1
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Lauper K, Mongin D, Bergstra SA, Choquette D, Codreanu C, Gottenberg JE, Kubo S, Hetland ML, Iannone F, Kristianslund EK, Kvien TK, Lukina G, Mariette X, Nordström DC, Pavelka K, Pombo-Suarez M, Rotar Z, Santos MJ, Tanaka Y, Turesson C, Courvoisier DS, Finckh A, Gabay C. Oral glucocorticoid use in patients with rheumatoid arthritis initiating TNF-inhibitors, tocilizumab or abatacept: Results from the international TOCERRA and PANABA observational collaborative studies. Joint Bone Spine 2024; 91:105671. [PMID: 38042363 DOI: 10.1016/j.jbspin.2023.105671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/12/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE To evaluate and compare the use of oral glucocorticoids with three classes of bDMARDs in patients with rheumatoid arthritis (RA). METHODS We included patients from 13 observational registries treated with a TNF-inhibitor, abatacept or tocilizumab and with available information on the use of oral glucocorticoids. The main outcome was oral glucocorticoid withdrawal. A McNemar test was used to analyse the change in the use of glucocorticoids after 1 year. Kaplan-Meier estimates and Cox regressions, adjusted for patient, treatment, and disease characteristics, were used to evaluate glucocorticoid discontinuation in patients with glucocorticoids at baseline. Because of heterogeneity, analyses were done by registers and pooled using random-effects meta-analysis. RESULTS A total of 12,334 participants treated with TNF-inhibitors, 2100 with tocilizumab and 3229 with abatacept were included. At one-year, oral glucocorticoid use decreased in all treatment groups (odds ratio for stopping vs. starting of 2.19 [95% CI 1.58; 3.04] for TNF-inhibitors, 2.46 [1.39; 4.35] for tocilizumab; 1.73 [1.25; 2.21] for abatacept). Median time to glucocorticoid withdrawal was ≈2 years or more in most countries, with a gradual decrease over time. Compared to TNF-inhibitors, crude hazard ratios of glucocorticoid discontinuation were 0.65[0.48-0.87] for abatacept, and 1.04 [0.76-1.43] for tocilizumab, and adjusted hazard ratios were 1.1 [0.83-1.47] for abatacept, and 1.30 [0.96-1.78] for tocilizumab. CONCLUSION After initiation of a bDMARD, glucocorticoid use decreased similarly in all treatment groups. However, glucocorticoid withdrawal was much slower than advocated by current international guidelines. More effort should be devoted to glucocorticoid tapering when low disease activity is achieved.
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Affiliation(s)
- Kim Lauper
- Division of Rheumatology, Geneva University Hospitals and Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Centre for Epidemiology versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PT Manchester, United Kingdom.
| | - Denis Mongin
- Division of Rheumatology, Geneva University Hospitals and Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Denis Choquette
- Institut de rhumatologie de Montréal, University of Montreal, Quebec, Canada
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Jacques-Eric Gottenberg
- CNRS, Institut de biologie moléculaire et cellulaire, immunopathologie, et chimie thérapeutique, Strasbourg University Hospital and University of Strasbourg, Strasbourg, France
| | - Satoshi Kubo
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Eirik K Kristianslund
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Tore K Kvien
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Galina Lukina
- ARBITER, Institute of Rheumatology, Moscow, Russian Federation
| | - Xavier Mariette
- Rheumatology Department, centre de recherche en Immunologie des infections virales et des maladies auto-immunes, hôpital Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, Inserm, CEA, Le Kremlin-Bicêtre, France
| | - Dan C Nordström
- Departments of Medicine and Rheumatology, Helsinki University Hospital and Helsinki University, Helsinki, Finland; ROB-FIN
| | - Karel Pavelka
- Institute of Rheumatology and Rheumatology Clinic of Medical faculty Charles university
| | - Manuel Pombo-Suarez
- Rheumatology Unit, Clinical University Hospital, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ziga Rotar
- biorx.si, Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maria J Santos
- Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
| | - Delphine S Courvoisier
- Division of Rheumatology, Geneva University Hospitals and Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Axel Finckh
- Division of Rheumatology, Geneva University Hospitals and Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Cem Gabay
- Division of Rheumatology, Geneva University Hospitals and Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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2
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Chan JSK, Murray RB, Price D. Oral corticosteroids in asthma and beyond: moving forward. Eur Respir J 2022; 60:60/3/2200776. [PMID: 36109044 DOI: 10.1183/13993003.00776-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/21/2022] [Indexed: 11/05/2022]
Affiliation(s)
| | - Ruth B Murray
- Observational and Pragmatic Research Institute, Midview City, Singapore
| | - David Price
- Observational and Pragmatic Research Institute, Midview City, Singapore .,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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3
