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Kaudewitz D, Lorenz HM. [Drug therapy of rheumatoid arthritis: where do biologics and novel synthetic disease-modifying antirheumatic drugs stand today?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1005-1012. [PMID: 37493758 DOI: 10.1007/s00108-023-01554-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/27/2023]
Abstract
Biologics and Janus kinase (JAK) inhibitors play an important role in the treatment of rheumatoid arthritis. As new therapeutic developments have emerged in recent decades, the morbidity and mortality of rheumatoid arthritis have been significantly reduced. The characterization of the structure and function of immune cell receptors has led to the development of biologics that specifically inhibit cytokines and immune cell receptors. An important therapeutic addition was the approval of JAK inhibitors, which act directly on intracellular signaling by tyrosine kinases. This article provides an overview of the current therapeutic options for rheumatoid arthritis with a special focus on indication, mechanism of action and the place in the treatment algorithm of biologics and JAK inhibitors.
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Affiliation(s)
- Dorothee Kaudewitz
- Medizinische Klinik V, Klinik für Hämatologie, Onkologie und Rheumatologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland.
| | - Hanns-Martin Lorenz
- Medizinische Klinik V, Klinik für Hämatologie, Onkologie und Rheumatologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
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Increase of Circulating Monocyte-Platelet Conjugates in Rheumatoid Arthritis Responders to IL-6 Blockage. Int J Mol Sci 2022; 23:ijms23105748. [PMID: 35628558 PMCID: PMC9144642 DOI: 10.3390/ijms23105748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 02/01/2023] Open
Abstract
Platelets (PLT) bind to a significant percentage of circulating monocytes and this immunomodulatory interaction is increased in several inflammatory and autoimmune conditions. The therapeutic blockage of IL-6 with Tocilizumab (TCZ) alters PLT and the phenotype and function of monocytes in rheumatoid arthritis (RA). However, the relationship between monocyte−PLT conjugates (CD14+PLT+) and clinical and immunological variables and the regulation of this interaction by IL-6 blockage are still unknown. Here, we compared the presence of monocyte−PLT conjugates (CD14+PLT+) and membrane CD162 expression using flow cytometry, and, by ELISA, the markers of PLT activation (sCD62P and sCD40L) in healthy donors (HD) and patients with long-standing RA before TCZ (baseline). We found higher percentages and absolute counts of CD14+PLT+, and higher plasmatic levels of sCD62P and sCD40L but lower CD162 expression on monocytes from RA patients than those from HD. Additionally, the levels of CD14+PLT+ inversely correlated with inflammatory parameters. Interestingly, 95% of patients with lower percentages of CD14+PLT+ and only 63% of patients with higher percentages of CD14+PLT+ achieved a EULAR-defined response at four weeks (p = 0.036). After TCZ, the percentage of CD14+PLT+ increased in 92% of RA patients who achieved 12 w-remission (p < 0.001). Our results suggest that the binding of PLTs has a modulatory effect, accentuated by the increased binding of PLTs to monocytes in response to the therapeutic blockage of IL-6.
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Shukla R, Emery P, Buch MH. Efficacy of tumour-necrosis factor-inhibitor in moderate disease activity rheumatoid arthritis: sub-analysis of the 'VEDERA' trial. Rheumatology (Oxford) 2021; 61:868-869. [PMID: 34664622 DOI: 10.1093/rheumatology/keab766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/26/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rudresh Shukla
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Foundation NHS Trust, Manchester, UK
| | - Paul Emery
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maya H Buch
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Foundation NHS Trust, Manchester, UK.,Leeds Institute of Rheumatic & Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
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McKenna F. Treatment of Moderate Rheumatoid Arthritis. Rheumatology (Oxford) 2021; 61:478-479. [PMID: 34289023 DOI: 10.1093/rheumatology/keab582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/15/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Frank McKenna
- Manchester University NHS Trust, Dept of Rheumatology, Trafford General Hospital, Moorside Rd, Davyhulme, Manchester, M41 5SL
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Nikiphorou E, Jacklin H, Bosworth A, Jacklin C, Kiely P. Disease impact of rheumatoid arthritis in patients not treated with advanced therapies; survey findings from the National Rheumatoid Arthritis Society. Rheumatol Adv Pract 2021; 5:rkaa080. [PMID: 34322656 PMCID: PMC8314206 DOI: 10.1093/rap/rkaa080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/03/2020] [Indexed: 11/21/2022] Open
Abstract
Objective The aim was to reveal the everyday impact of living with RA in people not treated with advanced therapies (i.e. biologic or targeted synthetic DMARDs). Methods People with RA, with disease duration >2 years, not currently treated with advanced therapies, completed an online survey promoted by the National Rheumatoid Arthritis Society. Items covered demographics, current treatment, RA flare frequency, the Rheumatoid Arthritis Impact of Disease (RAID) tool and questions reflecting work status and ability. Descriptive and multivariable regression analyses were performed. Results There were 612 responses from patients having a mean age of 59 years, 88% female, 37.7% with disease duration 2–5 years and 27.9% with disease duration 5–10 years. In the last year, 90% reported an RA flare, with more than six flares in 23%. A RAID patient acceptable state was recorded in 12.4%. Each of the seven domains was scored in the high range by >50% respondents; 74.3% scored sleep problems and 72% fatigue in the high range. A need to change working hours was reported by 70%. Multivariable analyses revealed that increasing difficulties with daily physical activities, reduced emotional and physical well-being in the past week were all significantly associated with pain, number of flares and ability to cope (P < 0.005). The RAID score was significantly predictive of the number of flares. Conclusion Patients not currently treated with advanced therapies experience profound difficulties in everyday living with RA, across a broad range of measures. We advocate that patient-reported measures be used to facilitate holistic care, addressing inflammation and other consequences of RA on everyday life.
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Affiliation(s)
- Elena Nikiphorou
- Department of Inflammation Biology, Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, Faculty of Life Sciences & Medicine
| | | | | | | | - Patrick Kiely
- Department of Rheumatology, St George's University Hospitals NHS Foundation Trust
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7
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Johnson TM, Michaud K, England BR. Measures of Rheumatoid Arthritis Disease Activity. Arthritis Care Res (Hoboken) 2020; 72 Suppl 10:4-26. [PMID: 33091244 DOI: 10.1002/acr.24336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/22/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Tate M Johnson
- US Department of Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Bryant R England
- US Department of Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
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Thomas K, Lazarini A, Kaltsonoudis E, Drosos A, Papalopoulos I, Sidiropoulos P, Tsatsani P, Gazi S, Pantazi L, Boki KA, Katsimbri P, Boumpas D, Fragkiadaki K, Tektonidou M, Sfikakis PP, Karagianni K, Sakkas LI, Grika EP, Vlachoyiannopoulos PG, Evangelatos G, Iliopoulos A, Dimitroulas T, Garyfallos A, Melissaropoulos K, Georgiou P, Areti M, Georganas C, Vounotrypidis P, Kitas GD, Vassilopoulos D. Treatment patterns and achievement of the treat-to-target goals in a real-life rheumatoid arthritis patient cohort: data from 1317 patients. Ther Adv Musculoskelet Dis 2020; 12:1759720X20937132. [PMID: 33062066 PMCID: PMC7534096 DOI: 10.1177/1759720x20937132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
Background Data regarding the real-life predictors of low disease activity (LDA) in rheumatoid arthritis (RA) patients are limited. Our aim was to evaluate the rate and predictors of LDA and treatment patterns in RA. Methods This was a multicenter, prospective, RA cohort study where patients were evaluated in two different time points approximately 12 months apart. Statistical analysis was performed in order to identify predictors of LDA while patterns of disease-modifying anti-rheumatic drug [DMARDs; conventional synthetic (csDMARD) or biologic (bDMARD)] and glucocorticoid (GC) use were also recorded. Results The total number of patients included was 1317 (79% females, mean age: 62.9 years, mean disease duration: 10.3 years). After 1 year, 57% had achieved LDA (DAS28ESR<3.2) while 43% did not (34%: moderate disease activity: DAS28ESR ⩾3.2 to <5.1, 9%: high disease activity, DAS28ESR ⩾5.1). By multivariate analysis, male sex was positively associated with LDA [odds ratio (OR) = 2.29 p < 0.001] whereas advanced age (OR = 0.98, p = 0.005), high Health Assessment Questionnaire (HAQ) score (OR = 0.57, p < 0.001), use of GCs (OR = 0.75, p = 0.037) or ⩾2 bDMARDs (OR = 0.61, p = 0.002), high co-morbidity index (OR = 0.86, p = 0.011) and obesity (OR = 0.62, p = 0.002) were negative predictors of LDA. During follow-up, among active patients (DAS28ESR >3.2), 21% initiated (among csDMARDs users) and 22% switched (among bDMARDs users) their bDMARDs. Conclusion In a real-life RA cohort, during 1 year of follow-up, 43% of patients do not reach treatment targets while only ~20% of those with active RA started or switched their bDMARDs. Male sex, younger age, lower HAQ, body mass index and co-morbidity index were independent factors associated with LDA while use of GCs or ⩾2 bDMARDs were negative predictors.
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Affiliation(s)
- Konstantinos Thomas
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Argiro Lazarini
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Ioannis Papalopoulos
- Clinical Immunology and Allergy Department, University of Crete, Heraklion, Greece
| | | | | | | | - Lina Pantazi
- Rheumatology Unit, Sismanoglio Hospital, Athens, Greece
| | | | - Pelagia Katsimbri
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Boumpas
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kalliopi Fragkiadaki
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Tektonidou
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros P Sfikakis
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Lazaros I Sakkas
- Department of Rheumatology, University of Thessaly, Larissa, Greece
| | - Eleftheria P Grika
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | | | | | | | | | | | | | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, 114 Vass. Sophias Avenue, Athens, 115 27, Greece
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Rheumatoid arthritis patients on persistent moderate disease activity on biologics have adverse 5-year outcome compared to persistent low-remission status and represent a heterogeneous group. Arthritis Res Ther 2020; 22:226. [PMID: 32993800 PMCID: PMC7523072 DOI: 10.1186/s13075-020-02313-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background The long-term outcome of rheumatoid arthritis (RA) patients who in clinical practice exhibit persistent moderate disease activity (pMDA) despite treatment with biologics has not been adequately studied. Herein, we analyzed the 5-year outcome of the pMDA group and assessed for within-group heterogeneity. Methods We included longitudinally monitored RA patients from the Hellenic Registry of Biologic Therapies with persistent (cumulative time ≥ 50% of a 5-year period) moderate (pMDA, 3.2 < DAS28 ≤ 5.1) or remission/low (pRLDA, DAS28 ≤ 3.2) disease activity. The former was further classified into persistent lower-moderate (plMDA, DAS28 < 4.2) and higher-moderate (phMDA, DAS28 ≥ 4.2) subgroups. Five-year trajectories of functionality (HAQ) were the primary outcome in comparing pRLDA versus pMDA and assessing heterogeneity within the pMDA subgroups through multivariable mixed-effect regression. We further compared serious adverse events (SAEs) occurrence between the two groups. Results We identified 295 patients with pMDA and 90 patients with pRLDA, the former group comprising of plMDA (n = 133, 45%) and phMDA (n = 162, 55%). pMDA was associated with worse 5-year functionality trajectory than pRLDA (+ 0.27 HAQ units, CI 95% + 0.22 to + 0.33; p < 0.0001), while the phMDA subgroup had worse 5-year functionality than plMDA (+ 0.26 HAQ units, CI 95% 0.18 to 0.36; p < 0.0001). Importantly, higher persistent disease activity was associated with more SAEs [pRLDA: 0.2 ± 0.48 vs pMDA: 0.5 ± 0.96, p = 0.006; plMDA: 0.32 ± 0.6 vs phMDA: 0.64 ± 1.16, p = 0.038]. Male gender (p = 0.017), lower baseline DAS28 (p < 0.001), HAQ improvement > 0.22 (p = 0.029), and lower average DAS28 during the first trimester since treatment initiation (p = 0.001) independently predicted grouping into pRLDA. Conclusions In clinical practice, RA patients with pMDA while on bDMARDs have adverse long-term outcomes compared to lower disease activity status, while heterogeneity exists within the pMDA group in terms of 5-year functionality and SAEs. Targeted studies to better characterize pMDA subgroups are needed, in order to assist clinicians in tailoring treatments.
