The perspective of patients with early rheumatoid arthritis on the journey from symptom onset until referral to a rheumatologist

Impact of filgotinib on pain control in the phase 3 FINCH studies

OBJECTIVE

This post hoc analysis of the FINCH 1-3 (NCT02889796, NCT02873936 and NCT02886728) studies assessed specific effects of filgotinib on pain control and their relationship with other aspects of efficacy in patients with rheumatoid arthritis (RA).

METHODS

Assessments included: residual pain responses of ≤10 and ≤20 mm on a 100 mm visual analogue scale (VAS); the proportion of patients who achieved VAS pain responses in addition to remission or low disease activity by Disease Activity Score-28 with C-reactive protein (DAS28-CRP) or Clinical Disease Activity Index (CDAI) criteria.

RESULTS

Across studies, filgotinib reduced pain from week 2, with responses sustained throughout the studies. In FINCH 1, at week 24, 35.8%, 25.0%, 24.6% and 11.6% of patients in the filgotinib 200 mg, filgotinib 100 mg, adalimumab and placebo arms (each plus methotrexate) achieved VAS pain ≤20 mm in addition to DAS28-CRP remission; 26.3%, 17.9%, 17.2% and 7.6% achieved VAS pain ≤10 mm in addition to DAS28-CRP remission. A similar pattern was seen for CDAI remission. Time during which VAS pain was ≤10 or ≤20 mm was longest with filgotinib 200 mg and comparable between adalimumab and filgotinib 100 mg. Similar findings were reported for filgotinib in FINCH 2 and 3.

CONCLUSION

In all RA populations studied, pain improvements occurred from week 2 and were sustained over time. In FINCH 1, filgotinib 100 mg provided similar pain amelioration to adalimumab, whereas filgotinib 200 mg resulted in greater pain improvement and higher proportion of patients with residual pain ≤10 or ≤20 mm and meeting DAS28-CRP remission criteria.

A Cross-Sectional Survey of Physicians' Knowledge and Awareness of Chronic Pain Associated with Rheumatoid Arthritis in Rheumatology Departments in Zhejiang Province, China

Objective

To assess physicians' knowledge and awareness of chronic pain associated with rheumatoid arthritis (RA) in Rheumatology departments throughout Zhejiang province to improve chronic pain relief in RA patients.

Methods

A cross-sectional questionnaire survey was conducted onsite and online among rheumatologists in tertiary and secondary hospitals across Zhejiang province, China. The questionnaire inquired about rheumatoid arthritis-related pain cognition, pain assessment, pain management protocols, and medication choice.

Results

Among the 150 questionnaires included, 98 were from tertiary hospitals, and 52 were from secondary hospitals. There was no difference in rheumatologists' perceptions of chronic pain in RA patients between tertiary and secondary hospitals. About 55.1% of rheumatologists from tertiary hospitals and 44.2% of rheumatologists from secondary hospitals utilized unstandardized pain assessment scales. About 46.9% of rheumatologists in tertiary hospitals and 36.5% of rheumatologists in secondary hospitals favored the numerical rating scale (NRS). About 87.8% of rheumatologists in tertiary hospitals and 71.7% of rheumatologists in secondary hospitals conducted pain assessment within 4 hours of admission. About 66.3% of rheumatologists working in tertiary hospitals and 32.7% of rheumatologists practicing in secondary hospitals believed their hospitals had pain departments. For RA patients who complained of pain for the first time, secondarily, or repeatedly, 48%, 26%, and 36.7% of rheumatologists preferred nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and opioid analgesics, respectively. For RA patients with mild, moderate, or severe pain, 74%, 6%, and 16% of rheumatologists preferred NSAIDs, glucocorticoids, and opioid analgesics, respectively.

Conclusion

The assessment and treatment of chronic pain associated with RA are not standardized. For management, more rheumatologists preferred NSAIDs and glucocorticoids.

The effects of Phycocyanobilin on experimental arthritis involve the reduction in nociception and synovial neutrophil infiltration, inhibition of cytokine production, and modulation of the neuronal proteome

Introduction

The antinociceptive and pharmacological activities of C-Phycocyanin (C-PC) and Phycocyanobilin (PCB) in the context of inflammatory arthritis remain unexplored so far. In the present study, we aimed to assess the protective actions of these compounds in an experimental mice model that replicates key aspects of human rheumatoid arthritis.