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Brogan P, Naden R, Ardoin SP, Cooper JC, De Benedetti F, Dicaire JF, Eleftheriou D, Feldman B, Goldin J, Karol SE, Price-Kuehne F, Skuse D, Stratakis CA, Webb N, Stone JH. The pediatric glucocorticoid toxicity index. Semin Arthritis Rheum 2022; 56:152068. [PMID: 35917759 DOI: 10.1016/j.semarthrit.2022.152068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/21/2022] [Accepted: 07/08/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To develop a Pediatric glucocorticoid toxicity index (pGTI), a standardized, weighted clinical outcome assessment that measures change in glucocorticoid (GC) toxicity over time. METHODS Fourteen physician experts from 7 subspecialties participated. The physician experts represented multiple subspecialties in which GCs play a major role in the treatment of inflammatory disease: nephrology, rheumatology, oncology, endocrinology, genetics, psychiatry, and maternal-fetal medicine. Nine investigators were from Canada, Europe, or New Zealand, and 5 were from the United States. Group consensus methods and multi-criteria decision analysis were used. The pGTI is an aggregate assessment of GC toxicities that are common, important, and dynamic. These toxicities are organized into health domains graded as minor, moderate, or major and are weighted according to severity. The relative weights were derived by group consensus and multi-criteria decision analysis using the 1000MindsTM software platform. Two quantitative scores comprise the overall toxicity profile derived from pGTI data: (1) the Cumulative Worsening Score; and (2) the Aggregate Improvement Score. The pGTI also includes a qualitative, unweighted record of GC side-effects known as the Damage Checklist, which documents less common toxicities that, although potentially severe, are unlikely to change with varying GC dosing. RESULTS One hundred and seven (107) toxicity items were included in the pGTI and thirty-two (32) in the Damage Checklist. To assess the degree to which the pGTI corresponds to expert clinical judgement, the investigators ranked 15 cases by clinical judgement from highest to lowest GC toxicity. Expert rankings were then compared to case ranking by the pGTI, yielding excellent agreement (weighted kappa 0.86). The pGTI was migrated to a digital environment following its development and initial validation. The digital platform is designed to ensure ease-of-use in the clinic, rigor in application, and accuracy of scoring. Clinic staff enter vital signs, laboratory results, and medication changes relevant to pGTI scoring. Clinicians record findings for GC myopathy, skin toxicity, mood dysfunction, and infection. The pGTI algorithms then apply the weights to these raw data and calculate scores. Embedded logic accounts for the impact of age- and sex-related reference ranges on several health domains: blood pressure, lipid metabolism, and bone mineral density. Other algorithms account for anticipated changes in the height Z-scores used in the growth domain, thereby addressing a concern unique to GC toxicity in children. The Damage Checklist ensures comprehensive measurement of GC toxicity but does not contribute to pGTI scoring, because the scored domains emphasize manifestations of GC toxicity that are likely to change over the course of a trial. CONCLUSIONS We describe the development and initial evaluation of a weighted, composite toxicity index for the assessment of morbidity related to GC use in children and adolescents. Developing the pGTI digital platform was essential for performing the nuanced calculations necessary to ensure rigor, accuracy, and ease-of-use in both clinic and research settings.
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Affiliation(s)
- Paul Brogan
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Ray Naden
- McMasterUniversity, Hamilton, Ontario, Canada
| | | | - Jennifer C Cooper
- University of Colorado Anschutz Medical Alifornia, San Francisco, CA, USA
| | | | | | - Despina Eleftheriou
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Brian Feldman
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jon Goldin
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Seth E Karol
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - David Skuse
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Nicholas Webb
- Royal Manchester Children's Hospital, Manchester, UK; Rheumatology Clinic, Bulfinch 165, Massachusetts General Hospital, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - John H Stone
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK.
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4
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Suzuki M, Kojima T, Takahashi N, Asai S, Terabe K, Kaneko A, Hirano Y, Hanabayashi M, Oguchi T, Takagi H, Kanayama Y, Yabe Y, Funahashi K, Fujibayashi T, Tsuboi S, Ito T, Yoshioka Y, Ishikawa H, Sobue Y, Nishiume T, Yokota Y, Ishiguro N. Higher doses of methotrexate associated with discontinuation of oral glucocorticoids after initiation of biological DMARDs: A retrospective observational study based on data from a Japanese multicenter registry study. Mod Rheumatol 2021; 31:796-802. [PMID: 33492191 DOI: 10.1080/14397595.2021.1879428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Glucocorticoids are important drugs used to treat rheumatoid arthritis. We recommend glucocorticoid discontinuation as soon as possible given the associated side-effects, but many patients continue to take oral glucocorticoids long-term. The present study aimed to explore factors associated with glucocorticoid discontinuation at 52 weeks after initiating biological disease-modifying antirheumatic drugs (bDMARDs). METHODS Subjects were 564 patients from a Japanese multicenter registry who were administered glucocorticoids and methotrexate (MTX) followed by initiation of the first bDMARD. We examined the status of oral glucocorticoid use at 52 weeks after initiating the first bDMARD. RESULTS By 52 weeks after bDMARD initiation, 164 patients (29.1%) discontinued glucocorticoids. Multivariable analysis identified age, MTX dose, and glucocorticoid dose as factors independently associated with glucocorticoid discontinuation. After adjusting for baseline characteristics using propensity score matching, among patient groups administered MTX ≤ 8 mg/week and MTX > 8 mg/week, 105 pairs remained. A significantly higher rate of glucocorticoid discontinuation (41.0%) was noted for patients administered MTX > 8 mg/week. CONCLUSION Our findings suggest that glucocorticoids may be discontinued after initiating bDMARDs. Moreover, higher MTX doses (>8 mg/week) at the time of bDMARD initiation were associated with glucocorticoid discontinuation among patients treated with bDMARDs.
