The "Treat to Target" Approach to Rheumatoid Arthritis

Well-controlled disease activity with drug treatment will not improve the frailty status of RA patients to robust state: A multicenter observational study (T-FLAG)

OBJECTIVES

To investigate a plateau in treatment enhancement for improving the frailty status of rheumatoid arthritis (RA) patients.

METHODS

A total of 345 RA patients who were not robust in 2021 were assigned to the improved ("robust 2022," n = 51) and non-improved ("pre-frailty/frailty 2022," n = 294) groups. Factors associated with "robust 2022" were examined by logistic regression analysis. Patients were assigned to the stable (Follow-up mean DAS28-ESR in 2020 and 2021 < 3.2, n = 225) and unstable (≥3.2, n = 120) groups, which were further divided into the non-improved (stable: n = 180, unstable: n = 114) and improved (stable: n = 45, unstable: n = 6) groups. Factors influencing Japanese Cardiovascular Health Study (J-CHS) score were examined by multiple regression analysis. Changes over 2 years were compared between the non-improved and improved groups of the stable group.

RESULTS

The associated factor of "robust 2022" was the follow-up meanDAS28-ESR in 2020 and 2021 < 3.2 (i.e., stable state) (OR: 4.01). Follow-up mean DAS28-ESR in 2020 and 2021 was associated with J-CHS score (T = 2.536, p = .013) only in the unstable group. In the stable group, HAQ-DI was lower (2020: 0.32 vs. 0.16; 2021: 0.32 vs. 0.17; 2022: 0.32 vs. 0.21), and the proportion of J-CHS: Q4 (weakness) was lower (2020: 48.4 vs. 17.8%; 2021: 55.0 vs. 29.2%; 2022: 50.4 vs. 0%), in the improved group than in the non-improved group, whereas both groups maintained clinical and functional remission over 2 years.

CONCLUSIONS

Drug treatment to maintain well-controlled disease activity alone is insufficient for improving patients' frailty status after achieving treat-to-target goals, suggesting the need for multifaceted approaches.

Disease activity at baseline is an independent predictor of frailty at one year in pre-frail patients with rheumatoid arthritis; a multicenter retrospective observational study

OBJECTIVES

To investigate factors predicting frailty for one year in pre-frail patients with rheumatoid arthritis (RA).

METHOD

A total of 298 RA patients who were pre-frail in 2020 were evaluated in this structured, retrospective observational study. Of the 298 patients, 42 who were frail and 256 who were not in 2021 were assigned to the frailty and non-frailty groups, respectively. After comparing characteristics of both groups using univariate analysis, predictive factors of frailty were assessed by logistic regression analysis. The proportion of frail patients in 2021 by DAS28-ESR level in 2020 was examined by the Cochran-Armitage trend test and chi-squared test. After dividing pre-frail patients into those with DAS28-ESR ≥3.2 and DAS28-ESR <3.2 in 2020, one-year change in DAS28-ESR in the frailty and non-frailty groups for both subgroups were compared by the paired t-test.

RESULTS

The frailty group was older (mean: 71.0 vs. 65.4 years) and had a higher DAS28-ESR (mean: 3.22 vs. 2.70) than the non-frailty group. DAS28-ESR was identified as a predictive factor for frailty (OR: 1.49). Among patients with DAS28-ESR ≥3.2 in 2020, DAS28-ESR improved in the non-frailty group in 2021 (mean: 3.97 in 2020 vs. 3.13 in 2021) but did not in the frailty group (3.97 in 2020 vs. 3.81 in 2021). Among those with DAS28-ESR <3.2 in 2020, DAS28-ESR was unchanged in the non-frailty group in 2021 (2.15 in 2020 vs. 2.23 in 2021) but increased in the frailty group (2.53 in 2020 vs. 3.23 in 2021).

CONCLUSIONS

Disease activity at baseline is an independent predictor of frailty one year later in pre-frail patients with RA.

Factors associated with frailty in rheumatoid arthritis patients with decreased renal function

OBJECTIVES

To investigate factors associated with frailty in rheumatoid arthritis (RA) patients with decreased renal function.