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Nikiphorou E, Norton SJ, Carpenter L, Walsh DA, Creamer P, Dixey J, Young A, Kiely PDW. Remission vs low disease activity: function, quality of life and structural outcomes in the Early Rheumatoid Arthritis Study and Network. Rheumatology (Oxford) 2020; 59:1272-1280. [PMID: 31580448 PMCID: PMC7244786 DOI: 10.1093/rheumatology/kez461] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/26/2019] [Accepted: 09/07/2019] [Indexed: 01/29/2023] Open
Abstract
Objectives To examine associations between function, quality of life and structural outcomes in patients achieving remission vs low disease activity in early RA. Methods Demographic, clinical and radiographic variables were collected at baseline and then annually from the Early Rheumatoid Arthritis Study (ERAS) and Early Rheumatoid Arthritis Network (ERAN) inception cohorts in routine care from 1986 to 2012. Disease activity was categorized: mean DAS28 score between years 1 and 5: remission [mean remission DAS (mRDAS) <2.6] or low [mean low DAS (mLDAS) 2.6–3.2]; sustained low/remission DAS28 (sLDAS/sRDAS) at years 1 and 2; and sustained Boolean remission (sBR) at years 1 and 2. Changes in HAQ and Short Form 36 Health Survey Questionnaire [SF-36; physical (PCS) and mental (MCS) component score]) and total Sharp van der Heijde (SvdH) scores for each disease activity category were modelled using multi-level models. Covariates included year of onset, age, gender and DMARD use at first visit. Results Of 2701 patients, 562 (21%) were categorized mRDAS, 330 (12%) mLDAS, 279 (10%) sRDAS, 203 (7.5%) sLDAS and 93 (3%) sBR. Patients categorized as mRDAS had increasingly divergent improved HAQ, SF-36 PCS, MCS and total SvdH scores compared with mLDAS (P-values 0.001 to <0.0001, all time points). Patients categorized as sRDAS had better HAQ, SF-36 PCS and MCS scores (P-values 0.05 to <0.0001, all time points) and SvdH scores (P = 0.05, years 3–5) over sLDAS. sBR was associated with better HAQ, and SF-36 PCS and MCS scores over sLDAS (P-values 0.002 to <0.0001, all time points). Conclusion These findings from routine care support ACR/EULAR guidelines that remission is a preferable goal over low disease activity in early RA.
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Affiliation(s)
- Elena Nikiphorou
- Department of Inflammation Biology, King's College London, London
| | - Sam J Norton
- Department of Inflammation Biology, King's College London, London
| | - Lewis Carpenter
- Department of Inflammation Biology, King's College London, London
| | - David A Walsh
- Academic Rheumatology, The University of Nottingham, Nottingham
| | | | - Josh Dixey
- Rheumatology, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shrewsbury
| | - Adam Young
- Center for Health Services and Clinical Research and Post Graduate Medicine, University of Hertfordshire, Hatfield
| | - Patrick D W Kiely
- Rheumatology, St George's University Hospitals NHS Foundation Trust, London.,Institute of Medical and Biomedical Education, St George's University of London, London, UK
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11
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Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, Dougados M, Kerschbaumer A, McInnes IB, Sepriano A, van Vollenhoven RF, de Wit M, Aletaha D, Aringer M, Askling J, Balsa A, Boers M, den Broeder AA, Buch MH, Buttgereit F, Caporali R, Cardiel MH, De Cock D, Codreanu C, Cutolo M, Edwards CJ, van Eijk-Hustings Y, Emery P, Finckh A, Gossec L, Gottenberg JE, Hetland ML, Huizinga TWJ, Koloumas M, Li Z, Mariette X, Müller-Ladner U, Mysler EF, da Silva JAP, Poór G, Pope JE, Rubbert-Roth A, Ruyssen-Witrand A, Saag KG, Strangfeld A, Takeuchi T, Voshaar M, Westhovens R, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020; 79:685-699. [PMID: 31969328 DOI: 10.1136/annrheumdis-2019-216655] [Citation(s) in RCA: 1617] [Impact Index Per Article: 404.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations to account for the most recent developments in the field. METHODS An international task force considered new evidence supporting or contradicting previous recommendations and novel therapies and strategic insights based on two systematic literature searches on efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) since the last update (2016) until 2019. A predefined voting process was applied, current levels of evidence and strengths of recommendation were assigned and participants ultimately voted independently on their level of agreement with each of the items. RESULTS The task force agreed on 5 overarching principles and 12 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, sarilumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (the Janus kinase (JAK) inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering on sustained clinical remission is provided. Cost and sequencing of b/tsDMARDs are addressed. Initially, MTX plus GCs and upon insufficient response to this therapy within 3 to 6 months, stratification according to risk factors is recommended. With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAK inhibitor should be added to the csDMARD. If this fails, any other bDMARD (from another or the same class) or tsDMARD is recommended. On sustained remission, DMARDs may be tapered, but not be stopped. Levels of evidence and levels of agreement were mostly high. CONCLUSIONS These updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Robert B M Landewé
- Amsterdam University Medical Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Maxime Dougados
- Rhumatologie B, Hopital Cochin, 27 rue du Fbg Saint-Jacques, Paris, France
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alexandre Sepriano
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal, and Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Maarten de Wit
- EULAR Patient Research Partner; Department Medical Humanities, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - John Askling
- Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Alejandro Balsa
- Servicio de Reumatologia Hospital Universitario La Paz, Instituto de Investigacion IdiPAZ, Madrid, Spain
| | - Maarten Boers
- Department of Epidemiology and Biostatistics and Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Maya H Buch
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, and IRCCS S Matteo Foundation, Pavia, Italy
| | | | - Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Maurizio Cutolo
- Research Laboratory and Division of Clinical Rheumatology, Department of Internal Medicine - University of Genoa, Genoa, Italy
| | - Christopher John Edwards
- Musculoskeletal Research Unit, NIHR Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Yvonne van Eijk-Hustings
- Department of Patient & Care and Department of Rheumatology, University of Maastricht, Maastricht, The Netherlands
| | - Paul Emery
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Axel Finckh
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Laure Gossec
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris and Pitié Salpêtrière hospital, AP-HP, Rheumatology Department, Paris, France
| | - Jacques-Eric Gottenberg
- Strasbourg University Hospital and University of Strasbourg, CNRS, Institut de Biologie Moléculaire et Cellulaire, Immunopathologie, et Chimie Thérapeutique, Strasbourg, France
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marios Koloumas
- European League Against Rheumatism, Zurich, Switzerland.,Cyprus League against Rheumatism, Nikosia, Cyprus
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Xavier Mariette
- Université Paris-Sud, AP-HP, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus-Liebig University Giessen, Bad Nauheim, Germany
| | | | - Jose A P da Silva
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra Praceta Mota Pinto, and Coimbra Institute for Clinical and Biomedical Research (i-CRB), Faculty of Medicine of Coimbra, Coimbra, Portugal
| | - Gyula Poór
- National Institute of Rheumatology & Physiology, Semmelweis University, Budapest, Hungary
| | - Janet E Pope
- University of Western Ontario, Schulich School of Medicine & Dentistry, Department of Medicine, London, Ontario, Canada
| | | | | | - Kenneth G Saag
- Department of Medicine, Division of Rheumatology, University of Alabama at Birmingham, Brmingham, Alabama, USA
| | - Anja Strangfeld
- Programme Area Epidemiology, Deutsches Rheumaforschungszentrum Berlin, Berlin, Germany
| | - Tsutomu Takeuchi
- Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven; Rheumatology, University Hospitals Leuven, Leuven, Belgium
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Park EJ, Kim H, Jung SM, Sung YK, Baek HJ, Lee J. The Use of Biological Disease-modifying Antirheumatic Drugs for Inflammatory Arthritis in Korea: Results of a Korean Expert Consensus. JOURNAL OF RHEUMATIC DISEASES 2020. [DOI: 10.4078/jrd.2020.27.1.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Eun-Jung Park
- Division of Rheumatology, Department of Medicine, National Medical Center, Seoul, Korea
| | - Hyungjin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gachon University College of Medicine Gil Medical Center, Incheon, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
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13
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Park EJ, Kim H, Jung SM, Sung YK, Baek HJ, Lee J. The use of biological disease-modifying antirheumatic drugs for inflammatory arthritis in Korea: results of a Korean Expert Consensus. Korean J Intern Med 2020; 35:41-59. [PMID: 31935319 PMCID: PMC6960050 DOI: 10.3904/kjim.2019.411] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022] Open
Abstract
Biological disease-modifying antirheumatic drugs (bDMARDs) are highly effective agents for the treatment of inf lammatory arthritis; however, they also possess a potential risk for serious infection. Recently, with the rapid expansion of the bDMARDs market in Korea, reports of serious adverse events related to the agents have also increased, necessitating guidance for the use of bDMARDs. Current work entitled, "Expert consensus for the use of bDMARDs drugs for inflammatory arthritis in Korea," is the first to describe the appropriate use of bDMARDs in the management of inflammatory arthritis in Korea, with an aim to provide guidance for the local medical community to improve the quality of clinical care. Twelve consensus statements regarding the use of bDMARDs for the management of rheumatoid arthritis and ankylosing spondylitis were generated. In this review, we provide detailed guidance on bDMARDs use based on expert consensus, including who should prescribe, the role of education, indications for use, and monitoring strategies for safety.
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Affiliation(s)
- Eun-Jung Park
- Division of Rheumatology, Department of Medicine, National Medical Center, Seoul, Korea
| | - Hyungjin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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14
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Vanier A, Smolen JS, Allaart CF, Van Vollenhoven R, Verschueren P, Vastesaeger N, Saevarsdottir S, Visser K, Aletaha D, Combe B, Fautrel B. An updated matrix to predict rapid radiographic progression of early rheumatoid arthritis patients: pooled analyses from several databases. Rheumatology (Oxford) 2019; 59:1842-1852. [DOI: 10.1093/rheumatology/kez542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/19/2019] [Indexed: 01/23/2023] Open
Abstract
Abstract
Objective
In early RA, some patients exhibit rapid radiographic progression (RRP) after one year, associated with poor functional prognosis. Matrices predicting this risk have been proposed, lacking precision or inadequately calibrated. We developed a matrix to predict RRP with high precision and adequate calibration.
Methods
Post-hoc analysis by pooling individual data from cohorts (ESPOIR and Leuven cohorts) and clinical trials (ASPIRE, BeSt and SWEFOT trials). Adult DMARD-naïve patients with active early RA for which the first therapeutic strategy after inclusion was to prescribe methotrexate or leflunomide were included. A logistic regression model to predict RRP was built. The best model was selected by 10-fold stratified cross-validation by maximizing the Area Under the Curve. Calibration and discriminatory power of the model were checked. The probabilities of RRP for each combination of levels of baseline characteristics were estimated.
