.31, P = 0.98). MTX + LEF presented a lower hazard of SAEs (aHR 0.56, 95% CI 0.36-0.88, P = 0.01) and infectious SAEs (aHR 0.48, 95% CI 0.25-0.94, P = 0.03) than bDMARDs/JAKi with MTX or LEF. MTX + LEF presented lower hazard of SAEs than MTX + sulfasalazine (SSZ; aHR 0.33, 95% CI 0.16-0.65, P = 0.002). Analysis using PSMA confirmed the results obtained with traditional multivariate Cox analysis. CONCLUSION In our study, MTX + LEF presented a relatively good overall safety profile in comparison to MTX + SSZ and schemes involving advanced therapies in RA.
Collapse
Affiliation(s)
- Markus Bredemeier
- M. Bredemeier, MD, PhD, Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre;
| | - Roberto Ranza
- R. Ranza, MD, PhD, Universidade Federal de Uberlândia, Uberlândia
| | - Adriana M Kakehasi
- A.M. Kakehasi, MD, PhD, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte
| | - Aline Ranzolin
- A. Ranzolin, MD, PhD, A.L. Duarte, MD, PhD, Universidade Federal de Pernambuco (UFPE), Recife
| | - Inês G da Silveira
- I.G. da Silveira, MD, PhD, Hospital São Lucas, Faculdade de Medicina da PUCRS, Porto Algere
| | - Ana C M Ribeiro
- A.C. Ribeiro, MD, PhD, Hospital das Clínicas da Faculdade de Medicina da USP (HCFMUSP), São Paulo
| | - David C Titton
- D.C. Titton, MD, Universidade Federal do Paraná, Curitiba
| | | | | | - Bárbara S Kahlow
- B.S. Kahlow, MD, Hospital Universitário Evangélico de Curitiba, Curitiba
| | - Vander Fernandes
- V. Fernandes, MD, PhD, Hospital Geral Universitário de Cuiabá, Cuiabá
| | - Paulo Louzada
- P. Louzada Jr., MD, PhD, Faculdade de Medicina USP, Ribeirão Preto
| | - Manoel B Bértolo
- M. Bértolo, MD, PhD, Universidade Estadual de Campinas, Campinas
| | - Ângela L B P Duarte
- A. Ranzolin, MD, PhD, A.L. Duarte, MD, PhD, Universidade Federal de Pernambuco (UFPE), Recife
| | | | - José R S Miranda
- J.R. Miranda, MD, Artrocenter Clínica Médica de Taubaté, Taubaté
| | | | - Reginaldo B Teodoro
- R.B. Teodoro, MD, Hospital da Universidade Federal do Triângulo Mineiro, Uberaba
| | | | - Valéria Valim
- V. Valim, MD, PhD, Universidade Federal do Espírito Santo, Vitória
| | - Ivânio A Pereira
- I.A. Pereira, MD, PhD, Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis
| | | | | | - Laurindo F da Rocha
- L.F. da Rocha Jr., MD, PhD, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife
| | | | - Morgana O Gazzeta
- M.O. Gazzeta, MD, Santa Casa de Misericórdia do Rio de Janeiro, Rio de Janeiro
| | - Leticia G da Silveira
- L.G. da Silveira, MS, Universidade Federal do Rio Grande do Sul/Hospital de Clínicas de Porto Alegre, Porto Alegre
| | - Cristiano M Lupo
- C.M. Lupo, MD, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto
| | - Ieda M M Laurindo
- I.M. Laurindo, MD, PhD, Faculdade de Medicina da Universidade Nove de Julho, São Paulo, Brazil
| |
Collapse
|
3
|
Use of corticoids and non-steroidal anti-inflammatories in the treatment of rheumatoid arthritis: Systematic review and network meta-analysis. PLoS One 2021; 16:e0248866. [PMID: 33826610 PMCID: PMC8026036 DOI: 10.1371/journal.pone.0248866] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 03/08/2021] [Indexed: 02/07/2023] Open
Abstract
