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Potapova AS, Karateev AE, Polishchuk EY, Filatova ES, Amirdzhanova VN, Lila AM. [Reduction in the need for glucocorticoids on the background of therapy with biologic disease-modifying antirheumatic drugs and Janus kinase inhibitors in rheumatoid arthritis: evidence from real clinical practice]. TERAPEVT ARKH 2024; 96:465-470. [PMID: 38829807 DOI: 10.26442/00403660.2024.05.202701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Clinical guidelines for the treatment of rheumatoid arthritis (RA) recommend reducing the use of glucocorticoids (GCs) due to the high risk of associated complications. AIM To determine the frequency of GC cancellations and dose reductions in real clinical practice, while taking into account active RA therapy. MATERIALS AND METHODS The study group consisted of 303 patients with RA reliable according to ACR/EULAR criteria (women 79.9%, age 52.8±13.3, disease duration 9 [4; 16] years, DAS-28-CRP 4.9±1.0, RF seropositivity 77.4%, ACPA seropositivity 70.3%), who were prescribed or changed therapy with disease-modifying antirheumatic drugs (DMARDs), biologic disease-modifying antirheumatic drugs (bDMARDs) or Janus kinase inhibitors (iJAK) due to disease exacerbation and ineffectiveness of previous treatment. All patients initially received GC (7.7±3.8 mg/day equivalent of prednisolone). After adjustment of therapy, 42.9% of patients received methotrexate, 27.6% leflunomide, 2.5% sulfasalazine, hydroxychloroquine, or a combination with an Non-steroidal anti-inflammatory drugs, 63.7% bDMARDs, and 7.2% iJAK. The need for GC intake was assessed by a telephone survey conducted 6 months after the start of follow-up. RESULTS Telephone survey was possible in 274 (90.4%) persons. There was a significant decrease in pain intensity (numerical rating scale, NRS 0-10) from 6.3±1.4 to 4.3±2.4 (p<0.001), fatigue (NRS) from 6.7±2.3 to 5.2±2.1 (p<0.001), and functional impairment (NRS) from 5.4±2.1 to 3.9±2.0 (p<0.001). A positive PASS index (symptom status acceptable to patients) was noted in 139 (50.7%) patients. GC cancellation was noted in 19.7%, dose reduction in 25.9%, maintaining the same dose in 42.7%, and dose increase in 11.7%. CONCLUSION Against the background of intensive RA therapy, including combination of DMARDs with bDMARDs or iJAK, complete withdrawal or reduction of GC dose was achieved in less than half (45.6%) of patients after 6 months.
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Affiliation(s)
| | | | | | | | | | - A M Lila
- Nasonova Research Institute of Rheumatology
- Russian Medical Academy of Continuous Professional Education
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Dhital R, Singh NC, Spiker AM, Poudel DR, Pedersen B, Bartels CM. Trends in avascular necrosis and related arthroplasties in hospitalized patients with systemic lupus erythematosus and rheumatoid arthritis. Semin Arthritis Rheum 2024; 66:152444. [PMID: 38604118 DOI: 10.1016/j.semarthrit.2024.152444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Avascular necrosis (AVN) is a devastating complication often necessitating arthroplasty, particularly common in systemic lupus erythematosus (SLE). Limited research exists on arthroplasty trends since new steroid-sparing agents. We analyzed trends and characteristics associated with AVN and AVN-related arthroplasties among SLE and RA hospitalizations using two decades of data from the U.S. National Inpatient Sample (NIS). METHODS This cross-sectional study used NIS (2000-2019) to identify hospitalized adults with SLE and RA, with or without AVN, using ICD codes. AVN was further grouped by arthroplasty status. Primary outcomes were AVN and AVN-related arthroplasty rates and time trends in SLE and RA. Baseline sociodemographics and comorbidities were compared. Analyses used STATA and Joinpoint regression to calculate annual percent change (APC). RESULTS Overall, 42,728 (1.3 %) SLE and 43,600 (0.5 %) RA hospitalizations had concomitant AVN (SLE-AVN and RA-AVN). Of these, 16,724 (39 %) and 25,210 (58 %) underwent arthroplasties, respectively. RA-AVN increased (APC: 0.98*), with a decrease in arthroplasties (APC: -0.82*). In contrast, SLE-AVN initially increased with a breakpoint in 2011 (APC 2000-2011: 1.94* APC 2011-2019 -2.03), with declining arthroplasties (APC -2.03*). AVN hospitalizations consisted of individuals who were younger and of Black race; while arthroplasties were less likely in individuals of Black race or Medicaid coverage. CONCLUSION We report a breakpoint in rising SLE-AVN after 2011, which may relate to newer steroid-sparing therapies (i.e., belimumab). AVN-associated arthroplasties decreased in SLE and RA. Fewer AVN-associated arthroplasties were noted for Black patients and those with Medicaid, indicating potential disparities. Further research should examine treatment differences impacting AVN and arthroplasty rates.
