Rheumatoid Arthritis

Naringenin as a natural immunomodulator against T cell-mediated autoimmune diseases: literature review and network-based pharmacology study

T cells, especially CD4+ T helper (Th) cells, play a vital role in the pathogenesis of specific autoimmune diseases. Naringenin, a citrus flavonoid, exhibits anti-inflammatory, anti-oxidant, and antitumor properties, which have been verified in animal autoimmune disease models. However, naringenin's possible effects and molecular mechanisms in T cell-mediated autoimmune diseases are unclear. This review summarizes the findings of previous studies and predicts the target of naringenin in T cell-mediated autoimmune disorders such as multiple sclerosis, inflammatory bowel disease, and rheumatoid arthritis through network pharmacology analysis. We performed DAVID enrichment analysis, protein-protein interaction analysis, and molecular docking to predict the positive effect of naringenin on T cell-mediated autoimmune disorders. Sixteen common genes were screened, among which the core genes were PTGS2, ESR1, CAT, CASP3, MAPK1, and AKT1. The possible molecular mechanism relates to HIF-1, estrogen, TNF, and NF-κB signaling pathways. Our findings have significance for future naringenin treatment of T cell-mediated autoimmune diseases.

A deep learning classification of metacarpophalangeal joints synovial proliferation in rheumatoid arthritis by ultrasound images

OBJECTIVE

To evaluate if an automatic classification of rheumatoid arthritis (RA) metacarpophalangeal joint conditions in ultrasound images is feasible by deep learning (DL) method, to provide a more objective, automated, and fast way of RA diagnosis in clinical setting.

MATERIALS AND METHODS

DenseNet-based DL model was used and both training and testing are implemented in TensorFlow 1.13.1 with Keras DL libraries. The area under curve (AUC), accuracy, sensitivity, and specificity values with 95% CIs were reported. The statistical analysis was performed by using scikit-learn libraries in Python 3.7.

RESULTS

A total of 1337 RA ultrasound images were acquired from 208 patients, the number of images is 313, 657, 178, and 189 in OESS Grade L0, L1, L2, and L3, respectively. In Classification Scenario 1 SP-no versus SP-yes, three experiments with region of interest of size 192 × 448 (Group 1), 96 × 224 (Group 2), and 96 × 224 stacked with pre-segmented annotated mask of SP area (Group 3) as input achieve an AUC of 0.863 (95% CI: 0.809, 0.917), 0.861 (95% CI: 0.805, 0.916), and 0.886 (95% CI: 0.836, 0.936), respectively. In Classification Scenario 2 Healthy versus Diseased, experiments in Group 1, Group 2 and Group 3 achieve an AUC of 0.848 (95% CI: 0.799, 0.896), 0.864 (95% CI: 0.819, 0.909), and 0.916 (95% CI: 0.883, 0.952), respectively.

CONCLUSION

We combined DenseNet model with ultrasound images for RA condition assessment. The feasibility of using DL to create an automatic RA condition classification system was also demonstrated. The proposed method can be an alternative to the initial screening of RA patients.

Patient with rheumatoid arthritis with deep vein thrombosis presenting as a calf strain: a case report

Background

Patients with rheumatoid arthritis experience various comorbidities, including cardiovascular disease. More data and awareness exist regarding the adverse effects of rheumatoid arthritis affecting the arterial side of the cardiovascular system, such as stroke or myocardial infarction, than regarding adverse venous complications, such as deep vein thrombosis and pulmonary embolism. Rheumatoid arthritis affects more women than men, and the risk of venous thromboembolism in rheumatoid arthritis tends to increase with age; therefore, the presentation in this case report of deep vein thrombosis in a nonsmoking, young, fit man with rheumatoid arthritis is rare. This patient was sent away from a minor injuries unit with a diagnosis of a calf strain. Further assessment at an accident and emergency department later in the day confirmed deep vein thrombosis via ultrasonography. This case report underlines the need for vigilance because deep vein thrombosis is a risk factor in rheumatoid arthritis, even in young, male, and physically fit individuals.

Case presentation

A nonsmoking 39-year-old Caucasian man with a 2-year history of rheumatoid arthritis presented for assessment at a private physiotherapy clinic with a 4-week history of right-sided posterior calf pain that had developed following exercise at a gym. The patient therefore believed his symptoms were due to a calf strain. Findings at physiotherapy assessment suggested that the actual cause of the patient’s symptoms were as a result of deep vein thrombosis. The patient was directed to a local minor injuries unit with a referral letter from the author outlining this diagnosis. Following clinical assessment at the minor injuries unit, the patient was told that there was no likelihood of deep vein thrombosis, and his diagnosis was a calf strain. The patient harbored concerns at this point and decided to seek further medical opinion at a nearby accident and emergency department, where deep vein thrombosis was diagnosed using ultrasonography, and the patient was commenced on anticoagulants.

Conclusions

Venous thromboembolism risk in rheumatoid arthritis is stated as being less recognized as an arterial complication. This is borne out by this patient’s clinical journey, wherein his youth, fitness, athletic appearance, and onset of symptoms during exercise were said to suggest a diagnosis of a calf strain at a minor injuries unit. Ultrasonography at a different accident and emergency unit later that day ultimately was used to diagnose deep vein thrombosis.

The endocannabinoid signaling pathway as an emerging target in pharmacotherapy, earmarking mitigation of destructive events in rheumatoid arthritis

Rheumatoid arthritis is an inflammatory autoimmune disease, characterized by synovial proliferation, destruction to articular cartilage and severe pain. The cannabinoids obtained from Cannabis sativa exhibited their actions via cannabinoid-1 and -2 receptors, which also provides a platform for endocannabinoids to act. The endocannabinoid system comprises endocannabinoid molecules involved in signaling processes, along with G-protein coupled receptors and enzymes associated with ligand biosynthesis, activation and degradation. The action of endocannabinoid system in immune system regulation, via primary CB2 activation, followed by inhibition of production of pro-inflammatory cytokines, auto-antibodies and MMPs, FLSs proliferation and T-cell mediated immune response, are elaborated as potential therapeutic regimes in rheumatoid arthritis. The involvement of endocannabinoid system in immune cells like, B cells, T cells and macrophages, as well as regulatory actions on sensory noniceptors to ameliorate pain is significantly highlighted in the review, elaborating the actions of endocannabinoid signaling in mitigating the disease events. The review also focuses on enhancement of endocannabinoid tone, either by inhibiting the degradation enzymes, like FAAH, MAGL, COX, CytP450, LOX, etc. or by retarding cellular uptake processes. Moreover, the review portrays the optimizing role of endocannabinoid system, in abbreviating the symptoms and complications of rheumatoid arthritis in patients and mitigating inflammation, pain and immune mediated effects significantly.