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Affiliation(s)
- Mochihito Suzuki
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Nobunori Takahashi
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Shuji Asai
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kenya Terabe
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Atsushi Kaneko
- Department of Orthopedic Surgery and Rheumatology, Nagoya Medical Center, Aichi, Japan
| | - Yuji Hirano
- Department of Rheumatology, Toyohashi Municipal Hospital, Aichi, Japan
| | | | - Takeshi Oguchi
- Department of Orthopedic Surgery and Rheumatology, Anjo Kosei Hospital, Aichi, Japan
| | - Hideki Takagi
- Department of Orthopedic Surgery, Nagoya Central Hospital, Aichi, Japan
| | | | - Yuichiro Yabe
- Department of Rheumatology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Koji Funahashi
- Department of Orthopedic Surgery, Kariya-Toyota General Hospital, Aichi, Japan
| | - Takayoshi Fujibayashi
- Department of Orthopedic Surgery and Rheumatology, Konan Kosei Hospital, Aichi, Japan
| | - Seiji Tsuboi
- Department of Orthopedic Surgery, Shizuoka Kosei Hospital, Shizuoka, Japan
| | | | - Yutaka Yoshioka
- Department of Orthopedic Surgery, Handa Municipal Hospital, Aichi, Japan
| | - Hisato Ishikawa
- Department of Rheumatology, Japanese Red Cross, Nagoya Daiichi Hospital, Aichi, Japan
| | - Yasumori Sobue
- Department of Rheumatology, Japanese Red Cross, Nagoya Daiichi Hospital, Aichi, Japan
| | - Tsuyoshi Nishiume
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yutaka Yokota
- Department of Orthopedic Surgery and Rheumatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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5
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Burmester GR, Buttgereit F, Bernasconi C, Álvaro-Gracia JM, Castro N, Dougados M, Gabay C, van Laar JM, Nebesky JM, Pethoe-Schramm A, Salvarani C, Donath MY, John MR. Continuing versus tapering glucocorticoids after achievement of low disease activity or remission in rheumatoid arthritis (SEMIRA): a double-blind, multicentre, randomised controlled trial. Lancet 2020; 396:267-276. [PMID: 32711802 DOI: 10.1016/s0140-6736(20)30636-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/19/2020] [Accepted: 03/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with inflammatory diseases, such as rheumatoid arthritis, often receive glucocorticoids, but long-term use can produce adverse effects. Evidence from randomised controlled trials to guide tapering of oral glucocorticoids is scarce. We investigated a scheme for tapering oral glucocorticoids compared with continuing low-dose oral glucocorticoids in patients with rheumatoid arthritis. METHODS The Steroid EliMination In Rheumatoid Arthritis (SEMIRA) trial was a double-blind, multicentre, two parallel-arm, randomised controlled trial done at 39 centres from six countries (France, Germany, Italy, Russia, Serbia, and Tunisia). Adult patients with rheumatoid arthritis receiving tocilizumab and glucocorticoids 5-15 mg per day for 24 weeks or more were eligible for inclusion if they had received prednisone 5 mg per day for 4 weeks or more and had stable low disease activaity, confirmed by a Disease Activity Score for 28 joints-erythrocyte sedimentation rate (DAS28-ESR) of 3·2 or less 4-6 weeks before and on the day of randomisation. Patients were randomly assigned 1:1 to either continue masked prednisone 5 mg per day for 24 weeks or to taper masked prednisone reaching 0 mg per day at week 16. All patients received tocilizumab (162 mg subcutaneously every week or 8 mg/kg intravenously every 4 weeks) with or without csDMARDs maintained at stable doses during the entire 24-week study. The primary outcome was the difference in mean DAS28-ESR change from baseline to week 24, with a difference of more than 0·6 defined as clinically relevant between the continued-prednisone group and the tapered-prednisone group. The trial is registered with ClinicalTrials.gov, NCT02573012. FINDINGS Between Oct 21, 2015, and June 9, 2017, 421 patients were screened and 259 (200 [77%] women and 59 [23%] men) were recruited onto the trial. In all 128 patients assigned to the continued-prednisone regimen, disease activity control was superior to that in all 131 patients assigned to the tapered-prednisone regimen; the estimated mean change in DAS28-ESR from baseline to week 24 was 0·54 (95% CI 0·35-0·73) with tapered prednisone and -0·08 (-0·27 to 0·12) with continued prednisone (difference 0·61 [0·35-0·88]; p<0·0001), favouring continuing prednisone 5 mg per day for 24 weeks. Treatment was regarded as successful (defined as low disease activity at week 24, plus absence of rheumatoid arthritis flare for 24 weeks and no confirmed adrenal insufficiency) in 99 (77%) patients in the continued-prednisone group versus 85 (65%) patients in the tapered-prednisone group (relative risk 0·83; 95% CI 0·71-0·97). Serious adverse events occurred in seven (5%) patients in the tapered-prednisone group and four (3%) patients in the continued-prednisone group; no patients had symptomatic adrenal insufficiency. INTERPRETATION In patients who achieved low disease activity with tocilizumab and at least 24 weeks of glucocorticoid treatment, continuing glucocorticoids at 5 mg per day for 24 weeks provided safe and better disease control than tapering glucocorticoids, although two-thirds of patients were able to safely taper their glucocorticoid dose. FUNDING F Hoffmann-La Roche.