METHODS

RA patients who visited outpatient clinics from June to August 2021 were included (N = 625). Patients with estimated glomerular filtration rate <60 ml/min/1.73 m2 were defined as having decreased renal function (N = 221) and divided into the non-frailty (N = 153) and frailty (N = 58) groups. Patient characteristics were compared between the two groups by univariate analysis. Significant factors in univariate analysis were assessed by logistic regression analysis to determine their association with frailty in patients with decreased renal function.

RESULTS

Patients in the frailty group were older (74.0 vs.79.0 years) and had a longer duration of disease (11.1 vs. 17.8 years), higher Disease Activity Score erythrocyte sedimentation rate (DAS28-ESR; 2.99 vs. 3.80), higher Health Assessment Questionnaire Disability Index (0.42 vs. 1.43), and a lower rate of methotrexate (MTX) use (46.4% vs. 25.9) compared to those in the non-frailty group. Factors associated with frailty in patients with decreased renal function were age (odds ratio: 1.07), duration of disease (1.06), DAS28-ESR (1.85), and MTX use (0.42).

CONCLUSIONS

Among factors associated with frailty in RA patients with decreased renal function, improving DAS28-ESR is likely to be the most feasible approach to promote recovery from frailty (200/200 words).

A treat-to-target approach is needed for Behçet's syndrome

PURPOSE OF REVIEW

Treat-to-target (T2T) approach has improved outcomes in chronic diseases. The aim of this review is to discuss the long-term goals and review the evidence for possible targets that would predict the achievement of these goals for developing a T2T strategy for Behçet's syndrome.

RECENT FINDINGS

There are no trials comparing a tight control strategy to standard care in Behçet's syndrome but recent studies suggest better outcomes with earlier use of biologic agents compared with sustained conventional treatment. Fluorescein angiography may be a reliable tool for assessing remission in uveitis as fluorescein angiography findings were shown to predict relapses and long-term visual outcome. Good recanalization on Doppler ultrasonography can be a target for venous involvement as this was the only predictor of relapse. Fecal calprotectin levels were associated with small intestinal and colonic ulcers and may be used as a surrogate for remission of gastrointestinal involvement.

SUMMARY

There are several new treatment modalities that are tried for Behçet's syndrome and ongoing work on outcome measures for reliable disease assessment. In order to ensure the wise and efficient use of treatment modalities, development and implementation of T2T strategies are needed through multidisciplinary and multinational efforts that include patient research partners.

Clinical utility of quantitative analysis of bone scintigraphy in detecting clinically active joint and high disease activity in patients with rheumatoid arthritis

Background

The purpose of this study was to investigate the efficiency of quantitative parameters of bone scintigraphy in detecting clinically active joint and high disease activity in patients with rheumatoid arthritis.

Methods

We retrospectively enrolled 65 patients with rheumatoid arthritis who underwent bone scintigraphy for diagnostic work-up. Quantitative analysis of bone scintigraphy images was conducted using an in-house software, and joint uptake ratio of 28 joints was measured for the calculation of the disease activity score of 28 joints using erythrocyte sedimentation rate (DAS28-ESR). The relationship between joint uptake ratio and clinical findings and the efficiency of joint uptake ratio in detecting clinically active joint and high disease activity were assessed.

Results

Clinically active joint (tender and/or swollen joints) showed significantly higher joint uptake ratio than did other non-affected joints (p < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of joint uptake ratio for identifying clinically active joint were 78.7%, 52.0%, 32.9%, and 89.1%, respectively, and those of the summed joint uptake ratio for detecting high disease activity were 92.9%, 66.8%, 43.3%, and 97.1%, respectively; the joint uptake ratio showed high detection ability, especially for active joints of the elbow, wrist, and metacarpo-phalangeal joint areas. The summed joint uptake ratio of 28 joints showed a significantly strong positive correlation with DAS28-ESR (p < 0.001; correlation coefficient, 0.725).

Conclusion

Quantitative parameters of bone scintigraphy showed high sensitivity and NPV for detecting clinically active joint and high disease activity in patients with rheumatoid arthritis.