Results
1306 patients were pooled. 20.6% exhibited RRP. Four predictors were retained: rheumatoid factor positivity, presence of at least one RA erosion on X-rays, CRP > 30mg/l, number of swollen joints. The matrix estimates RRP probability for 36 combinations of level of baseline characteristics with a greatly enhanced precision compared with previously published matrices (95% CI: from ± 0.02 minimum to ± 0.08 maximum) and model calibration is excellent (P = 0.79).
Conclusion
A matrix proposing RRP probability with high precision and excellent calibration in early RA was built. Although the matrix has moderate sensitivity and specificity, it is easily usable and may help physicians and patients to make treatment decisions in daily clinical practice.
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Affiliation(s)
- Antoine Vanier
- Department of Biostatistics Public Health and Medical Informatics, Sorbonne University, APHP, University Hospitals Pitié-Salpêtrière Charles-Foix, Paris
- University Bretagne-Loire, University of Nantes, University of Tours, Inserm UMR U1246 SPHERE ‘Methods in patient-centered outcomes and health research’, Nantes
| | - Josef S Smolen
- Division of Rheumatology and Department of Medicine 3, University of Vienna, Vienna, Austria
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ronald Van Vollenhoven
- Rheumatology Unit, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Solna, Stockholm, Sweden
| | | | | | - Saedis Saevarsdottir
- Rheumatology Unit, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Karen Visser
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology and Department of Medicine 3, University of Vienna, Vienna, Austria
| | - Bernard Combe
- Department of Rheumatology, Montpellier 1 University, Montpellier University Hospital
| | - Bruno Fautrel
- Department of Rheumatology, Sorbonne University, GRC-08 (EEMOIS), APHP, University Hospitals Pitié-Salpêtrière Charles-Foix, Paris, France
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15
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Abstract
BACKGROUND Medication-based strategies to treat rheumatoid arthritis are crucial in terms of outcome. They aim at preventing joint destruction, loss of function and disability by early and consistent inhibition of inflammatory processes. OBJECTIVE Achieving consensus about evidence-based recommendations for the treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs in Germany. METHODS Following a systematic literature research, a structured process among expert rheumatologists was used to reach consensus. RESULTS The results of the consensus process can be summed up in 6 overarching principles and 10 recommendations. There are several new issues compared to the version of 2012, such as differentiated adjustments to the therapeutic regime according to time point and extent of treatment response, the therapeutic goal of achieving remission as assessed by means of the simplified disease activity index (SDAI) as well as the potential use of targeted synthetic DMARDs (JAK inhibitors) and suggestions for a deescalating in case of achieving a sustained remission. Methotrexate still plays the central role at the beginning of the treatment and as a combination partner in the further treatment course. When treatment response to methotrexate is inadequate, either switching to or combining with another conventional synthetic DMARD is an option in the absence of unfavourable prognostic factors. Otherwise biologic or targeted synthetic DMARDs are recommended according to the algorithm. Rules for deescalating treatment with glucocorticoids and-where applicable-DMARDs give support for the management of patients who have reached a sustained remission. DISCUSSION The new guidelines set up recommendations for RA treatment in accordance with the treat-to-target principle. Modern disease-modifying drugs, now including also JAK inhibitors, are available in an algorithm.
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16
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Aletaha D, Maa JF, Chen S, Park SH, Nicholls D, Florentinus S, Furtner D, Smolen JS. Effect of disease duration and prior disease-modifying antirheumatic drug use on treatment outcomes in patients with rheumatoid arthritis. Ann Rheum Dis 2019; 78:1609-1615. [PMID: 31434637 PMCID: PMC6900248 DOI: 10.1136/annrheumdis-2018-214918] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 07/01/2019] [Accepted: 07/25/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To determine if disease duration and number of prior disease-modifying antirheumatic drugs (DMARDs) affect response to therapy in patients with established rheumatoid arthritis (RA). METHODS Associations between disease duration or number of prior DMARDs and response to therapy were assessed using data from two randomised controlled trials in patients with established RA (mean duration, 11 years) receiving adalimumab+methotrexate. Response to therapy was assessed at week 24 using disease activity outcomes, including 28-joint Disease Activity Score based on C-reactive protein (DAS28(CRP)), Simplified Disease Activity Index (SDAI) and Health Assessment Questionnaire Disability Index (HAQ-DI), and proportions of patients with 20%/50%/70% improvement in American College of Rheumatology (ACR) responses. RESULTS In the larger study (N=207), a greater number of prior DMARDs (>2 vs 0-1) was associated with smaller improvements in DAS28(CRP) (-1.8 vs -2.2), SDAI (-22.1 vs -26.9) and HAQ-DI (-0.43 vs -0.64) from baseline to week 24. RA duration of >10 years versus <1 year was associated with higher HAQ-DI scores (1.1 vs 0.7) at week 24, but results on DAS28(CRP) and SDAI were mixed. A greater number of prior DMARDs and longer RA duration were associated with lower ACR response rates at week 24. Data from the second trial (N=67) generally confirmed these findings. CONCLUSIONS Number of prior DMARDs and disease duration affect responses to therapy in patients with established RA. Furthermore, number of prior DMARDs, regardless of disease duration, has a limiting effect on the potential response to adalimumab therapy.
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Affiliation(s)
- Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Jen-Fue Maa
- Data and Statistical Sciences, AbbVie Inc, North Chicago, Illinois, USA
| | - Su Chen
- Data and Statistical Sciences, AbbVie Inc, North Chicago, Illinois, USA
| | - Sung-Hwan Park
- Department of Internal Medicine, Division of Rheumatology, Seoul St. Mary's Hospital of The Catholic University of Korea, Seoul, Republic of Korea
| | - Dave Nicholls
- Clinical Trials Centre, University of the Sunshine Coast, Maroochydore, Queensland, Australia
| | | | - Daniel Furtner
- Global Medical Affairs, AbbVie, Mascot, New South Wales, Australia
| | - Josef S Smolen
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
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17
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Aletaha D, Smolen JS. Does Triple Conventional Synthetic Disease-Modifying Antirheumatic Drug Therapy Improve upon Methotrexate as the Initial Treatment of Choice for a Rheumatoid Arthritis Patient? Rheum Dis Clin North Am 2019; 45:315-324. [PMID: 31277746 DOI: 10.1016/j.rdc.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although many treatment options exist for the initial management of rheumatoid arthritis, there has long been discussion about whether initial treatment should be with methotrexate (MTX) as monotherapy or in combination with other conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Although studies initially showed additional benefit from combining MTX with other csDMARDs, this benefit disappears when glucocorticoids are added to MTX, a strategy recommended in current guidelines as a short-term bridging approach until MTX therapy exhibits its full efficacy. Also concomitant use of glucocorticoids, with MTX may not be inferior to combination therapy of MTX with TNF-inhibitors.
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Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine 3, Medical University Vienna, Spitalgasse 23, 1090 Vienna, Austria.
| | - Josef S Smolen
- Division of Rheumatology, Department of Internal Medicine 3, Medical University Vienna, Spitalgasse 23, 1090 Vienna, Austria
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18
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Not all moderate disease is the same - Identification of disability trajectories among patients with rheumatoid arthritis and moderate disease activity. PLoS One 2019; 14:e0215999. [PMID: 31107887 PMCID: PMC6527224 DOI: 10.1371/journal.pone.0215999] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/11/2019] [Indexed: 01/08/2023] Open
Abstract
Background United Kingdom guidelines for the use of biologic disease modifying anti-rheumatic drugs (bDMARDS) for rheumatoid arthritis (RA) require patients to have active disease (Disease Activity Score [DAS28] >5.1) and have failed ≥2 previous conventional synthetic DMARDs (csDMARD). Patients with moderate disease activity (MDA) do not meet these criteria, yet often have poor outcomes. This study aimed to identify trajectory groups of disability scores over three years in RA patients with MDA. Methods The study included biologic-naïve patients receiving csDMARDs only with MDA (3.2 <DAS28≤ 5.1) when recruited to the control cohort of the British Society for Rheumatology Biologics Register–RA (BSRBR-RA). Disability scores, measured using the Health Assessment Questionnaire (HAQ), were recorded every six months for three years. Trajectories of HAQ scores over follow-up were assessed using latent class growth models (LCGMs). Baseline age, gender, DAS28, symptom duration, rheumatoid factor status, number of prior csDMARDs and co-morbidities were assessed as potential predictors of group membership. Results In total, 1274 patients were included (mean age: 61 years (standard deviation: 12), 71.4% women). The best fitting model included seven HAQ trajectories. These trajectories were horizontal over follow-up and were related to baseline HAQ: very-low (6.8%, baseline (BL) HAQ: 0.22), low (11.5%, BL HAQ: 0.41), low-moderate (17.0%, BL HAQ: 0.93), moderate (13.4%, BL HAQ: 1.09), high-moderate (19.5%, BL HAQ: 1.61), severe (23.2%, BL HAQ: 1.98) and very-severe (8.6%, BL HAQ: 2.54). Higher DAS28, older age, female gender, longer disease duration and more co-morbidities were independently associated with higher HAQ trajectory group. Conclusion There is substantial heterogeneity in baseline HAQ scores in this population, and the trajectories of HAQ scores after baseline are, on average, relatively flat. As bDMARD therapy has been shown to improve HAQ scores, patients with MDA but high HAQ scores may benefit from a more aggressive approach to therapy.
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19
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Daien C, Hua C, Gaujoux-Viala C, Cantagrel A, Dubremetz M, Dougados M, Fautrel B, Mariette X, Nayral N, Richez C, Saraux A, Thibaud G, Wendling D, Gossec L, Combe B. Update of French society for rheumatology recommendations for managing rheumatoid arthritis. Joint Bone Spine 2019; 86:135-150. [DOI: 10.1016/j.jbspin.2018.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
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20
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Edwards CJ, Kiely P, Arthanari S, Kiri S, Mount J, Barry J, Mitchell CR, Field P, Conaghan PG. Predicting disease progression and poor outcomes in patients with moderately active rheumatoid arthritis: a systematic review. Rheumatol Adv Pract 2019; 3:rkz002. [PMID: 31431990 PMCID: PMC6649936 DOI: 10.1093/rap/rkz002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/18/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Access to biologic DMARDs for RA is often restricted to those with severe disease. This systematic review aimed to identify prognostic factors in patients with moderate disease activity who may be at risk of disease progression and poor clinical outcomes. METHODS MEDLINE, Embase and Cochrane databases were searched (final search 22 September 2017), and data from patients with moderate disease [28-joint DAS (DAS28) >3.2-≤5.1] were included. Studies were evaluated according to the measure(s) of progression/poor outcome used: radiographic, disease activity or other indicators. RESULTS The searches identified 274 publications, of which 30 were selected for data extraction. Fourteen studies were prioritized, because they specifically analysed patients with moderate RA. Nine studies reported radiographic progression outcomes for 3241 patients, three studies reported disease activity progression for 1516 patients, and two studies reported other relevant outcomes for 2094 patients. Prognostic factors with consistent evidence for progression/poor outcome prediction were as follows: DAS28 ≥ 4.2, the presence of anti-CCP antibodies, and power Doppler ultrasound score ≥1. Some predictors were specific to either disease activity or radiographic progression. CONCLUSION Several criteria used in standard clinical practice were identified that have the potential to inform the selection of patients with moderate RA who are at greater risk of a poor outcome. A combination of two or more of these factors might enhance their predictive potential. Further work is required to derive clinical decision rules incorporating these factors.