Methods

Antigen-induced arthritis (AIA) was established by intradermal injection of methylated bovine serum albumin in C57BL/6 mice, and one hour before the antigen challenge, either C-PC (2, 4, or 8 mg/kg) or PCB (0.1 or 1 mg/kg) were administered intraperitoneally. Proteome profiling was also conducted on glutamate-exposed SH-SY5Y neuronal cells to evaluate the PCB impact on this key signaling pathway associated with nociceptive neuronal sensitization.

Results and discussion

C-PC and PCB notably ameliorated hypernociception, synovial neutrophil infiltration, myeloperoxidase activity, and the periarticular cytokine concentration of IFN-γ, TNF-α, IL-17A, and IL-4 dose-dependently in AIA mice. In addition, 1 mg/kg PCB downregulated the gene expression for T-bet, RORγ, and IFN-γ in the popliteal lymph nodes, accompanied by a significant reduction in the pathological arthritic index of AIA mice. Noteworthy, neuronal proteome analysis revealed that PCB modulated biological processes such as pain, inflammation, and glutamatergic transmission, all of which are involved in arthritic pathology.

Conclusions

These findings demonstrate the remarkable efficacy of PCB in alleviating the nociception and inflammation in the AIA mice model and shed new light on mechanisms underlying the PCB modulation of the neuronal proteome. This research work opens a new avenue to explore the translational potential of PCB in developing a therapeutic strategy for inflammation and pain in rheumatoid arthritis.

Barriers to the Diagnosis of Early Inflammatory Arthritis: A Literature Review

The early identification of patients with inflammatory arthritis and their referral to rheumatologists in order to establish a diagnosis and to start treatment plays a crucial role in patient outcomes. However, it is recognized that a large proportion of patients with inflammatory arthritis are diagnosed very late, losing the opportunity to start treatment in the very early stages of disease, resulting in a worse prognosis. This delay depends on several factors related to the patient, the disease, socio-demographic and health system aspects. Over time, several strategies have been developed and implemented at different levels aiming to overcome such barriers and to reduce the time from the onset of the symptoms until the diagnosis and start of adequate treatment. In this non-systematic comprehensive review, we will describe the main barriers in the identification of patients with inflammatory arthritis at different levels. We will also discuss the different strategies that have been implemented with the objective to overcome the recognized barriers and their impact in the reduction of delays.

Emodin alleviates arthritis pain through reducing spinal inflammation and oxidative stress

Chronic pain is the predominant problem for rheumatoid arthritis patients, and negatively affects quality of life. Arthritis pain management remains largely inadequate, and developing new treatment strategies are urgently needed. Spinal inflammation and oxidative stress contribute to arthritis pain and represent ideal targets for the treatment of arthritis pain. In the present study, collagen-induced arthritis (CIA) mouse model was established by intradermally injection of type II collagen (CII) in complete Freund's adjuvant (CFA) solution, and exhibited as paw and ankle swelling, pain hypersensitivity and motor disability. In spinal cord, CIA inducement triggered spinal inflammatory reaction presenting with inflammatory cells infiltration, increased Interleukin-1β (IL-1β) expression, and up-regulated NOD-like receptor thermal protein domain associated protein 3 (NLRP3) and cleaved caspase-1 levels, elevated spinal oxidative level presenting as decreased nuclear factor E2-related factor 2 (Nrf2) expression and Superoxide dismutase (SOD) activity. To explore potential therapeutic options for arthritis pain, emodin was intraperitoneally injected for 3 days on CIA mice. Emodin treatment statistically elevated mechanical pain sensitivity, suppressed spontaneous pain, recovered motor coordination, decreased spinal inflammation score and IL-1β expression, increased spinal Nrf2 expression and SOD activity. Further, AutoDock data showed that emodin bind to Adenosine 5'-monophosphate (AMP)-activated protein kinase (AMPK) through two electrovalent bonds. And emodin treatment increased the phosphorylated AMPK at threonine 172. In summary, emodin treatment activates AMPK, suppresses NLRP3 inflammasome response, elevates antioxidant response, inhibits spinal inflammatory reaction and alleviates arthritis pain.