Measurement of synovium and serum dual specificity phosphatase 22 level: Their inter-correlation and potency as biomarkers in rheumatoid arthritis

Background

Dual specificity phosphatase 22 (DUSP22), also named as Jun N‐terminal kinase pathway associated phosphatase recently, is reported to be closely engaged in immune and inflammation regulation. This study aimed to investigate the interaction between synovium DUSP22 and serum DUSP22 levels and to explore their correlation with rheumatoid arthritis (RA) risk, inflammation, and disease activity.

Methods

Synovium and serum samples from 42 RA patients with knee involvement underwent arthroscopy, and 20 knee trauma patients were collected. Besides, serum samples from 40 healthy controls were also obtained. Synovium DUSP22 expression was detected by reverse transcription quantitative polymerase chain reaction, while serum DUSP22 level was detected by enzyme‐linked immunosorbent assay.

Results

Synovium DUSP22 level was greatly decreased in RA patients compared to trauma controls (p < 0.001), and it was negatively correlated with tender joint count (TJC) (r = −0.318, p = 0.040), C‐reactive protein (CRP) (r = −0.330, p = 0.033), and Lysholm score (r = −0.423, p = 0.005) in RA patients. Serum DUSP22 level was lowest in RA patients, followed by trauma controls, then highest in healthy controls (p < 0.001). Serum DUSP22 level was negatively associated with TJC (r = −0.438, p = 0.004), swollen joint count (SJC) (r = −0.372, p = 0.015), CRP (r = −0.391, p = 0.011), and disease activity score in 28 joints (DAS28_ESR) score (r = −0.406, p = 0.008), and it increased after treatment (p = 0.001) in RA patients. In addition, serum DUSP22 level positively related to synovium DUSP22 level in RA patients (r = 0.394, p = 0.010).

Conclusion

Synovium and serum DUSP22 are intercorrelated and insufficiently expressed in RA patients; meanwhile, their deficiency correlates with increased systemic inflammation, disease activity, and joint dysfunction.

Recent Advances in Understanding the Pathogenesis of Rheumatoid Arthritis: New Treatment Strategies

Rheumatoid arthritis (RA) is considered a chronic systemic, multi-factorial, inflammatory, and progressive autoimmune disease affecting many people worldwide. While patients show very individual courses of disease, with RA focusing on the musculoskeletal system, joints are often severely affected, leading to local inflammation, cartilage destruction, and bone erosion. To prevent joint damage and physical disability as one of many symptoms of RA, early diagnosis is critical. Auto-antibodies play a pivotal clinical role in patients with systemic RA. As biomarkers, they could help to make a more efficient diagnosis, prognosis, and treatment decision. Besides auto-antibodies, several other factors are involved in the progression of RA, such as epigenetic alterations, post-translational modifications, glycosylation, autophagy, and T-cells. Understanding the interplay between these factors would contribute to a deeper insight into the causes, mechanisms, progression, and treatment of the disease. In this review, the latest RA research findings are discussed to better understand the pathogenesis, and finally, treatment strategies for RA therapy are presented, including both conventional approaches and new methods that have been developed in recent years or are currently under investigation.

Non-invasive monitoring of arthritis treatment response via targeting of tyrosine-phosphorylated annexin A2 in chondrocytes

BACKGROUND

The development and optimization of therapies for rheumatoid arthritis (RA) is currently hindered by a lack of methods for early non-invasive monitoring of treatment response. Annexin A2, an inflammation-associated protein whose presence and phosphorylation levels are upregulated in RA, represents a potential molecular target for tracking RA treatment response.

METHODS

LS301, a near-infrared dye-peptide conjugate that selectively targets tyrosine 23-phosphorylated annexin A2 (pANXA2), was evaluated for its utility in monitoring disease progression, remission, and early response to drug treatment in mouse models of RA by fluorescence imaging. The intraarticular distribution and localization of LS301 relative to pANXA2 was determined by histological and immunohistochemical methods.