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Affiliation(s)
- Christopher J Edwards
- NIHR Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton
| | - Patrick Kiely
- Rheumatology Department, St George’s University Hospital NHS Foundation Trust, London, UK
| | - Subhashini Arthanari
- SAMETA (South Asia, Middle East, Turkey and Africa), Eli Lilly (Singapore) Pte Ltd, Singapore
| | | | - Julie Mount
- Global Patient Outcomes and Real Word Evidence (GPORWE) International
| | - Jane Barry
- Medical Affairs, Eli Lilly and Company Ltd, Basingstoke
| | | | - Polly Field
- Value Demonstration Practice, Oxford PharmaGenesis Ltd, Oxford
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds, UK
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21
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McWilliams DF, Dawson O, Young A, Kiely PDW, Ferguson E, Walsh DA. Discrete Trajectories of Resolving and Persistent Pain in People With Rheumatoid Arthritis Despite Undergoing Treatment for Inflammation: Results From Three UK Cohorts. THE JOURNAL OF PAIN 2019; 20:716-727. [PMID: 30658176 DOI: 10.1016/j.jpain.2019.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022]
Abstract
Rheumatoid arthritis (RA) is an example of human chronic inflammatory pain. Modern treatments suppress inflammation, yet pain remains a major problem for many people with RA. We hypothesized that discrete RA subgroups might display favorable or unfavorable pain trajectories when receiving treatment, and that baseline characteristics will predict trajectory allocation. Growth mixture modelling was used to identify discrete trajectories of Short Form-36 bodily pain scores during 3 years in 3 RA cohorts (Early RA Network (n = 683), British Society for Rheumatology Biologics Register Biologics (n = 7,090) and nonbiologics (n = 1,720) cohorts. Logistic regression compared baseline predictor variables between trajectories. The role of inflammation was examined in a subgroup analysis of people with normal levels of inflammatory markers after 3 years. The mean Short Form-36 bodily pain scores in each cohort improved but remained throughout 3 years of follow-up of >1 standard deviation worse than the UK general population average. Discrete persistent pain (59-79% of cohort participants) and resolving pain (19-27%) trajectories were identified in each cohort. In Early RA Network, a third trajectory displaying persistently low pain (23%) was also identified. In people with normal levels of inflammatory markers after 3 years, 65% were found to follow a persistent pain trajectory. When trajectories were compared, greater disability (adjusted odds ratio = 2.3-2.5 per unit baseline Health Assessment Questionnaire score) and smoking history (adjusted odds ratio = 1.6-1.8) were risk factors for persistent pain trajectories in each cohort. In conclusion, distinct trajectories indicate patient subgroups with very different pain prognosis during treatment for RA. Inflammation does not fully explain the pain trajectories, and noninflammatory factors as well as acute phase response predict which trajectory an individual will follow. Targeted treatments additional to those which suppress inflammation might reduce the long-term burden of arthritis pain. PERSPECTIVE: Immunosuppression decreases inflammation in RA, but pain outcomes are less favorable. Discrete persistent and resolving pain trajectories were identified after treatment, both in early and established RA. Smoking and greater disability at baseline predicted persistent pain. Identifying patient subgroups with a poor pain prognosis could enable adjunctive treatment to improve outcomes.
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Affiliation(s)
- Daniel F McWilliams
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; Division of ROD, University of Nottingham, Nottingham, UK.
| | - Olivia Dawson
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; Division of ROD, University of Nottingham, Nottingham, UK
| | - Adam Young
- Centre for Health Services & Clinical Research (CHSCR) & Postgraduate Medicine, University of Herts, Hatfield, UK
| | - Patrick D W Kiely
- Department of Rheumatology, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Eamonn Ferguson
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; School of Psychology, University of Nottingham, Nottingham, UK
| | - David A Walsh
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; Division of ROD, University of Nottingham, Nottingham, UK; Department of Rheumatology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton in Ashfield, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
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Abstract
IMPORTANCE Rheumatoid arthritis (RA) occurs in about 5 per 1000 people and can lead to severe joint damage and disability. Significant progress has been made over the past 2 decades regarding understanding of disease pathophysiology, optimal outcome measures, and effective treatment strategies, including the recognition of the importance of diagnosing and treating RA early. OBSERVATIONS Early diagnosis and treatment of RA can avert or substantially slow progression of joint damage in up to 90% of patients, thereby preventing irreversible disability. The development of novel instruments to measure disease activity and identify the presence or absence of remission have facilitated new treatment strategies to arrest RA before joints are damaged irreversibly. Outcomes have been improved by recognizing the benefits of early diagnosis and early therapy with disease-modifying antirheumatic drugs (DMARDs). The treatment target is remission or a state of at least low disease activity, which should be attained within 6 months. Methotrexate is first-line therapy and should be prescribed at an optimal dose of 25 mg weekly and in combination with glucocorticoids; 40% to 50% of patients reach remission or at least low disease activity with this regimen. If this treatment fails, sequential application of targeted therapies, such as biologic agents (eg, tumor necrosis factor [TNF] inhibitors) or Janus kinase inhibitors in combination with methotrexate, have allowed up to 75% of these patients to reach the treatment target over time. New therapies have been developed in response to new pathogenetic findings. The costs of some therapies are considerable, but these costs are decreasing with the advent of biosimilar drugs (drugs essentially identical to the original biologic drugs but usually available at lower cost). CONCLUSIONS AND RELEVANCE Scientific advances have improved therapies that prevent progression of irreversible joint damage in up to 90% of patients with RA. Early treatment with methotrexate plus glucocorticoids and subsequently with other DMARDs, such as inhibitors of TNF, IL-6, or Janus kinases, improves outcomes and prevents RA-related disability. A treat-to-target strategy aimed at reducing disease activity by at least 50% within 3 months and achieving remission or low disease activity within 6 months, with sequential drug treatment if needed, can prevent RA-related disability.
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Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
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McWilliams DF, Kiely PDW, Young A, Joharatnam N, Wilson D, Walsh DA. Interpretation of DAS28 and its components in the assessment of inflammatory and non-inflammatory aspects of rheumatoid arthritis. BMC Rheumatol 2018; 2:8. [PMID: 30886959 PMCID: PMC6390559 DOI: 10.1186/s41927-018-0016-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/07/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Daniel F McWilliams
- 1Arthritis Research UK Pain Centre, NIHR Nottingham Biomedical Research Centre & Division of Rheumatology Orthopaedics and Dermatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK
| | - Patrick D W Kiely
- 2Department of Rheumatology, St Georges Healthcare NHS Trust, London, UK
| | - Adam Young
- University of West Hertfordshire, Watford, UK
| | - Nalinie Joharatnam
- 1Arthritis Research UK Pain Centre, NIHR Nottingham Biomedical Research Centre & Division of Rheumatology Orthopaedics and Dermatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK
| | - Deborah Wilson
- 4Department of Rheumatology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - David A Walsh
- 1Arthritis Research UK Pain Centre, NIHR Nottingham Biomedical Research Centre & Division of Rheumatology Orthopaedics and Dermatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,4Department of Rheumatology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
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Anno S, Sugioka Y, Inui K, Tada M, Okano T, Mamoto K, Koike T. Evaluation of work disability in Japanese patients with rheumatoid arthritis: from the TOMORROW study. Clin Rheumatol 2018. [PMID: 29525846 DOI: 10.1007/s10067-018-4060-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To evaluate work disability and associated factors in patients with rheumatoid arthritis (RA) who participated in the TOMORROW study, a 10-year cohort study in Japan. Subjects in this cross-sectional analysis comprised 191 RA patients and 191 age- and sex-matched non-RA individuals. Work-related outcomes were measured using the Work Productivity and Activity Impairment questionnaire by employment status (full-time worker (FTW), employed ≥ 35 h/week; part-time worker (PTW), < 35 h/week; home worker (HW), non-employed). In addition, we assessed the EuroQol-5 Dimensions (EQ-5D) and Health Assessment Questionnaire (HAQ) to evaluate quality of life and activities of daily living. No significant differences were evident between groups in percentages of participants in each employment status (p = 0.11), percentages of absenteeism (FTW, p = 1.00; PTW, p = 0.29), presenteeism (FTW, p = 0.23; PTW, p = 0.54), overall work impairment (FTW, p = 0.23; PTW, p = 0.73), or percentage of activity impairment (AI) (FTW, p = 0.62; PTW, p = 0.60). In the HW group, percentage of AI was higher in RA patients than that in non-RA patients (p < 0.01). Among RA patients, HW showed lower EQ-5D and higher HAQ than FTW or PTW (p < 0.001 each). Higher disease activity was observed in HW than FTW (p < 0.01). In terms of the effect of biological disease-modifying anti-rheumatic drugs, no significant differences in work-related outcomes, health status, or daily activity were evident between users and non-users. No significant differences in employment status or work impairment were seen between RA and non-RA groups among paid workers. HW with RA showed more impaired daily activity and higher disease activity compared to working RA patients. TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trials Registry: UMIN000003876 . Registered 1 Jun 2010.
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Affiliation(s)
- Shohei Anno
- Department of Orthopaedic Surgery, Shirahama Hamayu Hospital, 1447 Shirahamacho, Nishimurogun, Wakayama, 649-2211, Japan
- Search Institute for Bone and Arthritis Disease (SINBAD), Shirahama Foundation for Health and Welfare, 1447 Shirahamacho, Nishimurogun, Wakayama, 649-2211, Japan
| | - Yuko Sugioka
- Center for Senile Degenerative Disorders (CSDD), Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kentaro Inui
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masahiro Tada
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tadashi Okano
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kenji Mamoto
- Department of Orthopaedic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tatsuya Koike
- Department of Orthopaedic Surgery, Shirahama Hamayu Hospital, 1447 Shirahamacho, Nishimurogun, Wakayama, 649-2211, Japan.
- Search Institute for Bone and Arthritis Disease (SINBAD), Shirahama Foundation for Health and Welfare, 1447 Shirahamacho, Nishimurogun, Wakayama, 649-2211, Japan.
