Impact of Etanercept Therapy on Disease Activity and Health-Related Quality of Life in Moderate Rheumatoid Arthritis Patients Population from a National British Observational Cohort

Harmonizing Medicine and Surgery in the Pursuit of Boolean Remission: A Rheumatological Magnum Opus

Rheumatic diseases encompass a diverse group of musculoskeletal conditions that often lead to inflammation, pain, and significant limitations in patients' lives. While traditional treatment approaches have primarily centered on medications to control symptoms, recent developments have introduced the concept of Boolean remission. Boolean remission offers a comprehensive evaluation of disease activity by considering clinical, biochemical, and patient-reported outcomes. This narrative review explores the multifaceted landscape of Boolean remission in the context of rheumatic diseases, with a focus on rheumatoid arthritis (RA), as it remains a substantial clinical challenge. The review outlines the definition, criteria, historical context, and development of Boolean remission, shedding light on its emergence as a more patient-centered and stringent treatment goal. The role of pharmacological interventions, including immunomodulators and biologics, in achieving Boolean remission is discussed, emphasizing the significance of treatment protocols that encompass regular monitoring, medication adjustment, shared decision-making, and patient education. Surgical interventions, such as joint replacements and synovectomies, complement medication-based strategies when joint damage becomes severe, with adherence to surgical protocols ensuring sustained Boolean remission. The integration of medicine and surgery through integrated care models and interdisciplinary teams is examined as a critical aspect of optimizing patient outcomes. Boolean remission's broader impact on healthcare policies and clinical trial endpoints is explored, underscoring its growing significance in rheumatic disease management. The review concludes by looking toward the future, where emerging technologies, biomarkers, and personalized medicine approaches hold promise in refining Boolean remission criteria and making it a more attainable and impactful treatment goal. Policy implications suggest the integration of Boolean remission into healthcare quality metrics, incentivizing healthcare providers to prioritize this rigorous standard of care. Boolean remission represents a pivotal shift in the holistic and patient-centered management of rheumatic diseases, offering hope for improved patient outcomes and enhanced quality of life in this challenging clinical landscape.

Approaches to optimising access to NICE-approved biologic anti-TNFs for patients with rheumatoid arthritis with moderately active disease

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease that is associated with joint pain and stiffness. Biologics represent some of the most effective treatments for RA, but previous guidance from the National Institute for Health and Care Excellence (NICE) has limited their use to patients with severely active disease. This has meant patients with moderately active RA have been treated as if they have an acceptable disease state, despite many cases where the inflammation has a major impact on joint damage, mobility, pain and quality of life. However, recent guideline changes (NICE TA715) have approved the use of three biologics - adalimumab, etanercept and infliximab - for the treatment of moderately active RA.

MAIN BODY

In response to these changes, we have held discussions with medical teams from across the UK to consider the main implications for implementation of these new recommendations, as well as any differences in approach that may exist at a local level. Several key challenges were identified. These included establishing methods of educating both physicians and patients concerning the new availability of the biologic treatments, with suggestions of various organisations that could be approached to circulate informative material. Identifying which patients with moderately active RA stand to benefit was another discussion topic. Relying solely on scoring systems like Disease Activity Score in 28 Joints (DAS28) was acknowledged to have limitations, and alternative complementary approaches such as ultrasound, as well as assessing a patient's co-morbidities, could also be useful tools in determining those who could benefit from biologics. An additional challenge for the process of patient identification has been the increase in the use of telemedicine consultations in response to the coronavirus disease 2019 (COVID-19) pandemic. More use of patient-reported outcomes was raised as one possible solution, and the importance of maintaining up-to-date databases on patient disease scores and treatment history was also stressed.

CONCLUSION

While challenges exist in education and identifying patients who may benefit from the use of biologics, the NICE TA715 recommendations hold great potential in addressing an unmet need for the treatment of moderate RA.

