Initial Management of Rheumatoid Arthritis

Pulsed Electromagnetic Field (PEMF) Treatment Ameliorates Murine Model of Collagen-Induced Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease of the joint synovial membranes. RA is difficult to prevent or treat; however, blocking proinflammatory cytokines is a general therapeutic strategy. Pulsed electromagnetic field (PEMF) is reported to alleviate RA's inflammatory response and is being studied as a non-invasive physical therapy. In this current study, PEMF decreased paw inflammation in a collagen-induced arthritis (CIA) murine model. PEMF treatment at 10 Hz was more effective in ameliorating arthritis than at 75 Hz. In the PEMF-treated CIA group, the gross inflammation score and cartilage destruction were lower than in the untreated CIA group. The CIA group treated with PEMF also showed lower serum levels of IL-1β but not IL-6, IL-17, or TNF-α. Serum levels of total anti-type II collagen IgG and IgG subclasses (IgG1, IgG2a, and IgG2b) remained unchanged. In contrast, tissue protein levels of IL-1β, IL-6, TNF-α, receptor activator of nuclear factor kappa-Β (RANK), RANK ligand (RANKL), IL-6 receptor (IL-6R), and TNF-α receptor1 (TNFR1) were all lower in the ankle joints of the PEMF-treated CIA group compared with the CIA group. The results of this study suggest that PEMF treatment can preserve joint morphology cartilage and delay the occurrence of CIA. PEMF has potential as an effective adjuvant therapy that can suppress the progression of RA.

Rehabilitation needs approached by health professionals at a rheumatism hospital

OBJECTIVE

The aim of the present study was to examine the characteristics of patients referred to occupational therapists (OTs), physiotherapists (PTs) and social workers (SWs) at a rehabilitation unit in a hospital specializing in rheumatology, and the rehabilitation needs that clinicians and patients agreed should be addressed in the encounters with the particular health professional groups.

METHODS

Consecutive hospitalized patients at a rheumatism hospital were recruited by the health professionals. Questions about patient characteristics and rehabilitation needs were posed. Free-text responses to questions about rehabilitation needs were coded by the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

The patients varied considerably in age distribution, disease duration, disability level and diagnoses, and several patients had comorbidities. The rehabilitation needs classified under the component Body Function fell into the chapters: Sensory Functions and Pain (PTs), Functions of Cardiovascular System (PTs), Neuromusculoskeletal and Movement-Related Functions (OTs, PTs); under the Activity and Participation component, these were: General Tasks and Demands (OTs), Mobility (OTs), Self-Care (PTs), Interpersonal Interactions and Relationships (SWs) and Major Life Stress (SWs); and under the Environmental Factors component these were: Products and Technology (OTs) and Services, Systems and Politics (SWs).

CONCLUSIONS

The patients were fairly heterogeneous. The needs identified in the encounters with the different professional groups fell into all three components of the ICF, and there was only a minor overlap between the health professionals at the chapter level of the ICF.

Physician Preferences and Variations in Prescription of Biologic Drugs for Rheumatoid Arthritis: A Register-Based Study of 4,010 Patients in Sweden

OBJECTIVE

The prescription of biologic drugs for rheumatoid arthritis (RA) patients has varied considerably across different regions. Previous studies have shown physician preferences to be an important determinant in the decision to select biologic disease-modifying antirheumatic drugs (bDMARDs) rather than nonbiologic, synthetic DMARDs (sDMARDs) alone. The aim of this study was to test the hypothesis that physician preferences are an important determinant for prescribing bDMARDs for RA patients in Sweden.

METHODS

Using data from the Swedish Rheumatology Quality Register, we identified 4,010 RA patients who were not prescribed bDMARDs during the period 2008-2012, but who, on at least 1 occasion, had an sDMARD prescription and changed treatment for the first time to either a new sDMARD or a bDMARD. Physician preference for the use of bDMARDs was calculated using data on each physician's prescriptions during the study period. The relationship between prescription of a bDMARD and physician preference, controlling for patient characteristics, disease activity, and the physician's local context was evaluated using multivariate logistic regression.