- Center for Senile Degenerative Disorders (CSDD), Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
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Smolen JS, Aletaha D, Barton A, Burmester GR, Emery P, Firestein GS, Kavanaugh A, McInnes IB, Solomon DH, Strand V, Yamamoto K. Rheumatoid arthritis. Nat Rev Dis Primers 2018; 4:18001. [PMID: 29417936 DOI: 10.1038/nrdp.2018.1] [Citation(s) in RCA: 1330] [Impact Index Per Article: 221.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic, inflammatory, autoimmune disease that primarily affects the joints and is associated with autoantibodies that target various molecules including modified self-epitopes. The identification of novel autoantibodies has improved diagnostic accuracy, and newly developed classification criteria facilitate the recognition and study of the disease early in its course. New clinical assessment tools are able to better characterize disease activity states, which are correlated with progression of damage and disability, and permit improved follow-up. In addition, better understanding of the pathogenesis of RA through recognition of key cells and cytokines has led to the development of targeted disease-modifying antirheumatic drugs. Altogether, the improved understanding of the pathogenetic processes involved, rational use of established drugs and development of new drugs and reliable assessment tools have drastically altered the lives of individuals with RA over the past 2 decades. Current strategies strive for early referral, early diagnosis and early start of effective therapy aimed at remission or, at the least, low disease activity, with rapid adaptation of treatment if this target is not reached. This treat-to-target approach prevents progression of joint damage and optimizes physical functioning, work and social participation. In this Primer, we discuss the epidemiology, pathophysiology, diagnosis and management of RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Anne Barton
- Arthritis Research UK Centre for Genetics and Genomics and NIHR Manchester Biomedical Research Centre, Manchester Academic Health Sciences Centre, The University of Manchester and Central Manchester Foundation Trust, Manchester, UK
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gary S Firestein
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego School of Medicine, La Jolla, CA, USA
| | - Arthur Kavanaugh
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego School of Medicine, La Jolla, CA, USA
| | - Iain B McInnes
- Institute of Infection Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Daniel H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Vibeke Strand
- Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA
| | - Kazuhiko Yamamoto
- Laboratory for Autoimmune Diseases, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
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26
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Martin NH, Ibrahim F, Tom B, Galloway J, Wailoo A, Tosh J, Lempp H, Prothero L, Georgopoulou S, Sturt J, Scott DL. Does intensive management improve remission rates in patients with intermediate rheumatoid arthritis? (the TITRATE trial): study protocol for a randomised controlled trial. Trials 2017; 18:591. [PMID: 29221496 PMCID: PMC5723045 DOI: 10.1186/s13063-017-2330-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 11/16/2017] [Indexed: 01/26/2023] Open
Abstract
Background Uncontrolled active rheumatoid arthritis can lead to increasing disability and reduced quality of life over time. ‘Treating to target’ has been shown to be effective in active established disease and also in early disease. However, there is a lack of nationally agreed treatment protocols for patients with established rheumatoid arthritis who have intermediate disease activity. This trial is designed to investigate whether intensive management of disease leads to a greater number of remissions at 12 months. Levels of disability and quality of life, and acceptability and cost-effectiveness of the intervention will also be examined. Methods The trial is a 12-month, pragmatic, randomised, open-label, two-arm, parallel-group, multicentre trial undertaken at specialist rheumatology centres across England. Three hundred and ninety-eight patients with established rheumatoid arthritis will be recruited. They will currently have intermediate disease activity (disease activity score for 28 joints assessed using an erythrocyte sedimentation rate of 3.2 to 5.1 with at least three active joints) and will be taking at least one disease-modifying anti-rheumatic drug. Participants will be randomly selected to receive intensive management or standard care. Intensive management will involve monthly clinical reviews with a specialist health practitioner, where drug treatment will be optimised and an individualised treatment support programme delivered based on several principles of motivational interviewing to address identified problem areas, such as pain, fatigue and adherence. Standard care will follow standard local pathways and will be in line with current English guidelines from the National Institute for Health and Clinical Excellence. Patients will be assessed initially and at 6 and 12 months through self-completed questionnaires and clinical evaluation. Discussion The trial will establish whether the known benefits of intensive treatment strategies in active rheumatoid arthritis are also seen in patients with established rheumatoid arthritis who have moderately active disease. It will evaluate both the clinical and cost-effectiveness of intensive treatment. Trial registration Current Controlled Trials, ID: ISRCTN70160382. Registered on 16 January 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2330-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Naomi H Martin
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK.
| | - Fowzia Ibrahim
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Brian Tom
- MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
| | - James Galloway
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Allan Wailoo
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Jonathan Tosh
- DRG Abacus, Manchester One, 53 Portland Street, Manchester, M1 3LF, UK
| | - Heidi Lempp
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Louise Prothero
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Sofia Georgopoulou
- Department of Physiotherapy, King's College London, 5th Floor, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - David L Scott
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
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27
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Smolen JS, Landewé RBM, van der Heijde D. Response to: '2016 update of the EULAR recommendations for the management of rheumatoid arthritis: no utopia for patients in low/middle-income countries?' by Misra et al. Ann Rheum Dis 2017; 76:e48. [PMID: 28478402 DOI: 10.1136/annrheumdis-2017-211455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 03/30/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Désirée van der Heijde
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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28
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Chaigne B, Finckh A, Alpizar-Rodriguez D, Courvoisier D, Ribi C, Chizzolini C. Differential impact of systemic lupus erythematosus and rheumatoid arthritis on health-related quality of life. Qual Life Res 2017; 26:1767-1775. [DOI: 10.1007/s11136-017-1534-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 01/24/2023]
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29
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Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, Nam J, Ramiro S, Voshaar M, van Vollenhoven R, Aletaha D, Aringer M, Boers M, Buckley CD, Buttgereit F, Bykerk V, Cardiel M, Combe B, Cutolo M, van Eijk-Hustings Y, Emery P, Finckh A, Gabay C, Gomez-Reino J, Gossec L, Gottenberg JE, Hazes JMW, Huizinga T, Jani M, Karateev D, Kouloumas M, Kvien T, Li Z, Mariette X, McInnes I, Mysler E, Nash P, Pavelka K, Poór G, Richez C, van Riel P, Rubbert-Roth A, Saag K, da Silva J, Stamm T, Takeuchi T, Westhovens R, de Wit M, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017; 76:960-977. [PMID: 28264816 DOI: 10.1136/annrheumdis-2016-210715] [Citation(s) in RCA: 1747] [Impact Index Per Article: 249.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 01/05/2017] [Accepted: 02/09/2017] [Indexed: 02/07/2023]
Abstract
Recent insights in rheumatoid arthritis (RA) necessitated updating the European League Against Rheumatism (EULAR) RA management recommendations. A large international Task Force based decisions on evidence from 3 systematic literature reviews, developing 4 overarching principles and 12 recommendations (vs 3 and 14, respectively, in 2013). The recommendations address conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GC); biological (b) DMARDs (tumour necrosis factor (TNF)-inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (Janus kinase (Jak) inhibitors tofacitinib, baricitinib). Monotherapy, combination therapy, treatment strategies (treat-to-target) and the targets of sustained clinical remission (as defined by the American College of Rheumatology-(ACR)-EULAR Boolean or index criteria) or low disease activity are discussed. Cost aspects were taken into consideration. As first strategy, the Task Force recommends MTX (rapid escalation to 25 mg/week) plus short-term GC, aiming at >50% improvement within 3 and target attainment within 6 months. If this fails stratification is recommended. Without unfavourable prognostic markers, switching to-or adding-another csDMARDs (plus short-term GC) is suggested. In the presence of unfavourable prognostic markers (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), any bDMARD (current practice) or Jak-inhibitor should be added to the csDMARD. If this fails, any other bDMARD or tsDMARD is recommended. If a patient is in sustained remission, bDMARDs can be tapered. For each recommendation, levels of evidence and Task Force agreement are provided, both mostly very high. These recommendations intend informing rheumatologists, patients, national rheumatology societies, hospital officials, social security agencies and regulators about EULAR's most recent consensus on the management of RA, aimed at attaining best outcomes with current therapies.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.,2nd Department of Medicine, Hietzing Hospital, Vienna, Austria
| | - Robert Landewé
- Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Johannes Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | | | | | - Jackie Nam
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Ronald van Vollenhoven
- Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Martin Aringer
- Division of Rheumatology, Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Chris D Buckley
- Birmingham NIHR Wellcome Trust Clinical Research Facility, Rheumatology Research Group, Institute of Inflammation and Ageing (IIA), University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Vivian Bykerk
- Department of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA.,Rebecca McDonald Center for Arthritis & Autoimmune Disease, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mario Cardiel
- Centro de Investigación Clínica de Morelia SC, Michoacán, México
| | - Bernard Combe
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Maurizio Cutolo
- Research Laboratory and Division of Clinical Rheumatology, University of Genoa, Genoa, Italy
| | - Yvonne van Eijk-Hustings
- Department of Patient & Care and Department of Rheumatology, University of Maastricht, Maastricht, The Netherlands
| | - Paul Emery
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Axel Finckh
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Cem Gabay
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Juan Gomez-Reino
- Fundación Ramón Dominguez, Hospital Clinico Universitario, Santiago, Spain
| | - Laure Gossec
- Department of Rheumatology, Sorbonne Universités, Pitié Salpêtrière Hospital, Paris, France
| | - Jacques-Eric Gottenberg
- Institut de Biologie Moléculaire et Cellulaire, Immunopathologie, et Chimie Thérapeutique, Strasbourg University Hospital and University of Strasbourg, CNRS, Strasbourg, France
| | - Johanna M W Hazes
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tom Huizinga
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Meghna Jani
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Dmitry Karateev
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Marios Kouloumas
- European League Against Rheumatism, Zurich, Switzerland.,Cyprus League against Rheumatism, Nicosia, Cyprus
| | - Tore Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Xavier Mariette
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, INSERM U1184, Center for Immunology of viral Infections and Autoimmune Diseases (IMVA), Le Kremlin Bicêtre, France
| | - Iain McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | - Peter Nash
- Department of Medicine, University of Queensland, Queensland, Australia
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Gyula Poór
- National Institute of Rheumatology and Physiotherapy, Semmelweis University, Budapest, Hungary
| | - Christophe Richez
- Rheumatology Department, FHU ACRONIM, Pellegrin Hospital and UMR CNRS 5164, Bordeaux University, Bordeaux, France
| | - Piet van Riel
- Department of Rheumatology, Bernhoven, Uden, The Netherlands
| | | | - Kenneth Saag
- Division of Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jose da Silva
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra Praceta Mota Pinto, Coimbra, Portugal
| | - Tanja Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten de Wit
- Department Medical Humanities, VU Medical Centre, Amsterdam, The Netherlands
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McWilliams DF, Ferguson E, Young A, Kiely PDW, Walsh DA. Discordant inflammation and pain in early and established rheumatoid arthritis: Latent Class Analysis of Early Rheumatoid Arthritis Network and British Society for Rheumatology Biologics Register data. Arthritis Res Ther 2016; 18:295. [PMID: 27964757 PMCID: PMC5154167 DOI: 10.1186/s13075-016-1186-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/17/2016] [Indexed: 12/18/2022] Open
Abstract
Background Rheumatoid arthritis (RA) disease activity is often measured using the 28-joint Disease Activity Score (DAS28). We aimed to identify and independently verify subgroups of people with RA that may be discordant with respect to self-reported and objective disease state, with potentially different clinical needs. Methods Data were derived from three cohorts: (1) the Early Rheumatoid Arthritis Network (ERAN) and the British Society for Rheumatology Biologics Register (BSRBR), (2) those commencing tumour necrosis factor (TNF)-α inhibitors and (3) those using non-biologic drugs. In latent class analysis, we used variables related to pain, central pain mechanisms or inflammation (pain, vitality, mental health, erythrocyte sedimentation rate, swollen joint count, tender joint count, visual analogue scale of general health). Clinically relevant outcomes were examined. Results Five, four and four latent classes were found in the ERAN, BSRBR TNF inhibitor and non-biologic cohorts, respectively. The proportions of people assigned with >80% probability into latent classes were 76%, 58% and 72% in the ERAN, TNF inhibitor and non-biologic cohorts, respectively. The latent classes displayed either concordance between measures indicative of mild, moderate or severe disease activity; discordantly worse patient-reported measures despite less markedly elevated inflammation; or discordantly less severe patient-reported measures despite elevated inflammation. Latent classes with discordantly worse patient-reported measures represented 12%, 40% and 21% of the ERAN, TNF inhibitor and non-biologic cohorts, respectively; contained more females; and showed worse function. In those latent classes with worse scores at baseline, DAS28 and function improved over 1 year (p < 0.001 for all comparisons), and scores differed less at follow-up than at baseline. Conclusions Discordant latent classes can be identified in people with RA, and these findings are robust across three cohorts with varying disease duration and activity. These findings could be used to identify a sizeable subgroup of people with RA who might gain added benefit from pain management strategies. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1186-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel F McWilliams
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK. .,Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK.