RESULTS

In mouse models of spontaneous and serum transfer-induced inflammatory arthritis, intravenously administered LS301 showed selective accumulation in regions of joint pathology including paws, ankles, and knees with positive correlation between fluorescent signal and disease severity by clinical scoring. Whole-body near-infrared imaging with LS301 allowed tracking of spontaneous disease remission and the therapeutic response after dexamethasone treatment. Histological analysis showed preferential accumulation of LS301 within the chondrocytes and articular cartilage in arthritic mice, and colocalization was observed between LS301 and pANXA2 in the joint tissue.

CONCLUSIONS

We demonstrate that fluorescence imaging with LS301 can be used to monitor the progression, remission, and early response to drug treatment in mouse models of RA. Given the ease of detecting LS301 with portable optical imaging devices, the agent may become a useful early treatment response reporter for arthritis diagnosis and drug evaluation.

Performance of three composite measures for disease activity in peripheral spondyloarthritis

OBJECTIVE

To investigate concurrent validity and discrimination of the Disease Activity Psoriatic Arthritis score (DAPSA), Psoriatic Arthritis Disease Activity Score (PASDAS) and Ankylosing Spondylitis Disease Activity Score (ASDAS) in peripheral spondyloarthritis (pSpA) in clinical practice.

METHODS

Data from a Dutch registry for SpA (SpA-Net) were used. Predefined hypotheses on concurrent validity of the composite measures with 15 other outcome measures of disease activity, physical function and health-related quality of life were tested. Concurrent validity was considered acceptable if ≥75% of the hypotheses were confirmed. Discrimination was assessed by stratifying patients in DAPSA, PASDAS and ASDAS predefined disease activity states and studying mean differences in health outcomes by one-way ANOVA. Furthermore, the concordance in disease activity states was determined. All analyses were repeated in subgroups with and without psoriasis.

RESULTS

DAPSA, PASDAS and ASDAS scores were available for 191, 139 and 279 patients with pSpA, respectively. The concurrent validity and discrimination of all composite measures were acceptable as the strength of correlations were as hypothesized in ≥75% of the studied correlations. With increasing disease activity states, scores in nearly all outcome measures worsened significantly. The DAPSA, PASDAS and ASDAS classified 22%, 56% and 48% of the patients, respectively, in the two highest disease activity states. Stratified analyses for concomitant psoriasis revealed no relevant subgroup differences.

CONCLUSION

The performance of DAPSA, PASDAS and ASDAS in pSpA was acceptable, and independent of concomitant psoriasis. Due to discrepancy in classification, the validity of existing thresholds for disease activity states warrants further study in pSpA.

Clinical utility of F-18 sodium fluoride PET/CT for estimating disease activity in patients with rheumatoid arthritis

Background

The present study aimed to investigate the clinical implication of F-18 sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT) for assessing the disease activity of rheumatoid arthritis.

Methods

Seventeen patients with rheumatoid arthritis according to the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria were prospectively enrolled. All enrolled patients underwent F-18 NaF PET/CT along with physical examination, blood test, and ultrasonography. On PET/CT images, two quantitative parameters, F-18 NaF uptake of the joint (joint SUV) and joint-to-bone uptake ratio, were measured for each of the 28 joints included in calculating the disease activity score in 28 joints using erythrocyte sedimentation rate (DAS28-ESR). The relationship between PET/CT parameters and clinical factors and the predictive values of PET/CT parameters for joints with synovitis and high disease activity were evaluated.

Results

Tender joints (joint SUV, 13.6±8.4; joint-to-bone uptake ratio, 1.70±1.02) and both tender and swollen joints (joint SUV, 13.9±5.4; joint-to-normal bone uptake ratio, 1.81±0.76) had significantly higher joint SUV and joint-to-bone uptake ratio than joints without synovitis (joint SUV, 6.0±2.4; joint-to-bone uptake ratio, 0.74±0.31; P<0.001). On correlation analysis, summed joint SUV (P=0.002, correlation coefficient=0.705) and summed joint-to-bone uptake ratio (P<0.001, correlation coefficient=0.861) of 28 joints showed strong positive correlation with DAS28-ESR after adjustment for age and body mass index. Summed joint SUV showed significant positive correlations with ultrasonography findings (grey scale ultrasonography: P=0.047, correlation coefficient =0.468; power Doppler ultrasonography: P=0.045, correlation coefficient =0.507). On the receiver operating characteristic curve analysis, the sensitivity and specificity for predicting synovitis were 83.2% and 92.7%, respectively, for joint SUV and 81.5% and 90.7%, respectively, for joint-to-bone uptake ratio. Moreover, the summation of both PET/CT parameters of 28 joints showed a diagnostic accuracy of 100.0% for predicting high disease activity in rheumatoid arthritis.