Evaluating the efficacy of upadacitinib in patients with moderate rheumatoid arthritis: a post-hoc analysis of the SELECT phase 3 trials

Objectives

Moderately active RA is associated with poor patient outcomes. Despite this, some health systems have restricted access to advanced therapies to those with severe RA. There is also limited evidence of the efficacy of advanced therapies in the moderately active RA population. This post-hoc analysis from four phase 3 trials explored the efficacy of upadacitinib (UPA) for moderately active RA.

Methods

Patients included in this analysis received UPA 15 mg once daily [monotherapy after switching from MTX or in combination with stable background conventional synthetic DMARDs (csDMARDs)] or placebo. Clinical, functional and radiographic outcomes were analysed separately for patients with moderate disease activity {28-joint count DAS using CRP [DAS28(CRP)] of >3.2 and ≤5.1} and severe disease activity [DAS28(CRP) >5.1].

Results

Patients with moderate disease activity who received UPA 15 mg (combination or monotherapy) after an inadequate response to biologic DMARDs and/or csDMARDs were significantly more likely to achieve a 20% improvement in the ACR response criteria, low disease activity status [DAS28(CRP) ≤ 3.2] or clinical remission [DAS28(CRP) < 2.6] by week 12/14 vs placebo. Statistically significant improvements in patient-reported functioning and pain from baseline were observed for UPA 15 mg vs placebo at week 12/14. Radiographic progression was also significantly reduced at week 26 compared with placebo. Similar improvements were observed for severe disease.

Conclusion

This analysis provides support for the use of UPA for the treatment of patients with moderate RA.

Trial registration

ClinicalTrials.gov: SELECT-NEXT: NCT02675426; SELECT-COMPARE: NCT02629159; SELECT-MONOTHERAPY: NCT02706951; SELECT-BEYOND: NCT02706847.

Targeted literature review of current treatments and unmet need in moderate rheumatoid arthritis in the United Kingdom

OBJECTIVES

The burden and treatment landscape of RA is poorly understood. This research aimed to identify evidence on quality of life, caregiver burden, economic burden, treatment patterns and clinical outcomes for patients with moderate RA in the United Kingdom.

METHODS

A systematic literature review was performed across multiple databases and screened against pre-defined inclusion criteria.

RESULTS

A total of 2610 records were screened; seven studies presenting evidence for moderate RA were included. These patients were found to incur substantial burden, with moderate to severe levels of disability. Compared with patients in remission, moderate RA patients reported higher levels of disability and decreased EQ-5D utility scores. The majority of patients did not feel that their current therapy adequately controlled their disease or provided sufficient symptom relief. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) have not approved advanced therapies (such as biological disease-modifying anti-rheumatic drugs) for patients with moderate disease, which restricts access for these patients.

CONCLUSION

The evidence available on the burden of moderate RA is limited. Despite current treatments, moderate RA still has a substantial negative impact, given that a DAS28 disease activity score defined as being in the moderate range does not qualify them for access to advanced therapies in the United Kingdom. For these patients, there is a particular need for further studies that investigate their burden and the impact of treating them earlier. Such information would help guide future treatment decisions and ensure the most effective use of resources to gain the best outcomes for patients with moderate RA.

The Preparation of a Novel Poly(Lactic Acid)-Based Sustained H2S Releasing Microsphere for Rheumatoid Arthritis Alleviation

Rheumatoid arthritis (RA) is a chronic, inflammatory autoimmune disease that mainly erodes joints and surrounding tissues, and if it is not treated in time, it can cause joint deformities and loss of function. S-propargyl-cysteine (SPRC) is an excellent endogenous hydrogen sulfide donor which can relieve the symptoms of RA through the promotion of H₂S release via the CSE/H₂S pathway in vivo. However, the instant release of H₂S in vivo could potentially limit its further clinical use. To solve this problem, in this study, a SPRC-loaded poly(lactic acid) (PLA) microsphere (SPRC@PLA) was prepared, which could release SPRC in vitro in a sustained manner, and further promote sustained in vivo H₂S release. Furthermore, its therapeutical effect on RA in rats was also studied. A spherical-like SPRC@PLA was successfully prepared with a diameter of approximately 31.61 μm, yielding rate of 50.66%, loading efficiency of 6.10% and encapsulation efficiency of 52.71%. The SPRC@PLA showed significant prolonged in vitro SPRC release, to 4 days, and additionally, an in vivo H₂S release around 3 days could also be observed. In addition, a better therapeutical effect and prolonged administration interval toward RA rats was also observed in the SPRC@PLA group.