| | - Eamonn Ferguson
- Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK.,School of Psychology, University of Nottingham, Nottingham, UK
| | - Adam Young
- West Hertfordshire Hospitals NHS Trust, St. Albans, UK
| | | | - David A Walsh
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK.,Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK
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31
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Dale J, Paterson C, Tierney A, Ralston SH, Reid DM, Basu N, Harvie J, McKay ND, Saunders S, Wilson H, Munro R, Richmond R, Baxter D, McMahon M, McLaren J, Kumar V, Siebert S, McInnes I, Porter D. The Scottish Early Rheumatoid Arthritis (SERA) Study: an inception cohort and biobank. BMC Musculoskelet Disord 2016; 17:461. [PMID: 27829394 PMCID: PMC5103386 DOI: 10.1186/s12891-016-1318-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022] Open
Abstract
Background The Scottish Early Rheumatoid Arthritis (SERA) study is an inception cohort of rheumatoid (RA) and undifferentiated arthritis (UA) patients that aims to provide a contemporary description of phenotype and outcome and facilitate discovery of phenotypic and prognostic biomarkers Methods Demographic and clinical outcome data are collected from newly diagnosed RA/UA patients every 6 months from around Scotland. Health service utilization data is acquired from Information Services Division, NHS National Services Scotland. Plain radiographs of hands and feet are collected at baseline and 12 months. Additional samples of whole blood, plasma, serum and filtered urine are collected at baseline, 6 and 12 months Results Results are available for 1073 patients; at baseline, 76 % were classified as RA and 24 % as UA. Median time from onset to first review was 163 days (IQR97-323). Methotrexate was first-line DMARD for 75 % patients. Disease activity, functional ability and health-related quality of life improved significantly between baseline and 24 months, however the proportion in any employment fell (51 to 38 %, p = 0.0005). 24 % patients reported symptoms of anxiety and/or depression at baseline. 35/391 (9 %) patients exhibited rapid radiographic progression after 12 months. The SERA Biobank has accrued 60,612 samples Conclusions In routine care, newly diagnosed RA/UA patients experience significant improvements in disease activity, functional ability and health-related quality of life but have high rates of psychiatric symptoms and declining employment rates. The co-existence of a multi-domain description of phenotype and a comprehensive biobank will facilitate multi-platform translational research to identify predictive markers of phenotype and prognosis Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1318-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James Dale
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK. .,Wishaw General Hospital, Wishaw, UK.
| | - Caron Paterson
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Ann Tierney
- Centre for Rheumatic Diseases, Glasgow Royal Infirmary, Glasgow, UK
| | - Stuart H Ralston
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - David M Reid
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Neil Basu
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | | | | | - Sarah Saunders
- Centre for Rheumatic Diseases, Glasgow Royal Infirmary, Glasgow, UK
| | | | | | | | | | | | | | | | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Iain McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Siebert S, Lyall DM, Mackay DF, Porter D, McInnes IB, Sattar N, Pell JP. Characteristics of rheumatoid arthritis and its association with major comorbid conditions: cross-sectional study of 502 649 UK Biobank participants. RMD Open 2016; 2:e000267. [PMID: 27403335 PMCID: PMC4932291 DOI: 10.1136/rmdopen-2016-000267] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/03/2016] [Accepted: 05/22/2016] [Indexed: 12/19/2022] Open
Abstract
Introduction To characterise the detailed phenotypic and comorbid characteristics of participants with rheumatoid arthritis (RA) in the large population-based UK Biobank, thereby enabling future longitudinal analyses. Methods We undertook a cross-sectional study using baseline data from the unique UK Biobank resource (n=502 649). RA was based on self-report, and type of medication was used as a proxy measure of valid diagnosis. Participants with and without RA were compared in terms of sociodemographic, lifestyle and other disease-related risk factors. Logistic regression models were used to determine whether participants with RA were more likely to report comorbid conditions, and whether this varied by RA severity. The models were adjusted for potential confounders and lifestyle risk factors. Results At baseline, 5657 (1.13%) eligible UK Biobank participants reported RA of whom 2849 (0.57%) had medically treated RA (median duration=10 years). Prevalence was significantly higher among female, South Asian and socioeconomically deprived participants. Participants with RA were significantly more likely to report diabetes (covariate-adjusted OR 1.18, 95% CI 1.06 to 1.32, p<0.01), hypertension (OR 1.19, 95% CI 1.21 to 1.27, p<0.001) and cardiovascular disease (OR 1.52, 95% CI 1.39 to 1.67, p<0.001). Conclusions UK Biobank provides extensive data concerning RA population-level comorbidity and risk factors. The frequency, distribution and characteristics of participants reporting RA in UK Biobank are largely consistent with other studies. It provides a unique opportunity to interrogate biomarkers, genetic data, detailed imaging and linkage to clinical records at the population level across primary and secondary care.
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Affiliation(s)
- Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow , Glasgow , UK
| | - Donald M Lyall
- Institute of Health & Wellbeing, University of Glasgow , Glasgow , UK
| | - Daniel F Mackay
- Institute of Health & Wellbeing, University of Glasgow , Glasgow , UK
| | - Duncan Porter
- Institute of Infection, Immunity and Inflammation, University of Glasgow , Glasgow , UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow , Glasgow , UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow , UK
| | - Jill P Pell
- Institute of Health & Wellbeing, University of Glasgow , Glasgow , UK
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Acar A, Guzel S, Sarifakioglu B, Guzel EC, Guzelant AY, Karadag C, Kiziler L. Calprotectin levels in patients with rheumatoid arthritis to assess and association with exercise treatment. Clin Rheumatol 2016; 35:2685-2692. [PMID: 27094943 DOI: 10.1007/s10067-016-3240-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/16/2016] [Accepted: 03/19/2016] [Indexed: 01/23/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic, inflammatory, and autoimmune disease that can cause permanent joint damage. In our study, we aim to analyze the change in calprotectin levels following the low-density exercise levels applied to the patients with RA. Twenty-eight patients with RA and 30 healthy controls were included in this study. To evaluate the activity of disease in RA, scores of disease activity that has increased (DAS-28) are figured. Calprotectin, nitric oxide (NO), white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and rheumatoid factor (RF) levels are tested as the laboratory evaluation. Calprotectin, NO, CRP, ESR, WBC, and RF levels were significantly higher in the patient group compared to the control group (p < 0.01, p < 0.001, p < 0.01, p < 0.01, p < 0.01, and p < 0.05, respectively). In correlation analysis applied to the patient group with RA, there has been determined a positive relation with calprotectin, and DAS-28, CRP, NO, RF, and WBC (p < 0.001, p < 0.05, p < 0.001, p < 0.05, and p < 0.05, respectively). In result of the low-density exercise treatment applied to patients with RA for 8 weeks, there has been determined a significant decrease in calprotectin, DAS-28, NO, CRP, ESR, and RF levels (p < 0.05, p < 0.001, p < 0.01, p < 0.05, p < 0.05, and p < 0.05, respectively). As a result, a significant relation is found between RA disease activity and calprotectin levels and other inflammatory parameters. At the same time, it shows that calprotectin which is a significant indicator of local inflammation can be used as a good identifier in following up exercise treatment.
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Affiliation(s)
- Ayse Acar
- Department of Medical Biochemistry, Faculty of Medicine, Namik Kemal University, Tekirdag, Turkey
| | - Savas Guzel
- Department of Medical Biochemistry, Faculty of Medicine, Namik Kemal University, Tekirdag, Turkey.
| | - Banu Sarifakioglu
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Namik Kemal University, Tekirdag, Turkey
| | - Eda Celik Guzel
- Department of Family Physician, Faculty of Medicine, Namik Kemal University, Tekirdag, Turkey
| | - Aliye Yildirim Guzelant
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Namik Kemal University, Tekirdag, Turkey
| | - Ceyda Karadag
- Department of Physical Medicine and Rehabilitation, Tekirdag Government Hospital, Tekirdag, Turkey
| | - Lebriz Kiziler
- Electrical and Computer Engineering, Independent Research Associated, Stuttgart, Germany
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34
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Nikiphorou E, Norton S, Young A, Carpenter L, Dixey J, Walsh DA, Kiely P. Association between rheumatoid arthritis disease activity, progression of functional limitation and long-term risk of orthopaedic surgery: combined analysis of two prospective cohorts supports EULAR treat to target DAS thresholds. Ann Rheum Dis 2016; 75:2080-2086. [PMID: 26979104 PMCID: PMC5136699 DOI: 10.1136/annrheumdis-2015-208669] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 02/18/2016] [Accepted: 02/21/2016] [Indexed: 11/17/2022]
Abstract
Objectives To examine the association between disease activity in early rheumatoid arthritis (RA), functional limitation and long-term orthopaedic episodes. Methods Health Assessment Questionnaire (HAQ) disability scores were collected from two longitudinal early RA inception cohorts in routine care; Early Rheumatoid Arthritis Study and Early Rheumatoid Arthritis Network from 1986 to 2012. The incidence of major and intermediate orthopaedic surgical episodes over 25 years was collected from national data sets. Disease activity was categorised by mean disease activity score (DAS28) annually between years 1 and 5; remission (RDAS≤2.6), low (LDAS>2.6–3.2), low-moderate (LMDAS≥3.2–4.19), high-moderate (HMDAS 4.2–5.1) and high (HDAS>5.1). Results Data from 2045 patients were analysed. Patients in RDAS showed no HAQ progression over 5 years, whereas there was a significant relationship between rising DAS28 category and HAQ at 1 year, and the rate of HAQ progression between years 1 and 5. During 27 986 person-years follow-up, 392 intermediate and 591 major surgeries were observed. Compared with the RDAS category, there was a significantly increased cumulative incidence of intermediate surgery in HDAS (OR 2.59 CI 1.49 to 4.52) and HMDAS (OR 1.8 CI 1.05 to 3.11) categories, and for major surgery in HDAS (OR 2.48 CI 1.5 to 4.11), HMDAS (OR 2.16 CI 1.32 to 3.52) and LMDAS (OR 2.07 CI 1.28 to 3.33) categories. There was no significant difference in HAQ progression or orthopaedic episodes between RDAS and LDAS categories. Conclusions There is an association between disease activity and both poor function and long-term orthopaedic episodes. This illustrates the far from benign consequences of persistent moderate disease activity, and supports European League Against Rheumatism treat to target recommendations to secure low disease activity or remission in all patients.
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Affiliation(s)
- Elena Nikiphorou
- Department of Rheumatology, Whittington Hospital NHS Trust, London, UK.,Early Rheumatoid Arthritis Study, Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Sam Norton
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Division of Health & Social Care Research, Faculty of Life and Medical Science, King's College London, London, UK
| | - Adam Young
- Early Rheumatoid Arthritis Study, Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Lewis Carpenter
- Centre for Lifespan & Chronic Illness Research, University of Hertfordshire, Hatfield, UK
| | - Josh Dixey
- Department of Rheumatology, New Cross Hospital, Wolverhampton, UK
| | | | - Patrick Kiely
- Department of Rheumatology, St Georges University Hospitals NHS Foundation Trust, London, UK
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35
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Buchbinder R, Maher C, Harris IA. Setting the research agenda for improving health care in musculoskeletal disorders. Nat Rev Rheumatol 2015; 11:597-605. [DOI: 10.1038/nrrheum.2015.81] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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36
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Atzeni F, Masala IF, Salaffi F, Di Franco M, Casale R, Sarzi-Puttini P. Pain in systemic inflammatory rheumatic diseases. Best Pract Res Clin Rheumatol 2015; 29:42-52. [PMID: 26266998 DOI: 10.1016/j.berh.2015.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The sometimes intense, persistent and disabling pain associated with rheumatoid arthritis (RA) and spondyloarthritis frequently has a multifactorial, simultaneously central and peripheral origin, and it may be due to currently active inflammation or joint damage and tissue destruction caused by a previous inflammatory condition. The symptoms of inflammatory pain symptoms can be partially relieved by non-steroidal anti-inflammatory drugs, but many patients continue to experience moderate pain due to alterations in central pain regulation mechanisms, as in the case of the chronic widespread pain (CWP) characterising fibromyalgia. The importance of distinguishing CWP from inflammatory pain is underlined by the fact that drugs such as tumour necrosis factor inhibitors are expensive, and direct costs are higher in patients with concomitant CWP than in those without. The management of pain requires a combination approach that includes pharmacological analgesia, and biological and non-biological treatments because, although joint replacement surgery can significantly improve RA-related pain, it may only be available to patients with the most severe advanced disease.