Evidence on the use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticoids for rheumatoid arthritis (RA) is inconclusive and is not up to date. This systematic review assessed the effectiveness and safety of these anti-inflammatories (AI) in the treatment of RA. COCHRANE (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science and Virtual Health Library were searched to identify randomized controlled trials (RCT) with adults which used AI (dose represented in mg/day) compared with placebo or active controls and was carried out up to December of 2019. Reviewers, in pairs and independently, selected studies, performed the data extraction and assessed the risk of bias. The quality of the evidence was assessed by GRADE. Network meta-analyses were performed using the Stata v.14.2. Twenty-six articles were selected (NSAIDs = 21 and corticoids = 5). Naproxen 1,000 improved physical function, reduced pain and the number of painful joints compared to placebo. Etoricoxib 90 reduced the number of painful joints compared to placebo. Naproxen 750 reduced the number of swollen joints, except for etoricoxib 90. Naproxen 1,000, etoricoxib 90 and diclofenac 150 were better than placebo regarding patient assessment. Assessment physician showed that NSAIDs were better than placebo. Meta-analyses were not performed for prednisolone and prednisone. Naproxen 1,000 was the most effective drug and celecoxib 200 showed fewer adverse events. However, the low quality of the evidence observed for the outcomes with NSAIDs, the absence of meta-analyses to assess the outcomes with corticoids, as well as the risk of bias observed, indicate that future RCT can confirm such findings.
Collapse
|
4
|
Wei Z, Huang L, Cui L, Zhu X. Mannose: Good player and assister in pharmacotherapy. Biomed Pharmacother 2020; 129:110420. [DOI: 10.1016/j.biopha.2020.110420] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/07/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022] Open
|
5
|
Yates M, MacGregor AJ, Ledingham J, Norton S, Bechman K, Dennison EM, Galloway JB. Variation and implications of treatment decisions in early rheumatoid arthritis: results from a nationwide cohort study. Rheumatology (Oxford) 2020; 59:2035-2042. [PMID: 31803913 DOI: 10.1093/rheumatology/kez550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/06/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Trial data have provided an evidence base to guide early treatment in RA. Few studies have investigated rheumatologists' adherence to guidelines, and subsequent impact on outcomes. The objectives of this study are to characterize baseline prescribing for patients with RA across the National Health Service, identifying treatment decisions that associate with patient outcomes. METHODS A nationwide audit of RA collected information on treatment choices, DAS and sociodemographic factors at baseline. Treatment response was assessed at 3 months. Multilevel regression models were used to characterize departmental variations in prescribing. Heat maps were used to visualize geographical variation. Mixed effects regression models were constructed to assess the relationship between treatment decisions and disease outcomes, adjusting for patient and department level covariates. RESULTS A total of 7154 patients with a diagnosis of RA were recruited from 136 departments. There was broad variation in prescribing choices, even between departments close to one another, with evidence of substantial deviation from guidelines. Over 75% of patients received glucocorticoids, fewer than half received combination conventional DMARDs. Early glucocorticoid therapy associated with achieving a good treatment response [odds ratio 1.93 (95% CI 1.31, 2.84), P-value = 0.001]. The association was maintained following propensity modelling and imputation. CONCLUSION Guideline adherence varies between departments and cannot be explained by case-mix alone. Departments that prescribe early adjunctive steroid achieve better short-term outcomes. Further research should work to ensure that the early arthritis evidence base translates into better outcomes for patients.