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MESH Headings
- Administration, Intravenous
- Administration, Oral
- Adult
- Aged
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/therapeutic use
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/ethnology
- Double-Blind Method
- Drug Administration Schedule
- Drug Therapy, Combination
- Female
- France/epidemiology
- Germany/epidemiology
- Glucocorticoids/administration & dosage
- Glucocorticoids/adverse effects
- Glucocorticoids/therapeutic use
- Humans
- Injections, Subcutaneous
- Italy/epidemiology
- Male
- Middle Aged
- Outcome Assessment, Health Care
- Prednisone/administration & dosage
- Prednisone/adverse effects
- Prednisone/therapeutic use
- Remission Induction/methods
- Russia/epidemiology
- Serbia/epidemiology
- Tunisia/epidemiology
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Affiliation(s)
- Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Free University and Humboldt University of Berlin, Berlin, Germany.
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Free University and Humboldt University of Berlin, Berlin, Germany
| | | | - Jose M Álvaro-Gracia
- Hospital General Universitario Gregorio Marañon, Universidad Complutense de Madrid, Spain
| | - Nidia Castro
- Pharmaceuticals Division, F Hoffmann-La Roche, Basel, Switzerland
| | - Maxime Dougados
- Rheumatology Service, Université Paris-Descartes, Paris, France
| | - Cem Gabay
- Department of Rheumatology, Hôpital Cochin, Geneva University Hospitals and Geneva School of Medicine, Geneva, Switzerland
| | | | | | | | - Carlo Salvarani
- Department of Rheumatology and Clinical Immunology, Università di Modena e Reggio Emilia and Azienda unità sanitaria locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marc Y Donath
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Markus R John
- Pharmaceuticals Division, F Hoffmann-La Roche, Basel, Switzerland
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6
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van der Leeuw MS, Welsing PMJ, de Hair MJH, Jacobs JWG, Marijnissen ACA, Linn-Rasker SP, Fodili F, Bos R, Tekstra J, van Laar JM. Effectiveness of TOcilizumab in comparison to Prednisone In Rheumatoid Arthritis patients with insufficient response to disease-modifying antirheumatic drugs (TOPIRA): study protocol for a pragmatic trial. Trials 2020; 21:313. [PMID: 32248829 PMCID: PMC7133012 DOI: 10.1186/s13063-020-04260-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/15/2020] [Indexed: 03/17/2023] Open
Abstract
Background Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease, predominantly affecting joints, which is initially treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). In RA patients with insufficient response to csDMARDs, the addition of prednisone or tocilizumab, a biological DMARD (bDMARD), to the medication has been shown to be effective in reducing RA symptoms. However, which of these two treatment strategies has superior effectiveness and safety is unknown. Methods In this multicenter, investigator-initiated, open-label, randomized, pragmatic trial, we aim to recruit 120 RA patients meeting the 2010 ACR/EULAR classification criteria for RA, with active disease defined as a Clinical Disease Activity Index (CDAI) > 10 and at least one swollen joint of the 28 assessed. Patients must be on stable treatment with csDMARDs for ≥ 8 weeks prior to screening and must have been treated with ≥ 2 DMARDs, of which a maximum of one tumor necrosis factor inhibitor (a class of bDMARDs) is allowed. Previous use of other bDMARDs or targeted synthetic DMARDs is not allowed. Patients will be randomized in a 1:1 ratio to receive either tocilizumab (subcutaneously at 162 mg/week) or prednisone (orally at 10 mg/day) as an addition to their current csDMARD therapy. Study visits will be performed at screening; baseline; and months 1, 2, 3, 6, 9, and 12. Study medication will be tapered in case of clinical remission (CDAI ≤ 2.8 and ≤ 1 swollen joint at two consecutive 3-monthly visits) with careful monitoring of disease activity. In case of persistent high disease activity at or after month 3 (CDAI > 22 at any visit or > 10 at two consecutive visits), patients will switch to the other strategy arm. Primary outcome is a change in CDAI from baseline to 12 months. Secondary outcomes are additional clinical response and quality of life measures, drug retention rate, radiographically detectable progression of joint damage, functional ability, and cost utility. Safety outcomes include tocilizumab-associated adverse events (AEs), glucocorticoid-associated AEs, and serious AEs. Discussion This will be the first randomized clinical trial comparing addition of oral prednisone or of tocilizumab head to head in RA patients with insufficient response to csDMARD therapy. It will yield important information for clinical rheumatology practice. Trial registration This trial was prospectively registered in the Netherlands Trial Register on October 7, 2019 (NL8070). The Netherlands Trial Register contains all items from the World Health Organization Trial Registration Data Set.