Ultrasonography in Early Rheumatoid Arthritis of Hand and Wrist Joints: Comparison with Magnetic Resonance Imaging

BACKGROUND

The aim of the study was to evaluate the use of ultrasonography (USG) including power Doppler in detecting hand and wrist joint changes in early rheumatoid arthritis (RA) and to compare USG findings with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Thirty-four patients diagnosed as RA by 2010 ACR/EULAR criteria; with the onset of symptoms within last one year, were included in the study after institute ethical clearance and informed consent to undergo USG and contrast-enhanced MRI of the dominant affected hand. Second to fifth metacarpophalangeal (MCP) joints, second to fifth proximal interphalangeal (PIP) joints and wrist joints (total nine joints) were evaluated for synovitis, erosions along with tenosynovitis. USG and MRI features were compared; agreement on the two imaging modalities as well as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of ultrasonography compared to MRI (gold standard) was calculated.

RESULTS

One hundred thirty-six MCP, 136 PIP and 34 wrist joints (total 306 joints) and 136 flexor tendons were evaluated. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of USG for diagnosing synovitis was 78.6%, 91.1%, 86.1%, 85.8%, 86.3%; for erosions 67.2%, 97.5%, 84.8%, 90.5%, 91.5%; for tenosynovitis 86.5%, 100%, 100%, 92.3% and 94.8% respectively. The overall agreement between USG and MRI for detection of synovitis was achieved in 83% joints and for erosions in 89.5% joints.

CONCLUSION

In early RA, USG was nearly as effective in diagnosing features of joint and tendon sheath involvement, with relatively better performance of USG for tenosynovitis. The performance of USG in diagnosing erosions was limited likely due to difficult access of three-dimensional joint structure.

Immunological adaptations in pregnancy that modulate rheumatoid arthritis disease activity

During pregnancy, the fetus that grows within the maternal uterus is not rejected by the maternal immune system. To enable both tolerance towards the fetus and defence against pathogens, modifications of the maternal immune system occur during gestation. These modifications are able to bring about a natural improvement in disease activity of some autoimmune diseases, such as rheumatoid arthritis (RA). Various mechanisms of the immune system contribute to the phenomenon of pregnancy-related improvement of RA, and the cessation of these immunomodulatory mechanisms after delivery correlates with postpartum disease flare. HLA disparity between mother and fetus, glycosylation of IgG, immunoregulatory pathways, and alterations in innate and adaptive immune cells and their cytokines have important roles in pregnancy and in pregnancy-related amelioration of RA.

The Role of TNF-α as a Proinflammatory Cytokine in Pathological Processes

TNF-α is a member of the vast cytokine family being considered a proinflammatory substance produced many by macrophages and other cells belonging to the innate immunity, many of them classified as indeed Antigen Presenting Cells (APCs) involved in the complex chemotactic process of activation of the adaptive immunity. The aim of this work was to accomplish a literature review concerning the main pathologies that have TNF-α as a modulating agent in other to bring light to the main interactions present in the inflammation installed.

Comparison of oral versus parenteral methotrexate in the treatment of rheumatoid arthritis: A meta-analysis

OBJECTIVE

Studies suggest that parenteral MTX may be more efficacious than the oral form at equivalent doses for the treatment of rheumatoid arthritis. We carried out a meta-analysis to compare the efficacy of oral versus parenteral MTX in RA.

METHODS

PubMed, Web of Science and Embase were systematically searched from inception to June 8th 2017 and reviewed following PRISMA 2009 guidelines, by two independent reviewers. To be included, trials had to study adults with RA randomized to the same dose of either oral or parenteral MTX. The primary endpoint was ACR20 at 6 months. Intention-to-treat analysis results were used when possible. Data from direct comparisons between oral and parenteral methotrexate quantitatively analyzed using maximum likelihood random effects meta-analysis. Relative treatment effects were generated as an odds ratio [OR] (OR>1 indicated a benefit for parenteral therapy).

RESULTS

The search yielded 357 papers or abstracts. After review of titles or abstracts and full text papers, we found 4 that met inclusion criteria with 703 patients randomized. Dose of MTX started at 15mg/week and increased up to 25mg/week. The summary OR for achieving ACR20 using parenteral vs. oral MTX was 3.02 (95% CI 1.41, 6.46), with no significant difference in the risk for all adverse events.

CONCLUSION

Parenteral MTX therapy had significantly higher odds than oral MTX of achieving reduction in disease activity. We propose that parenteral MTX is more effective than weekly oral MTX; its widespread use may lead to better control of disease and a decrease in demand for biologic agents.

Addressing the Gap in Physician Preparedness To Assess Cardiovascular Risk in Women: a Comprehensive Approach to Cardiovascular Risk Assessment in Women

PURPOSE OF REVIEW

Increased recognition of risk factors and improved knowledge of sex-specific presentations has led to improved clinical outcomes for women with cardiovascular disease (CVD) compared to two decades ago. Yet, CVD remains the leading cause of death for women in the USA. Women have unique risk factors for CVD that continue to go under-recognized by their physicians.

RECENT FINDINGS

In a nationwide survey of primary care physicians (PCPs) and cardiologists, only 22% of PCPs and 42% of cardiologists reported being extremely well prepared to assess CVD risk in women. A presidential advisory from the American Heart Association (AHA) and American College of Obstetrics and Gynecologist (ACOG) recommends that cardiologists and obstetricians and gynecologists (Ob/Gyns) collaborate to promote CVD risk identification and reduction throughout a woman's lifetime. We suggest a comprehensive approach to identify unique and traditional risk factors for CVD in women, address the gap in physician knowledge, and improve cardiovascular care for women.

Incidence and prevalence of rheumatoid arthritis in Saskatchewan, Canada: 2001-2014

Background

Rheumatoid arthritis (RA) is a chronic inflammatory and destructive arthritis. Understanding the incidence and prevalence of RA within the province facilitates appropriate health care resource planning.