Collapse
Affiliation(s)
- Mark Yates
- The Centre for Rheumatic Diseases, School of Immunology, Infection & Inflammatory Disease, King's College London, London
| | | | - Jo Ledingham
- Department of Rheumatology, Queen Alexandra Hospital, Portsmouth
| | - Sam Norton
- Institute of Psychiatry, Kings College London, London
| | - Katie Bechman
- The Centre for Rheumatic Diseases, School of Immunology, Infection & Inflammatory Disease, King's College London, London
| | | | - James B Galloway
- The Centre for Rheumatic Diseases, School of Immunology, Infection & Inflammatory Disease, King's College London, London
| |
Collapse
|
6
|
Blavnsfeldt ABG, de Thurah A, Thomsen MD, Tarp S, Langdahl B, Hauge EM. The effect of glucocorticoids on bone mineral density in patients with rheumatoid arthritis: A systematic review and meta-analysis of randomized, controlled trials. Bone 2018; 114:172-180. [PMID: 29913256 DOI: 10.1016/j.bone.2018.06.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE The role of glucocorticoids in the treatment of rheumatoid arthritis (RA) is widely debated. Impairment of bone formation may be counter-balanced by reduced systemic inflammation. This review aims to assess the effect of prednisolone/prednisone on bone mineral density (BMD) in patients with RA analyzed in randomized, controlled trials. METHODS We performed a systematic literature search and identified randomized, double-blinded placebo-controlled studies including patients with RA and using prednisolone or prednisone as the intervention. We selected studies that measured BMD by DXA at baseline and at least once thereafter. Two authors independently performed reference review, data extraction and risk of bias assessment. Primary outcome was mean change in BMD from baseline to follow-up. Secondary endpoints included radiographic scores, RA disease activity indices and fractures. We rated the quality of evidence using the GRADE approach. Outcomes were standardized for meta-analyses and 95% confidence intervals (95% CI) were calculated. RESULTS We identified 7 studies and included previously unpublished data. Studies were similar regarding study population and intervention. Standard mean difference (SMD) in change in BMD from 0 to 24 months was -0.02 (95%CI -0.16, 0.12) at the lumbar spine and -0.11 (95% CI -0.25, 0.02) at the hip (both high quality evidence) between patients treated with prednisolone/prednisone or not. Data completeness was low in some studies, concomitant treatment of RA differed between studies and differences in use of anti-osteoporotic medication may have influenced the results. However, sensitivity analyses excluding studies in which participants used either the most or the least potent concomitant RA treatment or used anti-osteoporotic therapies did not alter the estimates. CONCLUSIONS In patients with early and active RA, we found no difference in change in BMD between patients treated with prednisone/prednisolone versus placebo, suggesting that at least through 24 months, the suppression of inflammation by glucocorticoids may counterbalance their adverse effects on bone remodeling.
Collapse
Affiliation(s)
- Anne-Birgitte Garm Blavnsfeldt
- Department of Rheumatology, Aarhus University Hospital, Nørrebrogade 44, byg 3, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Incuba/Skejby, bygning 2, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark.
| | - Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Nørrebrogade 44, byg 3, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Incuba/Skejby, bygning 2, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | | | - Simon Tarp
- The Parker Institute, Bispebjerg & Frederiksberg Hospital, Nordre Fasanvej 57 Vej 8, Indgang 19, 2000, Frederiksberg, Denmark
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage Hansens Gade 2, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Incuba/Skejby, bygning 2, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Nørrebrogade 44, byg 3, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Incuba/Skejby, bygning 2, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| |
Collapse
|
7
|
Sanmartí R, Tornero J, Narváez J, Muñoz A, Garmendia E, Ortiz AM, Abad MA, Moya P, Mateo ML, Reina D, Salvatierra-Ossorio J, Rodriguez S, Palmou-Fontana N, Ruibal-Escribano A, Calvo-Alén J. Efficacy and safety of glucocorticoids in rheumatoid arthritis: Systematic literature review. ACTA ACUST UNITED AC 2018; 16:222-228. [PMID: 30057295 DOI: 10.1016/j.reuma.2018.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/12/2018] [Accepted: 06/21/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES 1) To systematically and critically review the evidence on the characteristics, efficacy and safety of glucocorticoids (CS) in rheumatoid arthritis (RA); 2) to generate practical recommendations. METHODS A systematic literature review was performed through a sensitive bibliographic search strategy in Medline, Embase and the Cochrane Library. We selected randomized clinical trials that analyzed the efficacy and/or safety of CS in patients with RA. Two reviewers performed the first selection by title and abstract. Then 10 reviewers selected the studies after a detailed review of the articles and data collection. The quality of the studies was evaluated with the Jadad scale. In a nominal group meeting, based on the results of the systematic literature review, related recommendations were reached by consensus. RESULTS A total of 47 articles were finally included. CS in combination with disease-modifying antirheumatic drugs help control disease activity and inhibit radiographic progression, especially in the short-to-medium term and in early RA. CS can also improve function and relieve pain. Different types and routes of administration are effective, but there is no standardized scheme (initial dose, tapering and duration of treatment) that is superior to others. Adverse events when using CS are very frequent and are dose-dependent and variable severity, although most are mild. Seven recommendations were generated on the use and risk management of CS. CONCLUSIONS These recommendations aim to resolve some common clinical questions and aid in decision-making for CS use in RA.