RESULTS

When adjusting for patient characteristics, disease activity, and the physician's local context, physician preference was an important predictor for prescription of bDMARDs. Compared with patients of a physician in the lowest preference tertile, patients of physicians in the highest and middle tertiles had an odds ratio for receiving bDMARDs of 2.8 (95% confidence interval [95% CI] 2.13-3.68) and 1.28 (95% CI 1.05-1.57), respectively.

CONCLUSION

Physician preference is an important determinant for prescribing bDMARDs.

Frequency of methotrexate intolerance in rheumatoid arthritis patients using methotrexate intolerance severity score (MISS questionnaire)

The objective of the study was to determine the frequency of methotrexate intolerance in rheumatoid arthritis (RA) patients by applying the methotrexate intolerance severity score (MISS) questionnaire and to see the effect of dose and concomitant use of other disease-modifying antirheumatic drugs (DMARDS) on methotrexate (MTX) intolerance. For the descriptive study, non-probability sampling was carried out in the Female Rheumatology Department of Fauji Foundation Hospital (FFH), Rawalpindi, Pakistan. One hundred and fifty diagnosed cases of RA using oral MTX were selected. The MISS questionnaire embodies five elements: abdominal pain, nausea, vomiting, fatigue and behavioural symptoms. The amplitude of each element was ranked from 0 to 3 being no complaint (0 points), mild (1 point), moderate (2 points) and severe (3 points). A cut-off score of 6 and above ascertained intolerance by the physicians. A total of 33.3 % of the subjects exhibited MTX intolerance according to the MISS questionnaire. Out of which, the most recurring symptom of all was behavioural with a value of 44 % whereas vomiting was least noticeable with a figure of 11 %. About 6.6 % of the women with intolerance were consuming DMARDs in conjunction with MTX. Those using the highest weekly dose of MTX (20 mg) had supreme intolerance with prevalence in 46.2 % of the patients. The frequency of intolerance decreased with a decrease in weekly dose to a minimum of 20 % with 7.5 mg of MTX. MTX intolerance has moderate prevalence in RA patients and if left undetected, the compliance to use of MTX as a first-line therapy will decrease. Methotrexate intolerance is directly proportional to the dose of MTX taken. Also, there is no upstroke seen in intolerance with the use of other disease-modifying agents.

Current Practice Patterns and Educational Needs of Rheumatologists Who Manage Patients with Rheumatoid Arthritis

INTRODUCTION

As the therapeutic landscape for rheumatoid arthritis (RA) continues to change, it is relevant to examine current treatment patterns among rheumatologists. The purpose of this study was to identify attitudes and practices of US rheumatologists with respect to RA.

METHODS

Nine-hundred and one US-practicing rheumatologists were sent electronic invites (via email or fax) to participate in a case-vignette survey in April 2013. All respondents were currently practicing rheumatology and seeing at least one RA patient per week. The survey examined current attitudes, existing knowledge, management choices and perceived barriers in the management of RA. Data collection stopped once 125 responses were received.

RESULTS

Approximately half of the 125 respondents were very familiar with current clinical practice guidelines for RA diagnosis and management. There was no consensus on which validated tools to use when assessing RA severity, with 54% using Physician Global Assessment and 34% using Disease Activity Score 28 at initial assessment. Most respondents (74%) used methotrexate (MTX) as initial therapy for a newly diagnosed RA patient. Eighty-six percent of respondents would add a tumor necrosis factor inhibitor (TNFi) when MTX alone could not control RA. There was no consensus on which treatment should be used when a TNFi is ineffective. The majority of respondents (66% of respondents) would prescribe TNFis indefinitely in patients with continued response. If a patient was in stable remission on MTX and a TNFi, respondents were most likely to maintain this regimen (53% of respondents); a notable minority (43%) would lower the MTX dose. When prescribing biologics, respondents were most concerned with infection; infection was considered a very significant barrier to biologic use. Although 98% of respondents indicated that they personally educate patients about RA, only 42% provide written material.