Objective

To estimate the incidence/prevalence of RA over time for the overall provincial population, for specific age range categories, and for gender.

Methods

Saskatchewan Provincial Administrative Health Databases (2001–2014) were utilized as data sources. Two RA case-definitions were employed: 1) > three physician billing diagnoses, at least one of which was submitted by a specialist (rheumatologist, general internist or orthopedic surgeon) within 2 years; 2) > one hospitalization diagnosis (ICD-9-CM code-714, and ICD-10-CA code-M05). Data from these definitions were combined to identify incident and prevalent RA cases. Using this data, annual incidence and prevalence rates were calculated for the provincial population, specified age range categories and gender categories.

Results

The number of RA cases meeting the case definition increased from 3731 to 6223 over the study period. The incidence of RA disease demonstrated variation within the study period with age and sex adjusted incidence ranging from 33.6 (95% CI 29.9–37.6) per 100,000 to 73.1 (95% CI 67.6–79.0) per 100,000. The prevalence of RA increased over time from 482 (95% CI 466.7–497.7) per 100,000 in 2001–2002 to 683.4 (95% CI 666.6–700.6) per 100,000 in 2014–2015. Both incidence and prevalence rates rose with increasing age. Women were found to have higher incidence and prevalence rates compared to men.

Conclusion

In Saskatchewan, the overall prevalence of RA is rising while there has been variability in the incidence.

Effect of communicating personalized rheumatoid arthritis risk on concern for developing RA: A randomized controlled trial

OBJECTIVE

To investigate the effect of providing comprehensive personalized risk information on concern for chronic disease development.

METHODS

Unaffected first-degree relatives (FDRs) of rheumatoid arthritis (RA) patients (n = 238) were randomly allocated to: 1) disclosure of RA risk personalized to demographics, genetics, biomarkers, and behaviors using a web-based tool (PRE-RA arm, n = 78); 2) PRE-RA with interpretation by a health educator (PRE-RA Plus arm, n = 80); and 3) standard RA education (Comparison arm, n = 80). Concern for developing RA was assessed at baseline and immediately, 6 weeks, 6 months, and 12 months post-intervention.

RESULTS

FDRs randomized to PRE-RA arms were less concerned about developing RA than the Comparison arm at all post-intervention assessments (p < 0.05). Among those concerned about RA risk at baseline, the PRE-RA (OR = 4.7, 95%CI 1.5-14.4) and PRE-RA Plus (OR = 5.2, 95%CI 1.6-17.3) arms were more likely to have reassurance 6 months post-intervention than the Comparison arm.

CONCLUSION

A comprehensive tool provided reassurance to those at risk for developing a chronic disease, with or without interpretation from a health educator, compared to standard education.

PRACTICE IMPLICATIONS

Individuals may be more likely to be reassured using a personalized chronic disease risk disclosure tool than a standard non-personalized approach.

When the plot thickens: a rare complication of rheumatoid arthritis

Introduction: Rheumatoid arthritis (RA) is a common illness with many extraarticular manifestations. Rheumatoid pachymeningitis is a rare neurologic complication of this common disease. Here in we present a patient with longstanding RA who developed this uncommon complication.

Case description: A 75-year-old woman with longstanding RA presented to the clinic with multiple seizure-like spells per day. Upon admission to the hospital, brain MRI showed enhancement of the meninges. After an extensive workup for possible other infectious or inflammatory causes, the patient was diagnosed with rheumatoid pachymeningitis.

Conclusion: Rheumatoid pachymeningitis is a rare complication of RA that usually occurs late in the disease course. It may have many neurologic manifestations include mimicking seizure or stroke and must be considered in patients with RA presenting with neurologic symptoms. Pachymeningitis is treated distinctly from articular RA, so early recognition can lead to appropriate treatment.

Progress towards universal health coverage in the context of rheumatic diseases in India

AIM

This study aims to measure current situation with regard to access and financial protection towards healthcare for rheumatic diseases (RDs) in India.

METHOD

The first part of this study is quantitative, and uses the data generated by the 71st Round of National Sample Survey 2014, which measured self-reported morbidity, choice of provider and utilization of services and out of pocket expenditure (OOPE) incurred on healthcare services in a sample of 65 932 households and 333 104 individuals from all across India. The second qualitative part of the study was done in one sample district to understand the barriers to access and financial protection.

RESULTS

3.5% of all hospitalizations in the preceding one year and 9.9% of all ambulatory care in the preceding 15 days of this study period were due to RDs. Cost of care for RDs was three times higher in private sector. Cost on medicines comprised the largest share in both sectors. 54% of the households faced catastrophic health expenditure at 10% threshold (CHE-10) and this was nine times higher in private provisioning (OR: 8.8, CI: 6.8-11.4). 24% of the households had to borrow or sell household assets to meet the hospitalization expenditure. Insurance had marginal impact and it did not help in preventing household from facing CHE-10 for the lowermost three economic quintiles. There was significant unmet health care needs and lack of continuity of care of RDs in India.

CONCLUSION

Addressing the gaps in access and financial protection for patients with RDs need greater emphasis in policy as well as implementation, if the country has to achieve Universal Health Coverage.

Baricitinib: The Second FDA-Approved JAK Inhibitor for the Treatment of Rheumatoid Arthritis

Objective: To review the pharmacology, pharmacokinetics, safety, and efficacy of baricitinib, a recently approved selective Janus Kinase (JAK) inhibitor for the treatment of rheumatoid arthritis (RA), and explore its potential role in therapy. Data Sources: Articles were identified using a PubMed search from inception through January 2019 using the terms rheumatoid arthritis, Olumiant, baricitinib, and LY3009104, its molecular name. Study Selection and Data Extraction: Articles relating to randomized clinical trials, pharmacology, pharmacokinetics, efficacy, and safety of baricitinib were evaluated. Data Synthesis: Baricitinib exerts its effects by inhibiting JAK1 and JAK2 enzymes, targeting cytokine and growth factor receptor stimulation, thus reducing downstream immune cell function. Four trials have demonstrated the efficacy of baricitinib with or without methotrexate in patients naïve to disease-modifying antirheumatic drugs (DMARDs) and those who had an inadequate response to or intolerance to both conventional and biological DMARDs. Furthermore, baricitinib was associated with delayed radiographic progression. Despite baricitinib 4 mg often demonstrating greater efficacy compared with the 2 mg dose, only the 2 mg dose is Food and Drug Administration approved because of safety concerns with the 4 mg dose, primarily thromboembolism. Relevance to Patient Care and Clinical Practice: Baricitinib provides an oral treatment option for patients failing tumor necrosis factor inhibitors (TNFis). Safety, cost, and comparative effectiveness to tofacitinib should be considered prior to prescribing baricitinib. Conclusion: Baricitinib is the second medication in its class and has been proven efficacious for the treatment of RA. Given concerns for adverse effects associated with baricitinib, it should be reserved for patients who have failed one or more TNFis.

