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Wink F, Bruyn GA, Maas F, Griep EN, van der Veer E, Bootsma H, Brouwer E, Arends S, Spoorenberg A. Ultrasound Evaluation of the Entheses in Daily Clinical Practice during Tumor Necrosis Factor-α Blocking Therapy in Patients with Ankylosing Spondylitis. J Rheumatol 2017; 44:587-593. [PMID: 28298566 DOI: 10.3899/jrheum.160584] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess structural and inflammatory ultrasound (US) lesions of entheses in ankylosing spondylitis (AS) patients with active disease and to evaluate inflammatory lesions after 6 months of tumor necrosis factor (TNF-α) blocking therapy, in daily clinical practice. METHODS Consecutive patients with AS were clinically evaluated and underwent US examination of 9 bilateral entheses before and after 6 months of TNF-α blocking therapy. US examination included the following as inflammatory lesions: bone erosions/cortical irregularities, enthesophytes, calcifications as structural lesions; adjacent bursitis, effusion, increased tendon hypoechogenicity or thickness; and positive power Doppler (PD) signal. RESULTS At baseline, 105 (95%) of 111 included patients showed US abnormalities. Structural lesions were seen in 74 patients (67%) and inflammatory lesions in 88 (79%). Enthesophytes and positive PD signal were the most prevalent structural and inflammatory lesions, respectively. Most lesions were found at the lower extremities. Additionally, inflammatory lesions occurred at the lateral epicondyle of the elbow. Patients with structural lesions at baseline were significantly older, had longer disease duration, higher modified Stoke AS Spine score, and higher C-reactive protein. Individually, there was a great diversity in changes of inflammatory entheseal lesions during treatment, but on the group level no significant decrease was found. CONCLUSION This prospective observational cohort study in daily clinical practice shows a high prevalence of structural and inflammatory US lesions in AS patients with longstanding and active disease. Positive PD signal was the most common inflammatory feature. No significant change in inflammatory US lesions was found after 6 months of TNF-α blocking therapy.
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Affiliation(s)
- Fréke Wink
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands. .,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden.
| | - George A Bruyn
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
| | - Fiona Maas
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
| | - Ed N Griep
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
| | - Eveline van der Veer
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
| | - Hendrika Bootsma
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
| | - Elisabeth Brouwer
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
| | - Suzanne Arends
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
| | - Anneke Spoorenberg
- From the Department of Rheumatology and Clinical Immunology, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen; Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden, the Netherlands.,F. Wink, MD, Department of Rheumatology, Medical Center Leeuwarden; G.A. Bruyn, MD, Department of Rheumatology, MC Groep; F. Maas, MSc, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E.N. Griep, MD, PhD, Antonius Ziekenhuis Sneek; E. van der Veer, PhD, Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen; H. Bootsma, MD, PhD, Professor, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; E. Brouwer, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen; S. Arends, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, and Department of Rheumatology, Medical Center Leeuwarden; A. Spoorenberg, MD, PhD, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Department of Rheumatology, Medical Center Leeuwarden
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Devauchelle-Pensec V, Gottenberg JE, Jousse-Joulin S, Berthelot JM, Perdriger A, Hachulla E, Hatron PY, Puechal X, Le Guern V, Sibilia J, Chiche L, Goeb V, Vittecoq O, Larroche C, Fauchais AL, Hayem G, Morel J, Zarnitsky C, Dubost JJ, Dieudé P, Pers JO, Cornec D, Seror R, Mariette X, Nowak E, Saraux A. Which and How Many Patients Should Be Included in Randomised Controlled Trials to Demonstrate the Efficacy of Biologics in Primary Sjögren's Syndrome? PLoS One 2015; 10:e0133907. [PMID: 26368934 PMCID: PMC4569343 DOI: 10.1371/journal.pone.0133907] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 07/03/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The goal of this study was to determine how the choice of the primary endpoint influenced sample size estimates in randomised controlled trials (RCTs) of treatments for primary Sjögren's syndrome (pSS). METHODS We reviewed all studies evaluating biotechnological therapies in pSS to identify their