CONCLUSIONS

The lack of consistency in responses suggests that rheumatologists may benefit from continuing medical education on; clinical practice guidelines; the most recent evidence for management of patients in remission; the use of biologic agents after infection; and management of patients with RA and comorbidities.

Research of the methylation status of miR-124a gene promoter among rheumatoid arthritis patients

Objective. To analyze the methylation status of miR-124a loci in synovial tissues of rheumatoid arthritis (RA) patients using methylation-specific polymerase chain reaction (MSP). Materials and Methods. DNA obtained from the frozen tissue of 7 RA samples, 6 osteoarthritis (OA) samples, and 3 healthy controls were undergoing bisulfite conversion and then analyzed for miR-124a promoter methylation using MSP assay. Results. miR-124-a1 and miR-124-a2 promoter methylation were both seen in 71.4% of RA samples compared to 16.7% of OA samples. miR-124-a3 promoter methylation was seen in 57.1% of RA samples and 0% of OA samples. All the three loci were unmethylated in 3 healthy controls. Conclusion. The methylation status of miR-124a seen in this study concurs with that reported in tumor cells, indicating epigenetic dysregulation constituents, a mechanism in the development of rheumatoid arthritis.

Wnt signaling pathway in rheumatoid arthritis, with special emphasis on the different roles in synovial inflammation and bone remodeling

Rheumatoid arthritis (RA) is a chronic symmetrical autoimmune disease of unknown etiology that affects primarily the diarthrodial joints. Characteristic features of RA pathogenesis are synovial inflammation and proliferation accompanied by cartilage erosion and bone loss. Fibroblast-like synoviocytes (FLS) display an important role in the pathogenesis of RA. Several lines of evidence show that the Wnt signaling pathway significantly participates in the RA pathogenesis. The Wnt proteins are glycoproteins that bind to the Fz receptors on the cell surface, which leads to several important biological functions, such as cell differentiation, embryonic development, limb development and joint formation. Accumulated evidence has suggested that this signaling pathway plays a key role in the FLS activation, bone resorption and joint destruction during RA development. Greater knowledge of the role of the Wnt signaling pathway in RA could improve understanding of the RA pathogenesis and the differences in RA clinical presentation and prognosis. In this review, new advances of the Wnt signaling pathway in RA pathogenesis are discussed, with special emphasis on its different roles in synovial inflammation and bone remodeling. Further studies are needed to reveal the important role of the members of the Wnt signaling pathway in the RA pathogenesis and treatment.

New advances of microRNAs in the pathogenesis of rheumatoid arthritis, with a focus on the crosstalk between DNA methylation and the microRNA machinery

Rheumatoid arthritis (RA) is a symmetrical polyarticular disease of unknown aetiology that affects primarily the articular cartilage and bone. Characteristic features of RA pathogenesis are persistent inflammation, synovium hyperplasia and cartilage erosion accompanied by joint swelling and joint destruction. Several lines of evidence have showed a crucial role of activated fibroblast-like synoviocytes (FLS) in the pathogenesis of RA. MicroRNAs (miRNAs) are endogenous, single-stranded, non-coding RNAs with about 21 nucleotides in length and have been detected in a variety of sources, including tissues, serum, and other body fluids, such as saliva. In light of key roles of miRNAs in the regulation of gene expression, miRNAs influence a wide range of physiological and pathological processes. For example, miRNAs are evident in various malignant and nonmalignant diseases, and accumulating evidence also shows that miRNAs have important roles in the pathogenesis of RA. It has been demonstrated that miRNAs can be aberrantly expressed even in the different stages of RA progression, allowing miRNAs to help understand the pathogenesis of the disease, to act as important biomarkers, and to monitor the disease severity and the effects of drug treatment. In addition, miRNAs are emerging as potential targets for new therapeutic strategies of this kind of autoimmune disorders. The ultimate goal is the identification of miRNA targets that could be manipulated through specific therapies, aiming at activation or inhibition of specific miRNAs responsible for the RA development. In this review, the importance of miRNAs in the pathogenesis of RA is discussed systematically, with particular emphasis on the role of the crosstalk between DNA methylation and the microRNA machinery.