Assessment of a Deep Learning Model Based on Electronic Health Record Data to Forecast Clinical Outcomes in Patients With Rheumatoid Arthritis

Importance

Knowing the future condition of a patient would enable a physician to customize current therapeutic options to prevent disease worsening, but predicting that future condition requires sophisticated modeling and information. If artificial intelligence models were capable of forecasting future patient outcomes, they could be used to aid practitioners and patients in prognosticating outcomes or simulating potential outcomes under different treatment scenarios.

Objective

To assess the ability of an artificial intelligence system to prognosticate the state of disease activity of patients with rheumatoid arthritis (RA) at their next clinical visit.

Design, Setting, and Participants

This prognostic study included 820 patients with RA from rheumatology clinics at 2 distinct health care systems with different electronic health record platforms: a university hospital (UH) and a public safety-net hospital (SNH). The UH and SNH had substantially different patient populations and treatment patterns. The UH has records on approximately 1 million total patients starting in January 2012. The UH data for this study were accessed on July 1, 2017. The SNH has records on 65 000 unique individuals starting in January 2013. The SNH data for the study were collected on February 27, 2018.

Exposures

Structured data were extracted from the electronic health record, including exposures (medications), patient demographics, laboratories, and prior measures of disease activity. A longitudinal deep learning model was used to predict disease activity for patients with RA at their next rheumatology clinic visit and to evaluate interhospital performance and model interoperability strategies.

Main Outcomes and Measures

Model performance was quantified using the area under the receiver operating characteristic curve (AUROC). Disease activity in RA was measured using a composite index score.

Results

A total of 578 UH patients (mean [SD] age, 57 [15] years; 477 [82.5%] female; 296 [51.2%] white) and 242 SNH patients (mean [SD] age, 60 [15] years; 195 [80.6%] female; 30 [12.4%] white) were included in the study. Patients at the UH compared with those at the SNH were seen more frequently (median time between visits, 100 vs 180 days) and were more frequently prescribed higher-class medications (biologics) (364 [63.0%] vs 70 [28.9%]). At the UH, the model reached an AUROC of 0.91 (95% CI, 0.86-0.96) in a test cohort of 116 patients. The UH-trained model had an AUROC of 0.74 (95% CI, 0.65-0.83) in the SNH test cohort (n = 117) despite marked differences in the patient populations. In both settings, baseline prediction using each patients' most recent disease activity score had statistically random performance.

Conclusions and Relevance

The findings suggest that building accurate models to forecast complex disease outcomes using electronic health record data is possible and these models can be shared across hospitals with diverse patient populations.

Expand the differential…think beyond rheumatoid arthritis

A 31-year-old male patient with severe, migratory arthralgias presented to our academic medical centre after being erroneously diagnosed and treated for rheumatoid arthritis for over 1 year. Multiple immunomodulatory therapies for rheumatoid arthritis were attempted with no relief of symptoms. Eventually, the pain was so bothersome that the patient became bedridden for 1 month prior to presenting to our facility. Our assessment revealed that the patient met the diagnostic criteria, known as the Yamaguchi criteria, needed to diagnose adult-onset Still's disease. Yamaguchi criteria include migratory inflammatory arthritis, quotidian fevers, leucocytosis and a salmon-coloured maculopapular rash. These signs and symptoms may go unnoticed or overlooked if adult-onset Still's disease is not considered. The patient was treated with anakinra (a recombinant human IL-1 receptor antagonist) and had rapid improvement in his symptoms, with the restoration of mobility.

The effect of glucocorticoids on bone mineral density in patients with rheumatoid arthritis: A systematic review and meta-analysis of randomized, controlled trials

PURPOSE

The role of glucocorticoids in the treatment of rheumatoid arthritis (RA) is widely debated. Impairment of bone formation may be counter-balanced by reduced systemic inflammation. This review aims to assess the effect of prednisolone/prednisone on bone mineral density (BMD) in patients with RA analyzed in randomized, controlled trials.

METHODS

We performed a systematic literature search and identified randomized, double-blinded placebo-controlled studies including patients with RA and using prednisolone or prednisone as the intervention. We selected studies that measured BMD by DXA at baseline and at least once thereafter. Two authors independently performed reference review, data extraction and risk of bias assessment. Primary outcome was mean change in BMD from baseline to follow-up. Secondary endpoints included radiographic scores, RA disease activity indices and fractures. We rated the quality of evidence using the GRADE approach. Outcomes were standardized for meta-analyses and 95% confidence intervals (95% CI) were calculated.

RESULTS

We identified 7 studies and included previously unpublished data. Studies were similar regarding study population and intervention. Standard mean difference (SMD) in change in BMD from 0 to 24 months was -0.02 (95%CI -0.16, 0.12) at the lumbar spine and -0.11 (95% CI -0.25, 0.02) at the hip (both high quality evidence) between patients treated with prednisolone/prednisone or not. Data completeness was low in some studies, concomitant treatment of RA differed between studies and differences in use of anti-osteoporotic medication may have influenced the results. However, sensitivity analyses excluding studies in which participants used either the most or the least potent concomitant RA treatment or used anti-osteoporotic therapies did not alter the estimates.

CONCLUSIONS

In patients with early and active RA, we found no difference in change in BMD between patients treated with prednisone/prednisolone versus placebo, suggesting that at least through 24 months, the suppression of inflammation by glucocorticoids may counterbalance their adverse effects on bone remodeling.

Canada's Study of Adherence Outcomes in Patients Receiving Adalimumab: 3-year Results From the COMPANION Study

PURPOSE

The aim of this study was to quantify the association between receiving care-coach calls (CCCs), a service provided by a patient-support program (PSP) in Canada, and persistence with and adherence to adalimumab therapy over a 3-year period in patients with immune-related inflammatory diseases (IMID).