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Affiliation(s)
- Rashmi Dhital
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA.
| | - Neha Chiruvolu Singh
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Dilli Ram Poudel
- Department of Medicine, Indiana Regional Medical Center, Indiana, PA
| | - Brian Pedersen
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA
| | - Christie M Bartels
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
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Menzies-Gow AN, Tran TN, Stanley B, Carter VA, Smolen JS, Bourdin A, Fitzgerald JM, Raine T, Chapaneri J, Emmanuel B, Jackson DJ, Price DB. Trends in Systemic Glucocorticoid Utilization in the United Kingdom from 1990 to 2019: A Population-Based, Serial Cross-Sectional Analysis. Pragmat Obs Res 2024; 15:53-64. [PMID: 38505738 PMCID: PMC10949995 DOI: 10.2147/por.s442959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/23/2024] [Indexed: 03/21/2024] Open
Abstract
Purpose Associations between systemic glucocorticoid (SGC) exposure and risk for adverse outcomes have spurred a move toward steroid-sparing treatment strategies. Real-world changes in SGC exposure over time, after the introduction of steroid-sparing treatment strategies, reveal areas of successful risk mitigation as well as unmet needs. Patients and Methods A population-based ecological study was performed from the Optimum Patient Care Research Database to describe SGC prescribing trends of steroid-sparing treatment strategies in primary care practices before and after licensure of biologics in the United Kingdom from 1990 to 2019. Each analysis year included patients aged ≥5 years who were registered for ≥1 year with a participating primary care practice. The primary analysis was SGC exposure, defined as total cumulative SGC dose per patient per year, for asthma, severe asthma, chronic obstructive pulmonary disease (COPD), nasal polyps, Crohn's disease, rheumatoid arthritis, ulcerative colitis, and systemic lupus erythematosus. Secondary outcomes were percentages of patients prescribed SGCs and number of SGC prescriptions per patient per year. Results The number of patients who met study inclusion criteria ranged from 219,862 (1990) to 1,261,550 (2019). At the population level, patients with asthma or COPD accounted for 67.7% to 73.2% of patients per year with an SGC prescription. Over three decades, decreases in SGC total yearly dose ≥1000 mg have been achieved in multiple conditions. Patients with COPD prescribed SGCs increased from 5.8% (1990) to 34.8% (2017). SGC prescribing trends for severe asthma, Crohn's disease, and ulcerative colitis show decreased prescribing trends after the introduction of biologics. Conclusion Decreases in total yearly SGC doses have been shown in multiple conditions; however, for conditions such as severe asthma and COPD, an unmet need remains for increased awareness of SGC burden and the adoption or development of SGC-sparing alternatives to reduce overuse.
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Affiliation(s)
- Andrew N Menzies-Gow
- Royal Brompton and Harefield Hospitals, Guys & St Thomas’ NHS Foundation Trust, London, UK
- AstraZeneca, Cambridge, UK
| | | | | | | | | | - Arnaud Bourdin
- Université de Montpellier, CHU Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - J Mark Fitzgerald
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - Tim Raine
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | | | | | - David J Jackson
- Guy’s Severe Asthma Centre, Guy’s & St Thomas’ NHS Trust, London, UK
- School of Immunology & Microbial Sciences, King’s College London, London, UK
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Fujii T, Murata K, Onizawa H, Onishi A, Tanaka M, Murakami K, Nishitani K, Furu M, Watanabe R, Hashimoto M, Ito H, Fujii T, Mimori T, Morinobu A, Matsuda S. Management and treatment outcomes of rheumatoid arthritis in the era of biologic and targeted synthetic therapies: evaluation of 10-year data from the KURAMA cohort. Arthritis Res Ther 2024; 26:16. [PMID: 38195572 PMCID: PMC10775516 DOI: 10.1186/s13075-023-03251-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Advances in rheumatoid arthritis (RA) treatment, highlighted by biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs), have altered the paradigm of RA treatment in the last decade. Therefore, real-world clinical evidence is needed to understand how treatment strategies and outcomes have changed. METHODS Using an observational cohort of RA from 2012 to 2021, we collected cross-sectional data of RA patients annually to analyze a trend in RA management. For patients who initiated b/tsDMRDs, we evaluated treatment outcomes between b/tsDMARDs. Mixed-effect models were applied to examine the statistical implications of changes over time in treatment outcomes with a background adjustment. RESULTS We analyzed annual cross-sectional data from 5070 patients and longitudinal data from 1816 patients in whom b/tsDMARDs were initiated between 2012 and 2021. b/tsDMARD use increased, whereas glucocorticoid use decreased from 2012 to 2021. Disease activity and functional disability measures improved over time. The percentage of tsDMARD prescriptions considerably increased. All b/tsDMARDs showed clinical improvements in disease activity and functional disability. Statistically, TNFi showed better short-term improvements in b/tsDMARD-naïve patients, while IL6Ri demonstrated significant long-term benefits. IL6Ri had better retention rates in switched patients. After adjustment for patient characteristics, the annual change of RA disease activity and functional disability fared significantly better from 2012 to 2021. CONCLUSIONS With the development of new RA therapeutics, overall treatment outcomes advanced in the past decade.