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Affiliation(s)
| | | | - Fausto Salaffi
- Chair of Rheumatology, Università Politecnica delle Marche, Italy
| | | | - Roberto Casale
- Department of Clinical Neurophysiology and Pain Rehabilitation Unit (RC), Foundation Salvatore Maugeri IRCCS, Montescano, Italy
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A maximum difference scaling survey of barriers to intensive combination treatment strategies with glucocorticoids in early rheumatoid arthritis. Clin Rheumatol 2015; 34:861-9. [PMID: 25711874 DOI: 10.1007/s10067-015-2876-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/26/2014] [Accepted: 01/13/2015] [Indexed: 10/23/2022]
Abstract
The objectives of the study were to determine the relative importance of barriers related to the provision of intensive combination treatment strategies with glucocorticoids (ICTS-GCs) in early rheumatoid arthritis (ERA) from the rheumatologists' perspective and to explore the relation between rheumatologists' characteristics and importance scores. A maximum difference scaling (MDS) survey was administered to 66 rheumatologists in Flanders and the Brussels-Capital Region. The survey included 25 barriers, previously being discovered in a qualitative study. The survey included 25 choice sets, each of which contained a different set of four barriers. In each choice situation, respondents were asked to choose the most important barrier. The mean relative importance score (RIS) for each barrier was calculated using hierarchical Bayes modeling. The potential relation between rheumatologists' characteristics and the RIS was examined using Spearman's correlation coefficient, Mann-Whitney U test, and Kruskal-Wallis H test. The three highest ranked barriers included "contraindicated for some patients (e.g., patients with comorbidities, older patients)," "an increased risk of side effects and related complications," and "patients' resistance" with a mean ± SD RIS of 9.76 ± 0.82, 8.50 ± 1.17, and 7.45 ± 1.22, respectively. Comparing the RISs based on rheumatologists' characteristics, a different ranking was found for three barriers depending on the age, university location, and/or frequency of prescribing ICTS-GCs. The dominant barriers hindering ICTS-GCs prescription from a rheumatologists' perspective are patient-related barriers and barriers related to the complexity of prescribing a combination therapy including GCs. A tailored improvement intervention is needed to overcome these barriers and should focus on the familiarity of rheumatologists with ICTS-GC and patient education.
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Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, Emery P, Gaujoux-Viala C, Gossec L, Nam J, Ramiro S, Winthrop K, de Wit M, Aletaha D, Betteridge N, Bijlsma JWJ, Boers M, Buttgereit F, Combe B, Cutolo M, Damjanov N, Hazes JMW, Kouloumas M, Kvien TK, Mariette X, Pavelka K, van Riel PLCM, Rubbert-Roth A, Scholte-Voshaar M, Scott DL, Sokka-Isler T, Wong JB, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014; 73:492-509. [PMID: 24161836 PMCID: PMC3933074 DOI: 10.1136/annrheumdis-2013-204573] [Citation(s) in RCA: 1433] [Impact Index Per Article: 143.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 10/05/2013] [Accepted: 10/11/2013] [Indexed: 02/07/2023]
Abstract
In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
| | - Robert Landewé
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Atrium Medical Center, Heerlen, The Netherlands
| | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maya Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Maxime Dougados
- Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital, Montpellier I University, Nimes, France
| | - Laure Gossec
- Rheumatology Department, Paris 06 UPMC University, AP-HP, Pite-Salpetriere Hospital, Paris, France
| | - Jackie Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sofia Ramiro
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Hospital Garcia de Orta, Almada, Portugal
| | - Kevin Winthrop
- Oregon Health and Science University, Portland, Oregon, USA
| | - Maarten de Wit
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Neil Betteridge
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Boers
- VU University Medical Center, Amsterdam, The Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Bernard Combe
- Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
| | - Maurizio Cutolo
- Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Nemanja Damjanov
- 2nd Hospital Department, Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, Dr Molewaterplein, Rotterdam, The Netherlands
| | - Marios Kouloumas
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Xavier Mariette
- Hopitaux Universitaires Paris Sud, AP-HP, and Université Paris-Sud, Le Kremlin Bicetre, France
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Piet L C M van Riel
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Marieke Scholte-Voshaar
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - David L Scott
- King's College School of Medicine, Weston Education Centre, London, UK
| | | | - John B Wong
- Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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Meyfroidt S, van Hulst L, De Cock D, Van der Elst K, Joly J, Westhovens R, Hulscher M, Verschueren P. Factors influencing the prescription of intensive combination treatment strategies for early rheumatoid arthritis. Scand J Rheumatol 2014; 43:265-72. [DOI: 10.3109/03009742.2013.863382] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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40
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Smolen JS, Emery P, Ferraccioli GF, Samborski W, Berenbaum F, Davies OR, Koetse W, Purcaru O, Bennett B, Burkhardt H. Certolizumab pegol in rheumatoid arthritis patients with low to moderate activity: the CERTAIN double-blind, randomised, placebo-controlled trial. Ann Rheum Dis 2014; 74:843-50. [PMID: 24431394 PMCID: PMC4392224 DOI: 10.1136/annrheumdis-2013-204632] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 12/14/2013] [Indexed: 12/29/2022]
Abstract
Objectives This 52-week, randomised, double-blind phase IIIb study assessed efficacy and safety of certolizumab pegol (CZP) as add-on therapy to non-biologic disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) patients with low to moderate disease activity, and stopping therapy in patients in sustained remission. Methods Patients were randomised 1:1 to CZP (400 mg at weeks 0, 2 and 4, then 200 mg every 2 weeks) or placebo (every 2 weeks) plus current non-biologic DMARDs. At week 24, patients who achieved the primary endpoint of Clinical Disease Activity Index (CDAI) remission at both weeks 20 and 24 stopped study treatment and continued in the study until week 52. Results Of 194 patients (CZP=96; placebo=98), >90% had moderate disease activity at baseline. Significantly more CZP patients met the primary endpoint than placebo patients (week 20 and 24 CDAI remission rates: 18.8% vs 6.1%; p≤0.05). At week 24, 63.0% vs 29.7% of CZP versus placebo patients (p<0.001) achieved LDA. Disease activity score (ESR) based on 28-joint count and Simplified Disease Activity Index remission rates were also significantly higher with CZP versus placebo (19.8% vs 3.1%; p≤0.01 and 14.6% vs 4.1%; p≤0.05). CZP patients reported improvements in physical function versus placebo (mean Health Assessment Questionnaire-Disability-Index change from baseline: CZP, −0.25 vs placebo, −0.03; p≤0.01). During the period following withdrawal of CZP or placebo, only 3/17 prior CZP patients and 2/6 prior placebo patients maintained CDAI remission until week 52, but CZP reinstitution allowed renewed improvement. Adverse and serious adverse event rates were comparable between CZP and placebo groups. Conclusions Addition of CZP to non-biologic DMARDs is an effective treatment in RA patients with predominantly moderate disease activity, allowing low-disease activity or remission to be reached in a majority of the patients. However, the data suggest that CZP cannot be withdrawn in patients achieving remission. Trial registration number NCT00674362.
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Affiliation(s)
- J S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, and 2nd Department of Medicine, Hietzing Hospital, Vienna, Austria
| | - P Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - G F Ferraccioli
- Institute of Rheumatology and Affine Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - W Samborski
- University of Medical Sciences, Poznan, Poland
| | - F Berenbaum
- Department of Rheumatology, DHU i2B, INSERM UMR-S938, Pierre & Marie Curie University Paris 06, Saint-Antoine hospital, AP-HP, Paris, France
| | | | - W Koetse
- UCB Pharma, Raleigh, North Carolina, USA
| | | | | | - H Burkhardt
- CIRI/Division of Rheumatology and Fraunhofer TMP, Goethe-University, Frankfurt am Main, Germany
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Combe B, Logeart I, Belkacemi MC, Dadoun S, Schaeverbeke T, Daurès JP, Dougados M. Comparison of the long-term outcome for patients with rheumatoid arthritis with persistent moderate disease activity or disease remission during the first year after diagnosis: data from the ESPOIR cohort. Ann Rheum Dis 2014; 74:724-9. [DOI: 10.1136/annrheumdis-2013-204178] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Iannone F, Gremese E, Gallo G, Sarzi-Puttini P, Botsios C, Trotta F, Gasperini S, Galeazzi M, Adami S, Cantini F, Sebastiani M, Gorla R, Marchesoni A, Giardina A, Foti R, Mele A, Bruschi E, Bagnato G, Erre GL, Lapadula G. High rate of disease remission in moderate rheumatoid arthritis on etanercept therapy: data from GISEA, the Italian biologics register. Clin Rheumatol 2013; 33:31-7. [PMID: 23954923 DOI: 10.1007/s10067-013-2348-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/15/2013] [Accepted: 07/21/2013] [Indexed: 12/16/2022]
Abstract
The aim of this study was to evaluate the clinical outcomes of etanercept in rheumatoid arthritis (RA) patients with moderate or severe disease activity. We analyzed data from the Italian biologics register Gruppo Italiano Studio Early Arthritides (GISEA) to investigate the rate of disease remission and functional improvement, based on the 28-Joint Disease Activity Score (DAS28) and the (Health Assessment Questionnaire (HAQ) score in RA patients with moderate or severe disease activity beginning etanercept therapy. Disease was defined as severe (H-RA) with DAS28 ≥5.1 and moderate (M-RA) with DAS28 ≥3.2 to 5.1 at baseline. Patients were considered in remission if DAS28 was ≤2.6, and HAQ ≤0.5 defined normal function. We enrolled 953 RA patients, 320 with M-RA and 633 H-RA. Age and disease duration were similar in the two cohorts, but H-RA patients had significantly more comorbidities (p < 0.01) and took significantly more disease-modifying antirheumatic drugs (p < 0.001) than M-RA patients. After 1 year, the percentage of patients achieving disease remission and normal function (DAS28 ≤2.6 plus HAQ ≤0.5) was higher in M-RA (21.4 %) than in H-RA patients (14.8 %, p = 0.007), regardless of the disease duration. Additionally, female gender (p = 0.006) and H-RA class (p = 0.002) negatively predicted disease remission at 1 year. However, the drug survival rate did not differ between the two subsets. This study confirms that etanercept was effective in the treatment of active RA, but best response, in terms of disease remission and normal function ability, was greater and easier to attain in M-RA patients. These findings may aid clinicians to choose the best strategy to treat RA.