METHODS

COMPANION, a longitudinal, retrospective cohort study, was conducted using patient-level data from the PSP combined with those from a longitudinal pharmacy-transaction database in patients initiating adalimumab therapy between 2010 and 2012. Patients aged ≥18 years who were naive to adalimumab therapy were selected, and data from their prescriptions from 36 months or until drug discontinuation, defined as >90 days without drug supply, were evaluated. Cox proportional hazards modeling was used to estimate hazard ratios for the association between persistence, and patient characteristics and PSP services. Adherence was measured using the medication possession ratio. Multivariate logistic regression was used to estimate adjusted odds ratios to determine the relationship between adherence (medication possession ratio ≥80%), and patient characteristics and PSP services.

FINDINGS

A total 4772 patients were included (55% women; 24% aged 50-59 years). Of these, 2866 qualified for the persistence analysis, and 51% received CCCs (n = 1452). Of the 4772 patients, 4630 qualified for the adherence analysis, and 33% received CCCs (n = 1511). Baseline characteristics were similar between the group that received CCCs versus the group that did not. During the follow-up period, patients who received CCCs had a significantly reduced risk for treatment discontinuation (hazard ratio = 0.350; 95% CI, 0.298-0.413; P < 0.0001) and a greater likelihood of being adherent (odds ratio, 2.248; 95% CI, 1.927-2.624; P < 0.0001).

IMPLICATIONS

CCCs were associated with greater adherence and improved persistence in these patients receiving adalimumab therapy over a 3-year period for IMID.

Long-term etanercept retention patterns and factors associated with treatment discontinuation: a retrospective cohort study using Canadian claims-level data

To examine 12-month retention rates over 6 years of etanercept patients in Canada, and to identify factors associated with treatment discontinuation. A retrospective cohort study was conducted using longitudinal prescription drug claims data from IQVIA Private Drug Plan database (PDP), Ontario Public Drug Plan database (OPDP), and Régie de l'assurance maladie du Québec database (RAMQ). Between 07/2008 and 06/2010, bio-naïve patients who initiated etanercept were identified and followed for 72 months. Twelve-month retention rates were estimated in one-year increments and factors associated with time to discontinuation over the 72-month period were identified using a Cox proportional hazards regression model. The study identified 4528 etanercept patients (61% female, 85% rheumatic diseases, and 15% psoriasis). Twelve-month etanercept retention rates increased significantly for patients following their first year on therapy (p < 0.0001), with 66% of patients retained at year 1 vs. 79, 82, 84, 83, and 79% at years 2, 3, 4, 5, and 6, respectively. 17.1% (n = 771) of patients were retained for the entire 72-month study. Patients with psoriasis were at increased risk (HR 1.199; p < 0.0001); while public drug coverage plan patients (OPDP HR 0.721; p < 0.0001 and RAMQ HR 0.537; p < 0.0001) were at decreased risk of treatment discontinuation. Twelve-month etanercept retention rates increased significantly for patients following their first year on therapy. Indication and drug coverage plan were associated with patients' time to etanercept discontinuation. With a better understanding of factors associated with retention, programs can be designed to address the specific needs of at-risk groups while supporting patients stable on therapy.

Metabolic syndrome and the decreased levels of uric acid by leflunomide favor redox imbalance in patients with rheumatoid arthritis

Oxidative stress plays a role in the pathophysiology of rheumatoid arthritis (RA). The aim of the present study was to verify the influence of metabolic syndrome (MetS) and disease-modifying antirheumatic drugs on nitrosative and oxidative biomarkers in patients with RA. A total of 177 patients with RA and 150 healthy volunteers participated in this study, which measured lipid hydroperoxides, advanced oxidation protein products (AOPP), nitric oxide metabolites (NOx), carbonyl protein, total radical-trapping antioxidant parameter (TRAP), uric acid (UA), and C-reactive protein (CRP). NOx and the NOx/TRAP ratio were significantly increased in RA, while no significant differences in lipid hydroperoxides, AOPP, UA, and TRAP levels were found between both groups. Treatment with leflunomide was associated with increased levels of carbonyl protein, and lowered levels in TRAP and UA, while the NOx/TRAP ratio further increased. NOx and the NOx/TRAP ratio were significantly higher in women than in men, while TRAP and UA were significantly lower in women. MetS was accompanied by increased AOPP and UA levels. RA was best predicted by increased NOx/TRAP ratio, CRP, and BMI. In conclusion, our data demonstrated that NOx and NOx/TRAP are strongly associated with RA physiopathology. Our findings suggest that inhibition of iNOS may become an interesting therapeutic approach for the treatment of RA. In addition, the presence of MetS and a decrease in levels of UA by leflunomide favor redox imbalance in RA patients. More studies are needed to evaluate the impact of antioxidant capacity reduction on RA progression.

Tapering biologics in rheumatoid arthritis: a pragmatic approach for clinical practice

Optimal rheumatoid arthritis (RA) therapy in daily clinical practice is based on the treat-to-target strategy. Quicker escalation of therapy and earlier introduction of biological disease-modifying anti-rheumatic drugs have led to improved outcomes in RA. However, chronic immunosuppressive therapy is associated with adverse events and higher costs. In addition, our patients frequently express a desire for lower dosing and drug holidays. Current clinical practice guidelines from the American College of Rheumatology and European League Against Rheumatism suggest that rheumatologists consider tapering treatment after achieving remission. However, the optimal approach for tapering therapy in RA, specifically de-escalation of biologics, remains unknown. This clinical review discusses biologic tapering strategies in RA. We draw our recommendations for everyday clinical practice from the most recent observational, pragmatic, and controlled clinical trials on de-escalation of biologics in RA. For each biologic, we highlight clinically relevant outcomes, such as flare rates, recapture of the disease control with retreatment, radiographic progression, side effects, and functional impact. We discuss the use of musculoskeletal ultrasound to select patients for successful tapering. In conclusion, we provide the reader with a practical guide for tapering biologics in the rheumatology clinic.