Conclusions

Summed joint uptake on F-18 NaF PET/CT had a strong positive correlation with DAS28-ESR and accurately predicted high disease activity. F-18 NaF PET/CT parameters might be used as an imaging biomarker for disease activity in rheumatoid arthritis.

Trial registration

This study was registered at the Clinical Research Information Service of the Korea (CRIS, http://cris.nih.go.kr/cris/en; registry number, KCT0002597; registered November 2017).

Effects of Yoga in Daily Life program in rheumatoid arthritis: A randomized controlled trial

OBJECTIVES

To explore the feasibility and effectiveness of a yoga program in improving health-related quality of life (HQOL), physical and psychological functioning in rheumatoid arthritis (RA) patients.

DESIGN

Single-centre parallel-arms randomized controlled trial comparing yoga (n = 30) and education control group (n = 27).

SETTING

Tertiary care University hospital.

INTERVENTION

A 12-week yoga program, based on the Yoga in Daily Life system, included 2x weekly/90-minute sessions. The control group had 1xweekly/60-minute educational lectures on arthritis-related topics.

MAIN OUTCOME MEASURES

Assessments were performed at baseline, 12 (post-intervention) and 24 weeks (follow-up). The primary outcome was change in The Short Form-36 (SF-36) HQOL at 12 weeks. Linear regression analysis was adjusted for baseline scores.

RESULTS

No significant between-group differences were found for SF-36 (all p > 0.05). At 12 weeks the adjusted mean difference between groups favoured yoga for Functional Assessment of Chronic Illness Therapy-fatigue (5.08 CI 1.29 to 8.86; p = 0.009) and Hospital Anxiety and Depression Scale (HADS)-depression (-1.37 CI -2.38 to -0.36); p = 0.008) and at 24 weeks for HADS-anxiety (-1.79 CI -3.34 to - 0.23; p = 0.025), while the impact on fatigue was sustained (5.43 CI 1.33 to 9.54, p = 0.01). The program had no impact on RA disease activity. Feasibility outcomes included recruitment rate 16 %, retention 80.7 %, and adherence to yoga 87.5 vs 82.7 % for control. No serious adverse events were recorded.

CONCLUSIONS

Yoga in Daily Life program was not associated with change in health-related quality of life of RA patients. Significant improvements in fatigue and mood were observed at postintervention and follow-up. This yoga program was found feasible and safe for patients and may complement standard RA treat-to-target strategy.

Future use of musculoskeletal ultrasonography and magnetic resonance imaging in rheumatoid arthritis

PURPOSE OF REVIEW

Musculoskeletal ultrasonography (MSUS) and magnetic resonance imaging (MRI) play important roles in diagnosis, monitoring, and prognostication of rheumatoid arthritis. This review highlights recent literature in this field and aims to provide insight into the future use in clinical practice.

RECENT FINDINGS

Recent studies concerning the use of MSUS and MRI in clinical practice show how MSUS and MRI can improve diagnosis and monitoring of rheumatoid arthritis and how they can predict both radiographic progression and clinical outcome (e.g., successful tapering of medical treatment). Moreover, novel technical developments of the two imaging modalities, such as 3D ultrasonography, ultrasound image reading with convolutional neural network, image fusion (MSUS and MRI) and whole-body MRI show promising results. Further validation of these novel techniques is required prior to implementation.

SUMMARY

MSUS and MRI will be important parts of the future management of rheumatoid arthritis patients, mostly because of their ability to detect rheumatoid arthritis changes at a very early stage and to predict the course of disease. However, the exact role in routine clinical practice is still to be defined.