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Affiliation(s)
- Florenzo Iannone
- Interdisciplinary Department of Medicine, Rheumatology Unit, Policlinico, Piazza G. Cesare 11, 70124, Bari, Italy,
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Norton S, Sacker A, Dixey J, Done J, Williams P, Young A. Trajectories of functional limitation in early rheumatoid arthritis and their association with mortality. Rheumatology (Oxford) 2013; 52:2016-24. [DOI: 10.1093/rheumatology/ket253] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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White D, Pahau H, Duggan E, Paul S, Thomas R. Trajectory of intensive treat-to-target disease modifying drug regimen in an observational study of an early rheumatoid arthritis cohort. BMJ Open 2013; 3:bmjopen-2013-003083. [PMID: 23903812 PMCID: PMC3731780 DOI: 10.1136/bmjopen-2013-003083] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Studies of early rheumatoid arthritis (RA) cohorts have analysed treatment response and prognostic factors at fixed time points. However, in treat-to-target protocols, therapeutic decision-making is dynamic and responsive to disease activity over time. To determine when a minimal residual disease response target should be expected, our primary objective was to identify the time-dependent therapeutic response to combination disease modifying antirheumatic drugs (DMARDs) for 12 months. Our secondary objective determined factors affecting this response trajectory. DESIGN Observational cohort. SETTING Treat-to-target early RA clinic in Australian tertiary referral hospital. PARTICIPANTS We enrolled consecutive patients attending an early arthritis clinic with symptom duration less than 12 months, who were diagnosed with RA for the first time between 2004 and 2008. 101 met these eligibility criteria and data were available at baseline through 12 months. INTERVENTIONS intensive DMARDs according to a treat-to-target protocol. PRIMARY AND SECONDARY OUTCOME MEASURES We measured disease activity scores (DAS) at each visit, then analysed therapeutic response and associated factors in a time-dependent fashion over 12 months. RESULTS The median DAS4vESR of 4.46 at baseline decreased 12 weeks later by 24%, while the proportion with DAS4v ≤ 2.6 increased (p<0.01). DAS4v continued to decrease over 52 weeks. DAS4v reduction of at least -0.45 at 4 weeks was predictive of DAS4v at 28 and 52 weeks. Female gender, current smoking, primary education and an interaction between baseline weight and C reactive protein (CRP) negatively impacted DAS4v reduction over 4 and 52 weeks. Time-varying effects of blood pressure, neutrophils, erythrocyte sedimentation rate and CRP also significantly influenced DAS4v over 52 weeks. CONCLUSIONS Time-dependent data suggest that the largest reduction of DAS4v to combination DMARDs occurs in the first month of therapy, and this predicts subsequent response. Variables known to impact long-term treatment response in RA also impacted early DAS4v response to combination DMARDs.
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Affiliation(s)
- Douglas White
- Diamantina Institute, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia
| | - Helen Pahau
- Diamantina Institute, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia
| | - Emily Duggan
- Diamantina Institute, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia
| | - Sanjoy Paul
- Queensland Clinical Trials and Biostatistics Centre, School of Population Health, University of Queensland, Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ranjeny Thomas
- Diamantina Institute, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia
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Smolen JS, Nash P, Durez P, Hall S, Ilivanova E, Irazoque-Palazuelos F, Miranda P, Park MC, Pavelka K, Pedersen R, Szumski A, Hammond C, Koenig AS, Vlahos B. Maintenance, reduction, or withdrawal of etanercept after treatment with etanercept and methotrexate in patients with moderate rheumatoid arthritis (PRESERVE): a randomised controlled trial. Lancet 2013; 381:918-29. [PMID: 23332236 DOI: 10.1016/s0140-6736(12)61811-x] [Citation(s) in RCA: 273] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Clinical remission and low disease activity are essential treatment targets in patients with rheumatoid arthritis. Although moderately active rheumatoid arthritis is common, treatment effects in moderate disease have not been well studied. Additionally, optimum use of biologics needs further investigation, including the use of induction, maintenance, and withdrawal treatment strategies. The aim of the PRESERVE trial was to assess whether low disease activity would be sustained with reduced doses or withdrawal of etanercept in patients with moderately active disease. METHODS In a randomised controlled trial, patients aged between 18 and 70 years with moderately active rheumatoid arthritis (disease activity score in 28 joints [DAS28] >3.2 and ≤5.1) despite treatment with methotrexate were enrolled at 80 centres in Europe, Latin America, Asia, and Australia between March 6, 2008, and Sept 9, 2009. To be eligible, patients had to have been receiving 15-25 mg of methotrexate every week for at least 8 weeks. In an open-label period of 36 weeks, all patients were given 50 mg etanercept plus methotrexate every week. To be eligible for a subsequent double-blind period of 52 weeks, participants had to have achieved sustained low disease activity. These patients were randomly assigned (1:1:1) by an interactive voice-response system to one of three treatment groups: 50 mg etanercept plus methotrexate, 25 mg etanercept plus methotrexate, or placebo plus methotrexate. Patients were stratified in blocks of three by DAS28 response (low disease activity or remission) at week 36. Patients, investigators, data analysts, and study staff were all masked to treatment allocation. The primary endpoint was the proportion of patients with low disease activity at week 88 in the groups given 50 mg etanercept or placebo in the double-blind period. A conditional primary endpoint was the proportion of patients receiving 25 mg etanercept who achieved low disease activity. Modified intention-to-treat populations were used for analyses. This trial is registered with ClinicalTrials.gov, number NCT00565409. FINDINGS 604 (72.4%) of 834 enrolled patients were eligible for the double-blind period, of whom 202 were assigned to 50 mg etanercept plus methotrexate, 202 to 25 mg etanercept plus methotrexate, and 200 to placebo plus methotrexate. At week 88, 166 (82.6%) of 201 patients who had received at least one dose of 50 mg etanercept and one or more DAS28 evaluations had low disease activity, compared with 84 (42.6%) of 197 who had received placebo (mean difference 40.8%, 95% CI 32.5-49.1%; p<0.0001). Additionally, 159 (79.1%) of 201 patients given 25 mg etanercept had low disease activity at week 88 (mean difference from placebo 35.9%, 27.0-44.8%; p<0.0001). INTERPRETATION Conventional or reduced doses of etanercept with methotrexate in patients with moderately active rheumatoid arthritis more effectively maintain low disease activity than does methotrexate alone after withdrawal of etanercept. FUNDING Pfizer.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Medical University of Vienna and Hietzing Hospital, Vienna, Austria.
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McWilliams DF, Zhang W, Mansell JS, Kiely PDW, Young A, Walsh DA. Predictors of change in bodily pain in early rheumatoid arthritis: an inception cohort study. Arthritis Care Res (Hoboken) 2013; 64:1505-13. [PMID: 22556121 PMCID: PMC3770924 DOI: 10.1002/acr.21723] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To investigate possible predictors for lack of pain improvement after 1 year of treatment for early rheumatoid arthritis (RA). METHODS The Early Rheumatoid Arthritis Network (ERAN) database was used for analysis of baseline and 1-year pain data. The ERAN is a hospital-based inception cohort of 1,189 people. Short Form 36 questionnaire bodily pain scores were used to calculate change in pain at 1 year as the outcome. The proportion of the Disease Activity Score in 28 joints (DAS28) attributable to patient-reported components (joint tenderness and visual analog scale score; DAS28-P) at baseline was derived as a predictor. Predictors of less improvement in pain were investigated using adjusted odds ratios (OR(adj) ) generated by logistic regression, adjusting for 14 additional clinical and demographic covariates. RESULTS Greater pain at baseline was associated with sex, high DAS28, worse mental health, and smoking. Most patients with early RA reported incomplete improvement in bodily pain after 1 year. The DAS28-P index did not significantly change in the patients whose disease remained active. Less improvement in pain was predicted by female sex (OR(adj) 3.41, 95% confidence interval [95% CI] 1.35-8.64) and a high DAS28-P index at baseline (OR(adj) for tertiles 2.09, 95% CI 1.24-3.55). Other conventional RA risk factors did not predict pain changes. CONCLUSION The factors most likely to predict less improvement in pain in early RA are female sex and a high DAS28-P index. A high DAS28-P index may reflect greater contributions of noninflammatory factors, such as central sensitization, to pain. Strategies in addition to inflammatory disease suppression may be required to adequately treat pain.
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Affiliation(s)
- Daniel F McWilliams
- Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK.
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Choy E, Taylor P, McAuliffe S, Roberts K, Sargeant I. Variation in the use of biologics in the management of rheumatoid arthritis across the UK. Curr Med Res Opin 2012; 28:1733-41. [PMID: 22978773 DOI: 10.1185/03007995.2012.731388] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Treatment options for rheumatoid arthritis (RA) include conventional synthetic disease-modifying antirheumatic drugs (sDMARDs) and newer biologic DMARDs (biologics). This study describes treatment patterns, adherence to guidance and outcomes at hospital/regional level in the UK. METHODS This was a retrospective cohort study of RA patients selected from six health regions and from four hospitals in each region, including at least one major teaching hospital and two to three district/general hospitals. Treatment with sDMARDs/biologics was examined between November 2009 and June 2010 in comparison with National Institute for Health and Clinical Excellence (NICE) guidance and in relation to disease activity. RESULTS NICE guidance focuses on initiation of therapy and recommends combination sDMARD/biologic therapy. Analysis of 588 patient records indicates that overall 23% of patients were receiving biologic monotherapy. NICE guidance recommends initiation of biologics in patients with active RA (DAS28 >5.1): average DAS28 score on initiation of biologic therapy was above six in all regions. Range of DAS28 improvement post-biologic therapy was similar across all regions. DAS28 scores were well recorded within patient records at baseline and 6 months but not at other time points. CONCLUSIONS Our data highlight that nearly a quarter of patients receiving biologic treatments are not receiving concomitant sDMARD therapy and that DAS28 is poorly documented in patient medical records other than when initiating biologics and at the 6-month review. Limitations of this study include the limited sample size, the retrospective rather than prospective nature of the audit and the use of medical records only rather than other records such as nursing and pharmacy data. Nevertheless, the reasons for our findings merit further investigation to ensure that optimum treatment regimes and long term outcomes are being achieved for patients.
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Affiliation(s)
- Ernest Choy
- Department of Medicine, Cardiff University School of Medicine, UK.
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Kiely PDW, Deighton C, Dixey J, Ostör AJK. Biologic agents for rheumatoid arthritis--negotiating the NICE technology appraisals. Rheumatology (Oxford) 2012; 51:24-31. [PMID: 22039226 PMCID: PMC3276292 DOI: 10.1093/rheumatology/ker321] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 08/10/2011] [Indexed: 12/31/2022] Open
Abstract
In England and Wales, the National Institute for Health and Clinical Excellence (NICE) has provided guidance [technology appraisals (TAs) 130, 186, 195, 198 and 225] on the use of biologic drugs for the treatment of RA. This is based on an analysis of efficacy, safety and cost-effectiveness, and has resulted in a complex management pathway that restricts freedom to prescribe biologics according to their licensed indications. Specifically, TNF antagonists are the only class of biologics that can be used first line in DMARD-inadequate responders, and only in patients with a persistent 28-joint DAS score of ≥5.1. Alternative biologic agents are denied to those with contraindications to anti-TNF drugs and are also not supported following intolerance to TNF antagonists. Rituximab is the only class of biologic permitted after TNF antagonist inefficacy, in the absence of a contraindication to its use, whereas abatacept and tocilizumab are licensed and may be a more efficacious choice at this stage in some patient groups. Furthermore, for patients who demonstrate sequential inadequate responses, treatment is restricted to one TNF antagonist, rituximab and tocilizumab, whereas abatacept is only a permitted choice when rituximab is contraindicated or has been withdrawn because of an adverse event. In this review, we discuss the treatment algorithm published by NICE, and suggest alternatives where perceived deficiencies exist.
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Affiliation(s)
- Patrick D W Kiely
- Department of Rheumatology, St Georges Healthcare NHS Trust, London SW17 0QT, UK.
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Factors associated with absenteeism, presenteeism and activity impairment in patients in the first years of RA. Rheumatology (Oxford) 2011; 51:375-84. [DOI: 10.1093/rheumatology/ker385] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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