Collapse
Affiliation(s)
- Raimon Sanmartí
- Servicio de Reumatología, Hospital Clínic, Barcelona, España.
| | - Jesús Tornero
- Servicio de Reumatología, Departamento de Medicina y Especialidades Médicas, Hospital Universitario de Guadalajara, Universidad de Alcalá, Guadalajara, España
| | - Javier Narváez
- Servicio de Reumatología, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Alejandro Muñoz
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Elena Garmendia
- Servicio de Reumatología, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
| | - Ana M Ortiz
- Servicio de Reumatología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria La Princesa (IIS-IP), Madrid, España
| | - Miguel Angel Abad
- Servicio de Reumatología, Hospital Virgen del Puerto, Plasencia, Cáceres, España
| | - Patricia Moya
- Sección de Reumatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - María Lourdes Mateo
- Servicio de Reumatología, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - Delia Reina
- Servicio de Reumatología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, España
| | | | - Sergio Rodriguez
- Servicio de Reumatología, Hospital Universitario Virgen de Valme, Sevilla, España
| | - Natalia Palmou-Fontana
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Cantabria, España
| | | | - Jaime Calvo-Alén
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, España
| |
Collapse
|
8
|
Mota LMHD, Kakehasi AM, Gomides APM, Duarte ALBP, Cruz BA, Brenol CV, de Albuquerque CP, Castelar Pinheiro GDR, Laurindo IMM, Pereira IA, Bertolo MB, Ubirajara Silva de Souza MPG, de Freitas MVC, Louzada-Júnior P, Xavier RM, Giorgi RDN. 2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis. Adv Rheumatol 2018; 58:2. [PMID: 30657071 DOI: 10.1186/s42358-018-0005-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 12/29/2022] Open
Abstract
The objective of this document is to provide a comprehensive update of the recommendations of Brazilian Society of Rheumatology on drug treatment of rheumatoid arthritis (RA), based on a systematic literature review and on the opinion of a panel of rheumatologists. Four general principles and eleven recommendations were approved. General principles: RA treatment should (1) preferably consist of a multidisciplinary approach coordinated by a rheumatologist, (2) include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record, (3) be based on decisions shared by the patient and the physician after clarification about the disease and the available therapeutic options; (4) the goal is sustained clinical remission or, when this is not feasible, low disease activity. Recommendations: (1) the first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established; (2) methotrexate (MTX) is the first-choice csDMARD; (3) the combination of two or more csDMARDs, including MTX, may be used as the first line of treatment; (4) after failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone; (5) after failure of two schemes with csDMARDs, a bDMARD may be preferably used or, alternatively a tsDMARD, preferably combined, in both cases, with a csDMARD; (6) the different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost; (7) the combination of a bDMARD and MTX is preferred over the use of a bDMARD alone; (8) in case of failure of an initial treatment scheme with a bDMARD, a scheme with another bDMARD can be used; in cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe; (9) tofacitinib can be used to treat RA after failure of bDMARD; (10) corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered; (11) reducing or spacing out bDMARD doses is possible in patients in sustained remission.