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Affiliation(s)
| | - Paco M J Welsing
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maria J H de Hair
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Johannes W G Jacobs
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Anne C A Marijnissen
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Faouzia Fodili
- Reumazorg Zuid West Nederland, Streuvelslaan 18, 4707 CH, Roosendaal, The Netherlands
| | - Reinhard Bos
- Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Janneke Tekstra
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jacob M van Laar
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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7
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Alexeeva E, Dvoryakovskaya T, Denisova R, Sleptsova T, Isaeva K, Chomahidze A, Fetisova A, Mamutova A, Alshevskaya A, Gladkikh V, Moskalev A. Dynamics of concomitant therapy in children with juvenile idiopathic arthritis treated with etanercept and methotrexate. Pediatr Neonatol 2019; 60:549-555. [PMID: 30885783 DOI: 10.1016/j.pedneo.2019.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 12/06/2018] [Accepted: 02/18/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Both the steroid- and NSAID-sparing effects of biologics in juvenile idiopathic arthritis (JIA) treatment are key aspects of the dynamics of patient's condition. The proper selection of biologics enables maximum treatment effectiveness and reduction of the dosage of concomitant therapy. Our aim was to study the dynamics of concomitant therapy during etanercept (ETA) and methotrexate (MTX) treatment in patients with JIA. METHODS This analysis included 215 JIA patients (63.3% females) showing sufficient response to main therapy. One hundred patients received MTX as main therapy, 24 received ETA monotherapy, and 91 received ETA þ MTX combination therapy. The dynamics of concomitant therapy were analyzed after 1 month, every 3 months during the first year, and every 6 months during the long-term follow-up (up to 5 years). RESULTS At the baseline, 24 (11.2%) patients received concomitant oral glucocorticoids (orGCs) and NSAIDs; the remaining 191 (88.8%) patients were treated with concomitant NSAIDs only. Within 1-year treatment, NSAIDs were discontinued in 162 (75.3%) patients. There were no significant differences in the dynamics of withdrawal of NSAIDs in patients who received and did not receive concomitant MTX. However, the percentage of treatment discontinuation in the MTX group was significantly lower compared to the other two groups (p < 0.001). Oral GCs were discontinued completely in 4 children (16.7%), and the dose of oral GCs was reduced in another 4 patients (16.7%). By the end of the follow-up period, 44 of 115 patients (38.3%) treated with ETA in combination with any concomitant therapy could switch to ETA monotherapy. CONCLUSION Therapy with ETA makes it possible to reduce the dosage or completely discontinue most concomitant medications (orGCs, NSAIDs, MTX) in a significant percentage of patients. This reduces the risk of development of NSAID- and GC-induced pathological conditions, while the effectiveness of therapy of the underlying condition remains high.
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Affiliation(s)
- Ekaterina Alexeeva
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia; Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Russia.
| | - Tatyana Dvoryakovskaya
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia; Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Russia
| | - Rina Denisova
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana Sleptsova
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Kseniya Isaeva
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexandra Chomahidze
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna Fetisova
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna Mamutova
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | | | - Victor Gladkikh
- Biostatistics and Clinical Trials Center, Novosibirsk, Russia
| | - Andrey Moskalev
- Biostatistics and Clinical Trials Center, Novosibirsk, Russia
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Khraishi M, Millson B, Woolcott J, Jones H, Marshall L, Ruperto N. Reduction in the utilization of prednisone or methotrexate in Canadian claims data following initiation of etanercept in pediatric patients with juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2019; 17:64. [PMID: 31500631 PMCID: PMC6734296 DOI: 10.1186/s12969-019-0358-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/07/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In adult patients with arthritis, use of the tumor necrosis factor (TNF) inhibitor etanercept (ETN) is often associated with a reduction in the utilization of co-medications, particularly steroids. Comparatively little is known about the utilization of co-medications when ETN is initiated in pediatric patients with juvenile idiopathic arthritis (JIA). METHODS This study analyzed Canadian longitudinal claims level data spanning January 2007 to April 2017. Data were collated from the IQVIA Private Drug Plan, Ontario Public Drug Plan, and the Quebec Public Drug Plan (Régie de l'assurance maladie du Québec) databases. Patients < 18 years of age were indexed when filling a prescription for ETN between January 2008 and January 2016. Those who met the inclusion and exclusion criteria were assessed for methotrexate (MTX), and prednisone (PRD) use in the 6 months prior to and 12 months following initiation of ETN. RESULTS Longitudinal claims data for 330 biologic-naive pediatric patients initiating ETN therapy were included. The majority of patients were female (67%), aged 10-17 years (64%), and with a drug history consistent with JIA (96%). Most patients were from Quebec (36%) or Ontario (33%). Dosing of ETN was weight-based with a mean dosage over the first year of 31 mg per week. ETN dosing was relatively consistent over the first year. In total, 222 (67%) patients did not use MTX and 223 (68%) did not use PRD before or after starting ETN. A total of 17% (18/103) of MTX-treated and 50% (46/92) of PRD-treated patients discontinued use of those medications upon initiation of ETN treatment. In patients continuing MTX or PRD, significant reductions in the weekly dosage from 14.3 to 6.8 mg per week for MTX and from 56 to 23 mg per week for PRD were observed (P < 0.01). CONCLUSIONS This study of Canadian claims-level data is the first large prespecified analysis of co-medication utilization following the initiation of ETN therapy in pediatric patients. A decline in both MTX and PRD use and dosage was observed and may be associated with benefits related to safety, tolerability, and overall healthcare costs.
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Affiliation(s)
- Majed Khraishi
- 0000 0000 9130 6822grid.25055.37Memorial University of Newfoundland, St. Johns, NL Canada
| | | | - John Woolcott
- 0000 0000 8800 7493grid.410513.2Global Outcomes and Evidence, Pfizer, Collegeville, PA USA
| | - Heather Jones
- 0000 0000 8800 7493grid.410513.2Global Medical Affairs, Pfizer, Collegeville, PA USA
| | - Lisa Marshall
- 0000 0000 8800 7493grid.410513.2Global Medical Affairs, Pfizer, Collegeville, PA USA
| | - Nicolino Ruperto
- IRCCS, Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia - PRINTO, Genoa, Italy.