Disease impact of rheumatoid arthritis in patients not treated with advanced therapies; survey findings from the National Rheumatoid Arthritis Society

Objective

The aim was to reveal the everyday impact of living with RA in people not treated with advanced therapies (i.e. biologic or targeted synthetic DMARDs).

Methods

People with RA, with disease duration >2 years, not currently treated with advanced therapies, completed an online survey promoted by the National Rheumatoid Arthritis Society. Items covered demographics, current treatment, RA flare frequency, the Rheumatoid Arthritis Impact of Disease (RAID) tool and questions reflecting work status and ability. Descriptive and multivariable regression analyses were performed.

Results

There were 612 responses from patients having a mean age of 59 years, 88% female, 37.7% with disease duration 2–5 years and 27.9% with disease duration 5–10 years. In the last year, 90% reported an RA flare, with more than six flares in 23%. A RAID patient acceptable state was recorded in 12.4%. Each of the seven domains was scored in the high range by >50% respondents; 74.3% scored sleep problems and 72% fatigue in the high range. A need to change working hours was reported by 70%. Multivariable analyses revealed that increasing difficulties with daily physical activities, reduced emotional and physical well-being in the past week were all significantly associated with pain, number of flares and ability to cope (P < 0.005). The RAID score was significantly predictive of the number of flares.

Conclusion

Patients not currently treated with advanced therapies experience profound difficulties in everyday living with RA, across a broad range of measures. We advocate that patient-reported measures be used to facilitate holistic care, addressing inflammation and other consequences of RA on everyday life.

Maintenance of Sustained Low Disease Activity or Remission in Patients With Rheumatoid Arthritis Treated With Etanercept Monotherapy: Results from the Corrona Registry

Objective

The purpose of this study was to evaluate maintenance of remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) who achieved remission/LDA with etanercept (ETN) plus a conventional synthetic disease‐modifying antirheumatic drug (csDMARD) and to compare patients who discontinued csDMARD to receive ETN monotherapy (Mono) with those remaining on combination therapy (Combo).

Methods

Patients from the Corrona RA registry between October 1, 2001, and August 31, 2017, were eligible. The index date for the Mono cohort was the csDMARD discontinuation date; the index visit for the Combo cohort was estimated from time between ETN initiation and csDMARD discontinuation in the Mono cohort. The main outcome calculated was maintenance of remission/LDA. Patients were censored if they switched to or added a biologic DMARD, discontinued ETN, when a csDMARD was reintroduced (Mono), or if methotrexate increased more than 5 mg/d (Combo). Trimming was used to balance demographic and clinical characteristics between groups. Cox regression models were adjusted for the remaining differences across groups.

Results

We identified 182 Mono and 403 Combo patients; 120 Mono and 207 Combo patients remained after trimming. Most patients (approximately 80%) were biologic medication–naive before initiating ETN. At 24 months postindex, modeled percentages of patients remaining in remission/LDA were 75% for Mono and 86% for Combo (overall adjusted P = 0.057). More patients were censored for therapy change in Mono than in Combo groups (37% versus 5%), largely due to reintroduction of csDMARDs in the Mono group.

Conclusion

Many patients with RA who achieved remission/LDA on combination therapy maintained remission/LDA with ETN monotherapy for 2 years after csDMARD discontinuation. ETN monotherapy may be a viable option for patients who discontinue csDMARDs after achieving LDA/remission.