Collapse
Affiliation(s)
- Licia Maria Henrique da Mota
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina- Universidade de Brasília; Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil. .,Rheos, Centro Médico Lúcio Costa, SGAS 610, bloco 1, salas T50- T51, L2 Sul, Asa Sul, Brasília, DF, 70200700, Brazil.
| | - Adriana Maria Kakehasi
- Disciplina de Reumatologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ana Paula Monteiro Gomides
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina- Universidade de Brasília; Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil.,Centro Universitário de Brasília- UniCEUB, Brasília, Brazil
| | | | | | - Claiton Viegas Brenol
- Serviço de Reumatologia, Departamento de Medicina Interna, Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | | | - Manoel Barros Bertolo
- Disciplina de Reumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | | | | | - Paulo Louzada-Júnior
- Disciplina de Reumatologia, Faculdade de Medicina de Universidade de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Ricardo Machado Xavier
- Serviço de Reumatologia, Departamento de Medicina Interna, Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rina Dalva Neubarth Giorgi
- Serviço de Reumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual, São Paulo, Brazil
| |
Collapse
|
9
|
Ishaq M, Razzaque S, Shohail F, Kumar A, Muhammad JS. Onset of Hypertension in Leflunamide Treated Low Socioeconomic Rheumatoid Arthritis Patients: An Unseen Iceberg. Curr Rheumatol Rev 2017; 15:242-245. [PMID: 29283072 DOI: 10.2174/1573397114666171227211048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the frequency of new-onset hypertension in patients with Rheumatoid arthritis taking leflunomide, in comparison with methotrexate in Asian setting. MATERIAL AND METHODS Perspective case-control study was conducted in 2014 in a tertiary care hospital located in Karachi, Pakistan. Adult patients, having rheumatoid arthritis were randomly prescribed leflunomide or methotrexate. Patients having chronic hypertension, proteinuria and chronic kidney disease were excluded. Patients were monthly followed for blood pressure and heart rate measurements. Hypertension was defined using JNC 7 criteria. RESULTS Out of 144 patients enrolled, 80 patients received Leflunomide while 64 were started on methotrexate. Mean systolic blood pressure in leflunomide group at the start and at the end of study was 108.5 and 135.4mmHg, respectively while in methotrexate group, mean systolic BP was 109.8 and 110.5 mmhg, respectively. After one year follow up, 33 out of 80 (41%) patients were receiving leflunomide had pre-hypertension or hypertension, while only 3 out of 64 patients (4.7%) were receiving methotrexate had hypertension. CONCLUSION Risk of developing hypertension in patient receiving Leflunomide is much higher in Asian population like Pakistan as compared to western population.
Collapse
Affiliation(s)
- Muhammad Ishaq
- Department of Internal Medicine, Jinnah Medical College Hospital, Korangi, Karachi, Pakistan
| | - Salma Razzaque
- Department of Internal Medicine, Jinnah Medical College Hospital, Korangi, Karachi, Pakistan
| | - Fadieleh Shohail
- Department of Internal Medicine, Jinnah Medical College Hospital, Korangi, Karachi, Pakistan
| | - Ajeet Kumar
- Department of Internal Medicine, Jinnah Medical College Hospital, Korangi, Karachi, Pakistan
| | - Jibran Sualeh Muhammad
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| |
Collapse
|
10
|
Abstract
The majority of rheumatic diseases are chronic and require long-term use of disease-modifying agents to confer the best chance of controlling the disease. A significant proportion of these drugs have a risk, albeit small, of potentially serious side effects, such as neutropenia; therefore, there has been an understandable concern over the use of potentially toxic rheumatic drugs in the elderly. Factors that may contribute to this concern include age, pre-existing co-morbidities, polypharmacy, difficulty in monitoring side effects, and patient perception. The risk of using such medication needs to be balanced with their benefits in controlling chronic disease. This review discusses how rheumatic disease and anti-rheumatic medication are associated with neutropenia in an older age group. Of the rheumatic diseases, we give special focus to rheumatoid arthritis and the use of methotrexate, as well as touching on management considerations in neutropenia.