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9
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Pappas DA, Etzel CJ, Zlotnick S, Best J, Blachley T, Kremer JM. Patterns of Prednisone Use in Patients with Rheumatoid Arthritis Initiating Treatment with Tocilizumab in Routine US Clinical Practice. Rheumatol Ther 2019; 6:421-433. [PMID: 31240499 PMCID: PMC6702615 DOI: 10.1007/s40744-019-0162-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Indexed: 10/29/2022] Open
Abstract
INTRODUCTION Prednisone is frequently administered in combination with other therapies for the treatment of rheumatoid arthritis (RA); however, its chronic use is associated with an increased risk of comorbidities and mortality. The objective of this analysis was to evaluate changes in prednisone use among patients with RA treated with tocilizumab (TCZ) in routine US clinical practice. METHODS TCZ-naïve patients in the Corrona RA registry who initiated TCZ were included. The primary outcome was the proportion of patients with changes in prednisone use over 12 months (primary analysis) and 6 months (secondary analysis). Changes in disease activity over 6 and 12 months (± 3 months) were assessed using the Clinical Disease Activity Index (CDAI). Outcomes were assessed in the overall population and separately for patients receiving TCZ monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs. RESULTS Of patients receiving prednisone at baseline (mean [SD] dose: 7.7 [5.2] mg/day), 30.6% discontinued prednisone over 12 months; among patients receiving > 7.5 mg of prednisone at the time of TCZ initiation, 63.0% discontinued prednisone or decreased their dose by ≥ 5 mg over 12 months. In secondary analyses, 29.7% of patients receiving prednisone at baseline had discontinued prednisone over 6 months; among those receiving > 7.5 mg of prednisone at baseline, 51.3% discontinued or decreased their dose by ≥ 5 mg over 6 months. Changes in prednisone use and improvement from baseline in CDAI score over 6 and 12 months were comparable between patients who initiated TCZ monotherapy vs. TCZ combination therapy. CONCLUSIONS In this real-world analysis, many patients initiating TCZ monotherapy or combination therapy were able to discontinue or decrease their prednisone dose over 12 months. Similar changes in prednisone dose were observed over 6 months. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01402661. FUNDING Corrona, LLC and Genentech, Inc. Plain language summary available for this article.
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Affiliation(s)
| | | | | | - Jennie Best
- Genentech, Inc, South San Francisco, CA, USA
| | | | - Joel M Kremer
- Corrona, LLC, Waltham, MA, USA
- Albany Medical College, The Center for Rheumatology, Albany, NY, USA
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10
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Ogata A, Kato Y, Higa S, Maeda K. Subcutaneous tocilizumab: recent advances for the treatment of rheumatoid arthritis. Expert Opin Drug Deliv 2019; 16:639-648. [PMID: 31088167 DOI: 10.1080/17425247.2019.1618828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Atsushi Ogata
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yasuhiro Kato
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shinji Higa
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
| | - Keiji Maeda
- Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
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Haraoui B, Casado G, Czirják L, Taylor A, Dong L, Button P, Luder Y, Caporali R. Tocilizumab Patterns of Use, Effectiveness, and Safety in Patients with Rheumatoid Arthritis: Final Results from a Set of Multi-National Non-Interventional Studies. Rheumatol Ther 2019; 6:231-243. [PMID: 30859494 PMCID: PMC6513939 DOI: 10.1007/s40744-019-0150-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The objective of this study was to observe the patterns of usage, efficacy, and safety of tocilizumab (TCZ) in clinical practice in patients with rheumatoid arthritis. METHODS Data on the real-world usage, efficacy, and safety of TCZ were collected from patients during routine follow-up visits conducted over a 6-month period. Patients were grouped by previous exposure to biologic therapies (biologic exposed vs. biologic naive). RESULTS Of 1912 patients enrolled from 16 countries, 639 (33.4%) received TCZ monotherapy and 1273 (66.6%) received TCZ combination therapy. At baseline, 1073 patients (56.1%) were biologic naive and 839 (43.9%) were biologic exposed. At 6 months, 1504 patients (78.7%) continued to receive TCZ treatment, with no descriptive differences in retention rates between biologic-exposed and biologic-naive patients and between patients receiving TCZ monotherapy or combination therapy. Dose and use of methotrexate and prednisone were reduced at 6 months. Efficacy at 6 months, including patient-reported outcomes, was demonstrated in both biologic-naive and biologic-exposed groups. Adverse events (AEs) occurred in 817 patients [42.7%; incidence rate: 179 events per 100 patient-years (PY)], and serious AEs (SAEs) occurred in 118 patients (6.2%; 17 events per 100 PY), with comparable rates of AEs and SAEs between subgroups. CONCLUSION In routine clinical practice, TCZ discontinuation rates were low and unaffected by prior use of biologics. Effectiveness was similar between groups, and no new safety signals were identified. FUNDING F. Hoffmann-La Roche.