Influence of patient personality in the treatment of rheumatoid arthritis

Individualized treatment of rheumatoid arthritis (RA) based on genetic/serologic factors is increasingly accepted. Moreover, patients are more actively involved in the management of their disease. However, personality has received little attention with respect to perception of the need and adherence to treatment. Our objective was to evaluate whether patient personality was associated with the acceptance or rejection of more aggressive early treatment. We performed a cross-sectional study in two hospitals with early arthritis clinics where sociodemographic, clinical, and therapeutic variables are systematically recorded. Patients completed Eysenck Personality Questionnaire, Multidimensional Health Locus of Control, Pain-Related Self-Statement Scale and Pain-Related Control Scale. Aggressive treatment was considered if patients received more than two DMARDs or biological agents during the first year of follow-up. Multivariate logistic regression analysis was performed to determine predictors of aggressive treatment. One hundred seventy-six RA patients were included (80 % women, disease begin median age 55 years). Treatment was considered aggressive in 57.9 % of the sample. Scores were high in extraversion in 50.8 % of patients, neuroticism in 29.5 % and psychoticism in 14.7 %. Neuroticism was the only factor associated with aggressive treatment, which was less probable (p = 0.04, OR = 0.40). Neuroticism also decreased the possibility of receiving a combination of biologics and DMARDs (p = 0.04, OR = 0.28). Patients with high scores on neuroticism are more worried, obsessive and hypochondriac, leading them to reject more aggressive therapy. It is important to educate about their disease so that they will accept more aggressive approaches in clear cases of poor outcome.

The Burden of Rheumatic Diseases: An Analysis of an Italian Administrative Database

INTRODUCTION

Chronic inflammatory rheumatic diseases (RDs) trigger high costs for healthcare systems and society due to the disability and comorbidity associated with these disease entities. The aim of this study was to analyze patients with RD, assess the use of conventional synthetic and biologic therapies, and estimate the overall cost of treatment in Italy.

METHODS

Administrative healthcare claims from the Piedmont region in Northwest Italy were reviewed to identify patients who received disease-modifying antirheumatic drugs (DMARDs) between 2007 and 2010. Confirmation of RD was based on: (1) diagnosis-specific exemption code; (2) hospitalization or emergency care events characterized by disease-specific ICD9 codes; (3) inclusion in the regional registry of biologic drugs. The follow-up period was 3 years.

RESULTS

A total of 9560 subjects, of whom the majority were women (58.1%), were entered into the study; the average age of the study population was 55.3 years. On the index date 12.9% of patients were receiving a biologic DMARD, with adalimumab the most frequently prescribed biologic DMARD (4.7%), followed by etanercept (4.4%). The average total healthcare expenditure was €377.98 per patient per month (patient-month). In the subgroup analysis of healthcare costs according to use of biologics, the total expenditure was €1037.97/€230.86 patient-month for those receiving/not receiving at least one biologic DMARD. In the subgroup analysis of healthcare costs according to type of biologic used, the total expenditure ranged from €657.61 (golimumab) to €1384.15 (rituximab) patient-month.

CONCLUSIONS

A substantial difference in the total costs according to treatment/no treatment with a biologic and the specific biologic DMARD prescribed was identified. However, this result should be interpreted with caution as a bias in terms of patient selection was most likely present. The results of this study shed some light on RD in an relevant sample of Italian patients. The preliminary conclusions need to be confirmed by further analysis.

Rheumatoid Arthritis, Kartagener's Syndrome, and Hyperprolactinemia: Who Started It?

We report a case of an 18-year-old girl who presented to our hospital with history of recurrent respiratory infections, amenorrhea, and symmetric polyarthritis. She was diagnosed with rheumatoid arthritis (RA), Kartagener's syndrome (KS), and hyperprolactinemia. There have been very few case reports in the literature of RA occurring in the setting of KS, theoretically proposed to be due to chronic stimulation of the immune system by recurrent infections. Furthermore, hyperprolactinemia has been hypothesized to mirror RA disease activity and case reports of treatment with dopamine agonists have led to the speculation of whether or not they represent a new line of experimental treatment in the future. Our patient was found to have both KS and hyperprolactinemia together in the setting of RA, and based on our literature search, this is the first reported case of such a combination. This strikes a very intriguing question: are these three conditions interlinked by a yet to be defined association? And treatment of which condition leads to the resolution of the other?

Characteristics of traditional Chinese medicine use in patients with rheumatoid arthritis in Taiwan: A nationwide population-based study

ETHNOPHARMACOLOGICAL RELEVANCE

Large-scale study of traditional Chinese medicine (TCM) usage among patients with rheumatoid arthritis (RA) is lacking. The aim of this study is to evaluate the TCM usage among RA patients in Taiwan.

MATERIALS AND METHODS

We examined the "registry for catastrophic illness patient dataset" of the National Health Insurance Research Database (NHIRD; n=23 million people) in Taiwan. Patients (n=25,263) newly diagnosed as RA in 2001-2009 were included and then followed-up until the end of 2011. Based on the medical utilization, they were further categorized into TCM users (n= 6891; 27.3%) and non-TCM users (n=18,372; 72.7%). The demographic data and core prescription patterns of the TCM users were analyzed.

RESULTS

Compared to non-TCM user, TCM users were younger (mean age: 49.6 versus 54.0 years), had a higher female/male ratio (82.7%/17.3% versus 74.1%/25.9%), resided in more urbanized area. Herbal remedies were the most commonly used therapeutic approach (76.4%), followed by combining acupuncture (21.1%). The frequency of outpatient visits in TCM users was higher across all disease categories except circulatory system. The most commonly prescribed formula and herb was Shang-Jong-Shiah-Tong-Yong-Tong-Feng-Wan and Rhizoma Corydalis, respectively. The analysis of core pattern revealed that Dang-Gui-Nian-Tong-Tang, Shu-Jing-Huo-Xie-Tang, Gui-Zhi-Shao-Yao-Zhi-Mu-Tang, Myrrha and Olibanum, were among the most frequently used combinations. RA patients who had anxiety and depression, allergic rhinitis, osteoporosis, menstrual disorder, and menopausal syndrome were prone to have more TCM visits compared to non-TCM users.

CONCLUSIONS

Our population-based study revealed the high prevalence and specific usage patterns of TCM in the RA patients in Taiwan. The information could be used for further pharmacological investigation and clinical trials.