Collapse
|
11
|
Daien CI, Hua C, Combe B, Landewe R. Non-pharmacological and pharmacological interventions in patients with early arthritis: a systematic literature review informing the 2016 update of EULAR recommendations for the management of early arthritis. RMD Open 2017; 3:e000404. [PMID: 28151539 PMCID: PMC5237765 DOI: 10.1136/rmdopen-2016-000404] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 12/09/2016] [Indexed: 12/20/2022] Open
Abstract
Objective To perform a systematic literature review (SLR) on pharmacological and non-pharmacological treatments, in order to inform the European League Against Rheumatism (EULAR) recommendations for the management of early arthritis (EA). Methods The expert committee defined research questions concerning non-pharmacological interventions, patient information and education, non-steroidal anti-inflammatory drug, glucocorticoid (GC) and disease-modifying antirheumatic drugs (DMARDs) use, as well as on disease monitoring. The SLR included articles published after the last EULAR SLR until November 2015 found in the MEDLINE, EMBASE and Cochrane databases and abstracts from the 2014 and 2015 American College of Rheumatology and EULAR conferences. Results Exercise programmes may improve pain and physical function in patients with EA. Patients with EA treated within the first 3 months of symptoms have better clinical and radiological outcomes than those treated beyond 3 months. The clinical and radiological efficacy of GCs is confirmed, with similar efficacy of oral and parenteral administrations. Long-term data raise concerns regarding cardiovascular safety when using GCs. Step-up DMARD therapy is as effective as intensive DMARD therapy ‘ab initio’ for the long-term outcome of EA. Short-term superiority of intensive therapy with bDMARDs is not maintained on withdrawal of bDMARD. Patients with early psoriatic arthritis have better skin and joint outcomes when tight control is used compared to standard care. Conclusions The findings confirm the beneficial effect of exercise programmes and the importance of early drug therapy and tight control. They support the use of methotrexate and GCs as first-line drugs, although the long-term use of GCs raises safety concerns.
Collapse
Affiliation(s)
- Claire Immediato Daien
- Rheumatology department , Lapeyronie Hospital, Montpellier University , Montpellier , France
| | - Charlotte Hua
- Rheumatology department , Lapeyronie Hospital, Montpellier University , Montpellier , France
| | - Bernard Combe
- Rheumatology department , Lapeyronie Hospital, Montpellier University , Montpellier , France
| | - Robert Landewe
- Department of Clinical Immunology & Rheumatology , Amsterdam Rheumatology Center, Amsterdam & Zuyderland Medical Centre , Heerlen , The Netherlands
| |
Collapse
|
12
|
Huang QC, Wang MJ, Chen XM, Yu WL, Chu YL, He XH, Huang RY. Can active components of licorice, glycyrrhizin and glycyrrhetinic acid, lick rheumatoid arthritis? Oncotarget 2016; 7:1193-202. [PMID: 26498361 PMCID: PMC4811453 DOI: 10.18632/oncotarget.6200] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/09/2015] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES This review stated the possible application of the active components of licorice, glycyrrhizin (GL) and glycyrrhetinic acid (GA), in rheumatoid arthritis (RA) treatment based on the cyclooxygenase (COX)-2/thromboxane A2 (TxA2) pathway. METHODS The extensive literature from inception to July 2015 was searched in PubMed central, and relevant reports were identified according to the purpose of this study. RESULTS The active components of licorice GL and GA exert the potential anti-inflammatory effects through, at least in part, suppressing COX-2 and its downstream product TxA2. Additionally, the COX-2/TxA2 pathway, an auto-regulatory feedback loop, has been recently found to be a crucial mechanism underlying the pathogenesis of RA. However, TxA2 is neither the pharmacological target of non-steroidal anti-inflammatory drugs (NSAIDs) nor the target of disease modifying anti-rheumatic drugs (DMARDs), and the limitations and side effects of those drugs may be, at least in part, attributable to lack of the effects on the COX-2/TxA2 pathway. Therefore, GL and GA capable of targeting this pathway hold the potential as a novel add-on therapy in therapeutic strategy, which is supported by several bench experiments. CONCLUSIONS The active components of licorice, GL and GA, could not only potentiate the therapeutic effects but also decrease the adverse effects of NSAIDs or DMARDs through suppressing the COX-2/TxA2 pathway during treatment course of RA.
Collapse
Affiliation(s)
- Qing-Chun Huang
- Department of Rheumatology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Mao-Jie Wang
- Central Laboratory, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xiu-Min Chen
- Department of Rheumatology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Wan-Lin Yu
- Central Laboratory, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Yong-Liang Chu
- Department of Rheumatology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xiao-Hong He
- Department of Rheumatology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Run-Yue Huang
- Department of Rheumatology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| |
Collapse
|