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Affiliation(s)
| | - Gustavo Casado
- Department of Rheumatology, Hospital Militar Central, Buenos Aires, Argentina
| | - László Czirják
- Rheumatology and Immunology Clinic, Medical Center, University of Pécs, Pécs, Hungary
| | - Andrew Taylor
- Medicine and Pharmacology RPH Unit, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | | | - Yves Luder
- F. Hoffmann-La Roche, Ltd, Basel, Switzerland
| | - Roberto Caporali
- Department of Rheumatology, University of Pavia, IRCCS S. Matteo Foundation, Pavia, Italy
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12
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Koller G, Katz S, Charrois TL, Ye C. Glucocorticoid-induced osteoporosis preventive care in rheumatology patients. Arch Osteoporos 2019; 14:16. [PMID: 30723883 DOI: 10.1007/s11657-019-0570-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/27/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Glucocorticoid-induced osteoporosis (GIOP) is common in patients prescribed with long-term glucocorticoids. Guidelines suggest patients receiving moderate-dose glucocorticoid therapy receive GIOP preventive care. Previous studies have shown preventive care rates are not optimal. We look at GIOP preventive care rates in rheumatology patients and predictors of various components of care. PURPOSE Glucocorticoid-induced osteoporosis (GIOP) is a common concern in patients prescribed with long-term glucocorticoids. Studies have shown GIOP preventive care is not provided optimally in the general population; however, little is published on GIOP preventive care among patients with rheumatic disease. The objective of this study is to determine the proportion of rheumatology patients who received GIOP preventive care. METHODS A population-based retrospective quality assurance study of adults seen at the University of Alberta Rheumatology Clinic was performed using the electronic outpatient medical record. Records of adult patients prescribed with prednisone from January 1st to December 31st, 2016 by a rheumatologist were initially included for review. Those who had been prescribed ≥ 7.5 mg/day for ≥ 3 months were assessed for concurrent GIOP preventive care. RESULTS A total of 745 discreet courses of prednisone were prescribed in 433 patients with 113 meeting the above inclusion criteria. Following the prednisone prescription, 79% were taking vitamin D, 86% were taking calcium, and 50% were prescribed with osteoporosis pharmacotherapy. Twenty-five percent of patients had DXA imaging ordered by the rheumatologist within the first 6 months; of these, 86% of patients completed the DXA. CONCLUSIONS Overall, our study shows that patients under the care of rheumatologists receive better GIOP preventative care than previously reported care in the general population. However, there is still room for improvement. In particular, men, younger patients, and rural patients seem to be at the most at risk of not receiving optimal GIOP prevention.
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Affiliation(s)
- G Koller
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - S Katz
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - T L Charrois
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - C Ye
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada.
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Ogata A, Kato Y, Higa S, Yoshizaki K. IL-6 inhibitor for the treatment of rheumatoid arthritis: A comprehensive review. Mod Rheumatol 2019; 29:258-267. [PMID: 30427250 DOI: 10.1080/14397595.2018.1546357] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Tocilizumab (TCZ) is an interleukin-6 (IL-6) inhibitor used for the treatment of rheumatoid arthritis (RA). It was developed in 2008, and its effectiveness is supported by evidence from all over the world based on its first decade of use. Although the overall efficacy and safety profiles of TCZ are similar to those of tumor necrosis factor (TNF) inhibitors, TCZ displays certain differences. The most notable advantage of TCZ is its usefulness as a monotherapy. Additionally, TCZ is favorable in the improvement of systemic inflammatory symptoms such as anemia and fatigue. The low immunogenicity of TCZ contributes favorably to long-term drug retention. Due to frequent relapse after TCZ cessation, TCZ use should be tapered beyond remission. During TCZ therapy, C-reactive protein (CRP) is unable to recognize disease activity and the severity of infection. The most common adverse events (AEs) are infection and abnormalities in laboratory findings including dyslipidemia, neutropenia, thrombocytopenia, and abnormality of liver enzymes. TCZ obscures the symptoms of infection. Therefore, stealth infections without obvious CRP elevation can sometimes cause severe damage to patients. Lower intestinal perforation is an uncommon but serious AE in TCZ therapy. Further clinical investigations will continue to refine the IL-6 inhibitory strategy.
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Affiliation(s)
- Atsushi Ogata
- a Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan.,b Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine , Osaka University , Osaka , Japan
| | - Yasuhiro Kato
- a Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan.,b Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine , Osaka University , Osaka , Japan
| | - Shinji Higa
- a Division of Rheumatology, Department of Internal Medicine, NTT West Osaka Hospital, Osaka, Japan
| | - Kazuyuki Yoshizaki
- c Graduate School of Information Science and Technology , Osaka University , Osaka , Japan
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Pierrot A, Combe C, Lepelley M, Brucker M, Constant E. Maladie de Berger au cours d’une Polyarthrite Rhumatoïde traitée par Adalimumab. ANNALES PHARMACEUTIQUES FRANÇAISES 2018; 76:499-503. [DOI: 10.1016/j.pharma.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
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15
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Jones G, Hall S, Bird P, Littlejohn G, Tymms K, Youssef P, Chung E, Barrett R, Button P. A retrospective review of the persistence on bDMARDs prescribed for the treatment of rheumatoid arthritis in the Australian population. Int J Rheum Dis 2017; 21:1581-1590. [PMID: 29205926 DOI: 10.1111/1756-185x.13243] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To describe the persistence of biologic disease modifying anti-rheumatic drugs (bDMARDs) in Australian rheumatoid arthritis (RA) patients, and assess the influence of methotrexate and other conventional DMARD (cDMARD) concomitant medications, and treatment line on bDMARD persistence and glucocorticoids usage. METHOD RA patients, from the 10% Australian Medicare random sample, aged ≥18 for whom bDMARDs were dispensed were included. Individual sub-cutaneous (SC) anti-tumor necrosis factor-α (anti-TNFα) agents were combined as they were equivalent. RESULTS Data from 1230 patients were analyzed. For all patients the 12-month persistence rates (based on Kaplan-Meier estimates) were 76% for intravenous (IV) tocilizumab, 63% abatacept (SC/IV), 61% SC-anti-TNFs and 36% IV-infliximab. Persistence rates on first-line bDMARDs were 79% (tocilizumab and abatacept), 64% (SC-anti-TNFs) and 13% (infliximab); rates were sustained for tocilizumab but dropped to 49% for abatacept and 51% for SC-anti-TNFs in the second-line setting. Median treatment persistence was 40 months tocilizumab (95% CI: 30-ND), 33 months abatacept (95% CI: 20-ND); 22 months SC-anti-TNF (95% Cl: 18-27), and 4 months infliximab (95% CI: 2-13). Longer persistence was observed for SC-anti-TNFs and abatacept combined with methotrexate or other cDMARDs. For tocilizumab, persistence was robust with or without concomitant medications. The median oral glucocorticoid doses decreased from 4.1 mg/day (min 0, max 21) to 2.0 mg/day (min 0, max 17.3) over 2 years. CONCLUSIONS Treatment persistence was longer on tocilizumab followed by abatacept then SC-anti-TNF therapy and was influenced by co-therapy. Glucocorticoid dosage decreased with bDMARD use. This real-world data highlights that persistence on bDMARDs differs according to biologics mode of action and co-therapy.