Metabolic Profiling in Rheumatoid Arthritis, Psoriatic Arthritis, and Psoriasis: Elucidating Pathogenesis, Improving Diagnosis, and Monitoring Disease Activity

Immune-mediated inflammatory diseases (IMIDs), such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), and psoriasis (Ps), represent autoinflammatory and autoimmune disorders, as well as conditions that have an overlap of both categories. Understanding the underlying pathogeneses, making diagnoses, and choosing individualized treatments remain challenging due to heterogeneous disease phenotypes and the lack of reliable biomarkers that drive the treatment choice. In this review, we provide an overview of the low-molecular-weight metabolites that might be employed as biomarkers for various applications, e.g., early diagnosis, disease activity monitoring, and treatment-response prediction, in RA, PsA, and Ps. The literature was evaluated, and putative biomarkers in different matrices were identified, categorized, and summarized. While some of these candidate biomarkers appeared to be disease-specific, others were shared across multiple IMIDs, indicating common underlying disease mechanisms. However, there is still a long way to go for their application in a routine clinical setting. We propose that studies integrating omics analyses of large patient cohorts from different IMIDs should be performed to further elucidate their pathomechanisms and treatment options. This could lead to the identification and validation of biomarkers that might be applied in the context of precision medicine to improve the clinical outcomes of these IMID patients.

Angiotensin-(1-7) attenuates collagen-induced arthritis via inhibiting oxidative stress in rats

The present study was designed to investigate the anti-rheumatic effects and the mechanism of angiotensin (Ang)-(1-7) in rat models with collagen-induced arthritis (CIA). The CIA model was established using male Wistar rats by intradermal injection of bovine collagen-II in complete Freund's adjuvant at the base of the tail. The levels of angiotensin converting enzyme 2 (ACE2)/Ang-(1-7)/Mas receptor (MasR) were reduced in CIA rats. The attenuation of paw swelling and arthritis scores and improvement of indexes of spleen and thymus were done by Ang-(1-7) injection in CIA rats. The increased levels of inflammatory cytokines, such as interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ in the serum and hind paw were blocked by Ang-(1-7) administration. In addition, enhanced NADPH oxidase (Nox) activity, increased levels of superoxide anions and malondialdehyde (MDA), and weakened superoxide dismutase (SOD) activity, were all reversed by treatment with Ang-(1-7). Nox1 overexpression reversed the suppressing effects of Ang-(1-7) on paw swelling and arthritis scores in CIA rats. The Ang-(1-7)-induced improvement in spleen and thymus indexes in CIA rats was abolished by Nox1 overexpression. Nox1 overexpression reversed the inhibitory effects of Ang-(1-7) by increasing IL-1β, IL-6, TNF-α, and IFN-γ levels in the serum and hind paw of CIA rats. These results demonstrated that Nox1 increased the oxidative stress in arthritis, and Ang-(1-7) improved rheumatism in arthritis via inhibiting oxidative stress.

Delay in seeking medical help in patients with rheumatoid arthritis in India: A qualitative study

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disease with varied articular and extra-articular manifestations. In developing countries such as India patients with RA often delay seeking medical advice which may impact prognosis and disease burden.

AIM

To explore perceptions and experiences of patients living in India in seeking medical help for their RA symptoms.

METHODS

Clinician-diagnosed RA participants from different socioeconomic backgrounds were interviewed using a semi-structured topic guide. Participants were purposively selected and interviewed following an iterative approach. All interviews were recorded and transcribed by an independent company and analyzed using a thematic framework. Findings were reported in accordance with consolidated criteria for reporting qualitative research guidelines.

RESULTS

Twenty participants (13 male, 7 female) with median age 40 years (35.7-46.5) were recruited. Three overarching themes demonstrating participants' experiences and reasons for delay in seeking medical help were identified. (1) "Symptoms perspectives and delay in participants' journey" narrated participants' experiences of having RA symptoms, how these were perceived, rationalized and led to delay. (2) "Participants' experience of the healthcare system" illustrated delay in referral, reaching diagnosis and treatment initiation highlighting their experiences with the health system. (3) "Recommendations for improving care" where participants made recommendations for reducing the delay at local and national levels.

CONCLUSION

This is the first qualitative study which explored perceptions and experiences of RA patients in India resulting in delay. Improved provision of rheumatology care, effective referral system and greater involvement of government at local and national levels are needed to improve the delay in seeking medical help for Indian patients.

Pain Mechanism in Rheumatoid Arthritis: From Cytokines to Central Sensitization

Pain is the most common symptom in patients with rheumatoid arthritis (RA). Although in recent years, through the implementation of targeted treatment and the introduction of disease-modifying antirheumatic drugs (DMARDs), the treatment of RA patients has made a significant progress, a large proportion of patients still feel pain. Finding appropriate treatment to alleviate the pain is very important for RA patients. Current research showed that, in addition to inflammation, RA pain involves peripheral sensitization and abnormalities in the central nervous system (CNS) pain regulatory mechanisms. This review summarized the literature on pain mechanisms of RA published in recent years. A better understanding of pain mechanisms will help to develop new analgesic targets and deploy new and existing therapies.