Anthocyanin Extracted from Black Soybean Seed Coats Prevents Autoimmune Arthritis by Suppressing the Development of Th17 Cells and Synthesis of Proinflammatory Cytokines by Such Cells, via Inhibition of NF-κB

INTRODUCTION

Oxidative stress plays a role in the pathogenesis of rheumatoid arthritis (RA). Anthocyanin is a plant antioxidant. We investigated the therapeutic effects of anthocyanin extracted from black soybean seed coats (AEBS) in a murine model of collagen-induced arthritis (CIA) and human peripheral blood mononuclear cells (PBMCs) and explored possible mechanisms by which AEBS might exert anti-arthritic effects.

MATERIAL AND METHODS

CIA was induced in DBA/1J mice. Cytokine levels were measured via enzyme-linked immunosorbent assays. Joints were assessed in terms of arthritis incidence, clinical arthritis scores, and histological features. The extent of oxidative stress in affected joints was determined by measuring the levels of nitrotyrosine and inducible nitric oxide synthase. NF-κB activity was assayed by measuring the ratio of phosphorylated IκB to total IκB via Western blotting. Th17 cells were stained with antibodies against CD4, IL-17, and STAT3. Osteoclast formation was assessed via TRAP staining and measurement of osteoclast-specific mRNA levels.

RESULTS

In the CIA model, AEBS decreased the incidence of arthritis, histological inflammation, cartilage scores, and oxidative stress. AEBS reduced the levels of proinflammatory cytokines in affected joints of CIA mice and suppressed NF-κB signaling. AEBS decreased Th17 cell numbers in spleen of CIA mice. Additionally, AEBS repressed differentiation of Th17 cells and expression of Th17-associated genes in vitro, in both splenocytes of naïve DBA/1J mice and human PBMCs. In vitro, the numbers of both human and mouse tartrate-resistant acid phosphatase+ (TRAP) multinucleated cells fell, in a dose-dependent manner, upon addition of AEBS.

CONCLUSIONS

The anti-arthritic effects of AEBS were associated with decreases in Th17 cell numbers, and the levels of proinflammatory cytokines synthesized by such cells, mediated via suppression of NF-κB signaling. Additionally, AEBS suppressed osteoclastogenesis and reduced oxidative stress levels.

Diagnostic performance of anti-cyclic citrullinated peptide and rheumatoid factor in patients with rheumatoid arthritis

AIM

To compare the diagnostic performance of rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP) in the diagnosis of patients with rheumatoid arthritis (RA) in Taiwan.

METHODS

Serum concentrations of RF and anti-CCP were measured in 246 cases, including 39 patients with RA and 207 patients with other rheumatic diseases (non-RA). The age, sex, clinical presentation, RF, anti-CCP results and the final diagnoses were recorded and analyzed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were calculated.

RESULTS

Among all 246 patients, 39 (15.9%) were diagnosed with RA and 207 (84.1%) were diagnosed with other rheumatic diseases (non-RA). In the diagnosis of RA, the sensitivity, specificity, PPV, NPV, LR+ and LR- of the RF test were 67%, 79%, 37%, 93%, 3.12, and 0.42, respectively. The corresponding data for the anti-CCP test were 79%, 98%, 86%, 96%, 32.91 and 0.21, respectively. The presence of either anti-CCP or RF increased the sensitivity to 85%, and when they both were present, the specificity increased to 98%. Among the 39 RA patients, 26 (66.7%) tested positive for RF, and 31 (79.5%) tested positive for anti-CCP. RF was positive in two of eight anti-CCP-negative patients with RA, and anti-CCP was positive in seven of 13 RF-negative patients with RA.

CONCLUSIONS

The RF and anti-CCP tests are complementary, and the co-detection of these antibodies can increase the detection rate and provide important clinical value in the diagnosis of RA. Both anti-CCP and RF positivity are useful for the diagnosis of RA, and use of both tests together improves the diagnostic sensitivity.

Increased risk of mycobacterial infections associated with anti-rheumatic medications

RATIONALE

Anti-tumour necrosis factor (TNF) agents and other anti-rheumatic medications increase the risk of TB in rheumatoid arthritis (RA). Whether they increase the risk of infections with nontuberculous mycobacteria (NTM) is uncertain.

OBJECTIVES

To determine the effect of anti-TNF therapy and other anti-rheumatic drugs on the risk of NTM disease and TB in older patients with RA.

METHODS

Population-based nested case-control study among Ontario seniors aged ≥67 years with RA who were prescribed at least one anti-rheumatic medication between 2001 and 2011. We identified cases of TB and NTM disease microbiologically and identified drug exposures using linked prescription drug claims. We estimated ORs using conditional logistic regression, controlling for several potential confounders.

MEASUREMENTS AND MAIN RESULTS

Among 56 269 older adults with RA, we identified 37 cases of TB and 211 cases of NTM disease; each case was matched to up to 10 controls. Individuals with TB or NTM disease were both more likely to be using anti-TNF therapy (compared with non-use); adjusted ORs (95% CIs) were 5.04 (1.27 to 20.0) and 2.19 (1.10 to 4.37), respectively. Exposure to leflunomide and other anti-rheumatic drugs with high immunosuppressing potential also were associated with both TB and NTM disease, while oral corticosteroids and hydroxychloroquine were associated with NTM disease.

CONCLUSIONS

Anti-TNF use is associated with increased risk of both TB and NTM disease, but appears to be a relatively greater risk for TB. Several other anti-rheumatic drugs were also associated with mycobacterial infections.

Adjusting for comorbidities in cost of illness studies

MOTIVATION

Differences in cost of illness (COI) methodological approaches have led to disparate results. This analysis examines two sources of this variation: specification of comorbidities in the estimated cost models and assumed prevalence rates used for generating aggregate costs. The study provides guidance in determining which comorbidities are important to include and how to handle uncertainty in optimal model specification and prevalence rate assumptions.

METHODS

Comorbidities are categorized into four types. Type I comorbidities are those that increase the risk of the disease of interest; Type II comorbidities have no causal link to the disease of interest but are, nonetheless, highly correlated with that disease; Type III comorbidities are illnesses that the disease of interest may cause, and Type IV are comorbidities that have no causal link to the disease of interest and are only weakly correlated with that disease. Two-part models are used to estimate the direct costs of rheumatoid arthritis and diabetes mellitus using 2000-2007 Medical Expenditure Panel Survey data.