inclusion criteria and primary endpoints. Then, in a large cohort (ASSESS), we determined the proportion of patients who would be included in RCTs using various inclusion criteria sets. Finally, we used the population of a large randomised therapeutic trial in pSS (TEARS) to assess the impact of various primary objectives and endpoints on estimated sample sizes. These analyses were performed only for the endpoints indicating greater efficacy of rituximab compared to the placebo. RESULTS We identified 18 studies. The most common inclusion criteria were short disease duration; systemic involvement; high mean visual analogue scale (VAS) scores for dryness, pain, and fatigue; and biological evidence of activity. In the ASSESS cohort, 35 percent of patients had recent-onset disease (lower than 4 years), 68 percent systemic manifestations, 68 percent high scores on two of three VASs, and 52 percent biological evidence of activity. The primary endpoints associated with the smallest sample sizes (nlower than 200) were a VAS dryness score improvement higher to 20 mm by week 24 or variable improvements (10, 20, or 30 mm) in fatigue VAS by week 6 or 16. For patients with systemic manifestations, the ESSDAI change may be the most logical endpoint, as it reflects all domains of disease activity. However, the ESSDAI did not improve significantly with rituximab therapy in the TEARS study. Ultrasound score improvement produced the smallest sample size estimate in the TEARS study. CONCLUSION This study provides valuable information for designing future RCTs on the basis of previously published studies. Previous RCTs used inclusion criteria that selected a small part of the entire pSS population. The endpoint was usually based on VASs assessing patient complaints. In contrast to VAS dryness cut-offs, VAS fatigue cut-offs did not affect estimated sample sizes. SGUS improvement produced the smallest estimated sample size. Further studies are required to validate standardised SGUS modalities and assessment criteria. Thus, researchers should strive to develop a composite primary endpoint and to determine its best cut-off and assessment time point.
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Affiliation(s)
- Valérie Devauchelle-Pensec
- Rheumatology Department, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, 29609, Brest, France
- EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, 29200, Brest, France
| | | | - Sandrine Jousse-Joulin
- Rheumatology Department, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, 29609, Brest, France
- EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, 29200, Brest, France
| | | | - Aleth Perdriger
- Rheumatology Department, C.H.U. Hôpital Sud, 35000, Rennes, France
| | - Eric Hachulla
- Internal Medicine Department, Claude Huriez Hospital, Lille2 University, 59037, Lille Cedex, France
| | - Pierre Yves Hatron
- Internal Medicine Department, Claude Huriez Hospital, Lille2 University, 59037, Lille Cedex, France
| | - Xavier Puechal
- Internal Medicine Department, Hôpital Cochin, Paris, France
| | | | - Jean Sibilia
- Rheumatology Department, Strasbourg University Hospital, Strasbourg, France
| | - Laurent Chiche
- Internal Medicine Department, Hôpital de la Conception, 147 Bd Baille, 13005, Marseille, France
| | - Vincent Goeb
- Rheumatology Department, C.H.R.U. d’Amiens, 76 230 Bois-Guillaume, France
| | - Olivier Vittecoq
- Rheumatology Department, C.H.R.U. de Rouen, 76 230 Bois-Guillaume, France
| | - Claire Larroche
- Internal Medicine Department, Bobigny University Hospital, Paris, France
| | | | - Gilles Hayem
- Rheumatology Department, Ambroise Paré University Hospital, Paris, France
| | - Jacques Morel
- Immuno-Rhumatology Department, C.H.U. Lapeyronie, 34295 Montpellier, France
| | | | - Jean Jacques Dubost
- Rheumatology Department, Gabriel Montpied Teaching Hospital, Place H. Dunant, Clermont-Ferrand, 63000, France
| | - Philippe Dieudé
- Rheumatology Department, Bichat Claude-Bernard Hospital, Paris, France
| | - Jacques Olivier Pers
- EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, 29200, Brest, France
| | - Divi Cornec
- Rheumatology Department, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, 29609, Brest, France
- EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, 29200, Brest, France
| | - Raphaele Seror
- Rheumatology Department, Assistance Publique-Hôpitaux de Paris (AP-HP), INSERM U1012, Université Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Xavier Mariette
- Rheumatology Department, Assistance Publique-Hôpitaux de Paris (AP-HP), INSERM U1012, Université Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | | | - Alain Saraux
- Rheumatology Department, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, 29609, Brest, France
- EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, 29200, Brest, France
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