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Affiliation(s)
- Takayuki Fujii
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan.
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan.
| | - Koichi Murata
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Hideo Onizawa
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Masao Tanaka
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Kosaku Murakami
- Center for Cancer Immunotherapy and Immunobiology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Kohei Nishitani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Moritoshi Furu
- Furu Clinic, 1098 Terasho, Konancho, Koka, Shiga, 5203301, Japan
| | - Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahicho, Abeno, Osaka, 5450051, Japan
| | - Motomu Hashimoto
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahicho, Abeno, Osaka, 5450051, Japan
| | - Hiromu Ito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kuchiki, Okayama, 7100052, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 6410012, Japan
| | - Tsuneyo Mimori
- Takeda Clinic for Rheumatic Diseases, 606-3-2, Higashi-Shiokojicho, Sanoh Kyotoekimae Building 1F, Kyoto, 6008216, Japan
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
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Spinelli FR, Garufi C, Mancuso S, Ceccarelli F, Truglia S, Conti F. Tapering and discontinuation of glucocorticoids in patients with rheumatoid arthritis treated with tofacitinib. Sci Rep 2023; 13:15537. [PMID: 37730835 PMCID: PMC10511736 DOI: 10.1038/s41598-023-42371-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/09/2023] [Indexed: 09/22/2023] Open
Abstract
Although the rapid onset of effect of glucocorticoids (GCs) allows rapid control of rheumatoid arthritis (RA) symptoms, their chronic use may be associated with several adverse events. The 2022 update of EUALR recommendations for the management of patients with RA suggests to reduce and discontinue oral GCs as quickly as possible. Considering GCs as a "bridging therapy" to promptly reduce symptoms and control inflammation, fast-acting drugs such as tofacitinib could allow faster and safer tapering of GCs. The purpose of this pilot study was to evaluate the steroid-sparing effect of adding tofacitinib in patients with RA inadequately responsive to methotrexate taking concomitant GCs. In this open-label pilot study, we enrolled patients with moderate to severe RA on a stable dose of prednisone (5-12.5 mg/day) who started treatment with tofacitinib. After 1 month, in patients who achieved at least a moderate EULAR response (decrease of > 1.2 in DAS28_CRP), GCs was tapered according to a predetermined schedule until complete discontinuation at week 12. Disease activity was assessed after 4, 12, 24 and 48 weeks of treatment. The primary endpoint was the percentage of patients discontinuing GCs after 12 weeks of tofacitinib treatment. We enrolled 30 patients (26 F: 4 M, mean age 60 ± 13 years, mean disease duration 13.2 ± 7.8 years). The primary endpoint was achieved: 9 patients (30%) discontinued GCs at week-12. At week-24, other 12 patients (46%) withdrew GCs. The median prednisone dose decreased from 5 mg/day (interquartile range 5-10 mg) to 2.5 (0-5) mg/day at week 12 and 48 (p < 0.00001 vs baseline). At week 48, 12 out of 30 patients (40%) had discontinued prednisone. The percentage of patients achieving remission or low disease activity increased throughout the follow-up without any difference between patients who discontinued or not the GC. In this cohort of long-standing RA patients treated with tofacitinib, the discontinuation of glucocorticoids was achievable in up to 30% of patients. These results should encourage rheumatologists to consider GCs tapering and discontinuation of GCs, as suggested by the 2022 EULAR recommendations, an achievable goal.
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Affiliation(s)
- Francesca Romana Spinelli
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy.
| | - Cristina Garufi
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Silvia Mancuso
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Fulvia Ceccarelli
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Simona Truglia
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Fabrizio Conti
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
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