RESULTS

COI estimates are sensitive to the specification of comorbidities. The odds of incurring any expenses varies by 71% for diabetes mellitus and by 27% for rheumatoid arthritis, while conditional expenditures (e.g., expenditures among subjects incurring at least some expenditures) vary by 62% and 45%, respectively. Uncertainty in prevalence rates cause costs to vary. A sensitivity analysis estimated the COI for diabetes ranges from $131.7-$172.0 billion, while rheumatoid arthritis varies from $12.8-$26.2 billion.

CONCLUSIONS

The decision to include Type II and Type III comorbidities is crucial in COI studies. Alternative models should be included with and without the Type III comorbidities to gauge the range of cost effects of the disease. In generating costs, alternative values for prevalence rates should be used and a sensitivity analysis should be performed.

A systematic review of validated methods for identifying patients with rheumatoid arthritis using administrative or claims data

PURPOSE

To review the evidence supporting the validity of billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify patients with rheumatoid arthritis (RA) in administrative and claim databases.

METHODS

We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to RA and reference lists of included studies were searched. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria and extracted the data. Data collected included participant and algorithm characteristics.

RESULTS

Nine studies reported validation of computer algorithms based on International Classification of Diseases (ICD) codes with or without free-text, medication use, laboratory data and the need for a diagnosis by a rheumatologist. These studies yielded positive predictive values (PPV) ranging from 34 to 97% to identify patients with RA. Higher PPVs were obtained with the use of at least two ICD and/or procedure codes (ICD-9 code 714 and others), the requirement of a prescription of a medication used to treat RA, or requirement of participation of a rheumatologist in patient care. For example, the PPV increased from 66 to 97% when the use of disease-modifying antirheumatic drugs and the presence of a positive rheumatoid factor were required.

CONCLUSIONS

There have been substantial efforts to propose and validate algorithms to identify patients with RA in automated databases. Algorithms that include more than one code and incorporate medications or laboratory data and/or required a diagnosis by a rheumatologist may increase the PPV.

False-positive results for rapid diagnostic tests for malaria in patients with rheumatoid factor

Four different rapid diagnostic tests (RDTs) for malaria were evaluated by testing 82 healthy control patients, 89 Plasmodium vivax-infected patients, and 92 rheumatoid factor (RF)-positive nonmalaria patients. The false-positive rate ranged from 2.2% to 13% in RF-positive patients. High RF levels are associated with malaria RDT false positivity.

Cardiovascular comorbidity in rheumatic diseases: a focus on heart failure

Rheumatic diseases are associated with an increased risk of cardiovascular (CV) mortality attributed to a higher incidence of heart failure (HF) and ischemic heart disease. Although traditional CV risk factors contribute to the increased incidence seen in this population, by themselves they do not account for the increased risk; in fact, obesity and hyperlipidemia may play a paradoxic role. Immune-mediated mechanisms and chronic inflammation likely play a role in the pathogenesis of CV disease in patients with rheumatic diseases. The usual clinical features of ischemic heart disease and HF are less likely to be seen in this patient population.

Usability testing of ANSWER: a web-based methotrexate decision aid for patients with rheumatoid arthritis

BACKGROUND

Decision aids are evidence-based tools designed to inform people of the potential benefit and harm of treatment options, clarify their preferences and provide a shared decision-making structure for discussion at a clinic visit. For patients with rheumatoid arthritis (RA) who are considering methotrexate, we have developed a web-based patient decision aid called the ANSWER (Animated, Self-serve, Web-based Research Tool). This study aimed to: 1) assess the usability of the ANSWER prototype; 2) identify strengths and limitations of the ANSWER from the patient's perspective.

METHODS

The ANSWER prototype consisted of: 1) six animated patient stories and narrated information on the evidence of methotrexate for RA; 2) interactive questionnaires to clarify patients' treatment preferences. Eligible participants for the usability test were patients with RA who had been prescribed methotrexate. They were asked to verbalize their thoughts (i.e., think aloud) while using the ANSWER, and to complete the System Usability Scale (SUS) to assess overall usability (range = 0-100; higher = more user friendly). Participants were audiotaped and observed, and field notes were taken. The testing continued until no new modifiable issues were found. We used descriptive statistics to summarize participant characteristics and the SUS scores. Content analysis was used to identified usability issues and navigation problems.

RESULTS

15 patients participated in the usability testing. The majority were aged 50 or over and were university/college graduates (n = 8, 53.4%). On average they took 56 minutes (SD = 34.8) to complete the tool. The mean SUS score was 81.2 (SD = 13.5). Content analysis of audiotapes and field notes revealed four categories of modifiable usability issues: 1) information delivery (i.e., clarity of the information and presentation style); 2) navigation control (i.e., difficulties in recognizing and using the navigation control buttons); 3) layout (i.e., position of the videos, text, diagrams and navigation buttons); 4) aesthetic (i.e., the colour, look and feel of the online tool).

CONCLUSIONS

Although the SUS score indicated high usability before and after major modification, findings from the think-aloud sessions illustrated areas that required further refinement. Our results highlight the importance of formative evaluation in usability testing.

Rheumatoid Arthritis (RA) associated interstitial lung disease (ILD)

Rheumatoid Arthritis (RA) is the most common Connective Tissue Disease (CTD) and represents an increasing burden on global health resources. Interstitial lung disease (ILD) has been recognised as a complication of RA but its potential for mortality and morbidity has arguably been under appreciated for decades. New studies have underscored a significant lifetime risk of ILD development in RA. Contemporary work has identified an increased risk of mortality associated with the Usual Interstitial Pneumonia (UIP) pattern which shares similarity with the most devastating of the interstitial pulmonary diseases, namely Idiopathic Pulmonary Fibrosis (IPF). In this paper, we discuss recent studies highlighting the associated increase in mortality in RA-UIP. We explore associations between radiological and histopathological features of RA-ILD and the prognostic implications of same. We emphasise the need for translational research in this area given the growing burden of RA-ILD. We highlight the importance of the respiratory physician as a key stakeholder in the multidisciplinary management of this disorder. RA-ILD focused research offers the opportunity to identify early asymptomatic disease and define the natural history of this extra articular manifestation. This may provide a unique opportunity to define key regulatory fibrotic events driving progressive disease. We also discuss some of the more challenging and novel aspects of therapy for RA-ILD.