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Affiliation(s)
- Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Paul Bird
- University of New South Wales and Combined Rheumatology Practice, Kogarah, NSW, Australia
| | - Geoff Littlejohn
- Monash University and Monash Medical Centre, Clayton, Victoria, Australia
| | - Kathleen Tymms
- Australian National University and Canberra Rheumatology, Canberra, ACT, Australia
| | - Peter Youssef
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Rina Barrett
- Roche Products Pty Limited, Sydney, NSW, Australia
| | - Peter Button
- Roche Products Pty Limited, Sydney, NSW, Australia
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16
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Long-term effectiveness of tocilizumab in patients with rheumatoid arthritis, stratified by number of previous treatment failures with biologic agents: results from the German RABBIT cohort. Rheumatol Int 2017; 38:579-587. [PMID: 29143933 PMCID: PMC5854739 DOI: 10.1007/s00296-017-3870-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/31/2017] [Indexed: 02/06/2023]
Abstract
In Germany, Tocilizumab (TCZ) is used for the treatment of rheumatoid arthritis both in biologic-naïve patients and those with previous failures of biologic disease-modifying antirheumatic drugs (bDMARDs). The long-term effectiveness and retention rates of TCZ in patients with different numbers of prior bDMARD failures has rarely been investigated. We included 885 RA patients in the analyses, enrolled with the start of TCZ between 2009 and 2015 in the German biologics register RABBIT. Patients were stratified according to prior bDMARD failures: no prior bDMARD or 1, 2 or ≥ 3 bDMARD failures. We applied Kaplan–Meier methods and Cox-regression to examine treatment adherence as well as linear mixed effects models to investigate effectiveness over 3 years of follow-up. Compared to biologic-naïve patients, those with prior bDMARD failures at start of TCZ were younger but had significantly longer disease duration and more comorbidities. DAS28 at baseline and loss of physical function were highest in patients with ≥ 3 bDMARD failures. During follow-up, patients with up to two bDMARD failures on average reached low disease activity (LDA, DAS28 < 3.2). Those with ≥ 3 prior bDMARDs had a slightly lower response. However, after 3 years, nearly 50% of them achieved LDA. Treatment continuation on TCZ therapy was similar in patients with ≤ 2 bDMARD failures but significantly lower in those with ≥ 3 bDMARD failures. TCZ seems to be similarly effective in patients with no, one or two prior bDMARD failures. The majority of patients achieved LDA already after 6 months and maintained it over a period of 3 years. TCZ proved effective even in the high-risk group of patients with more than two prior bDMARD failures.
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Black RJ, Lester S, Buchbinder R, Barrett C, Lassere M, March L, Whittle S, Hill CL. Factors associated with oral glucocorticoid use in patients with rheumatoid arthritis: a drug use study from a prospective national biologics registry. Arthritis Res Ther 2017; 19:253. [PMID: 29141677 PMCID: PMC5688724 DOI: 10.1186/s13075-017-1461-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 10/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background Glucocorticoids (GCs) are used in ~ 60% of patients with rheumatoid arthritis (RA). Although disease-modifying, they also have significant adverse effects. Understanding factors associated with GC use may help minimise exposure. The aims of the present study were to describe oral GC use in RA; determine any change in use over time; and determine factors associated with oral GC use, commencement or cessation. Methods Adult patients with RA were identified in the Australian Rheumatology Association Database (ARAD), a national Australian registry that collects long-term outcome data from patients with inflammatory arthritis. Patients were categorised by their ARAD date of entry (DOE), with population-averaged logistic regression and transition state analysis used to determine any change in GC use over time. Fixed-effects panel regression was used to examine whether GC current use was associated with pain/arthritis activity/Health Assessment Questionnaire (HAQ) scores or medication use. Transition state analysis was used to assess whether these factors influenced the commencement or cessation of GCs. Results A total of 3699 patients with RA completed a baseline ARAD questionnaire (73% female, mean age 57 years). The probability of GC use decreased over time according to ARAD DOE: September 2001 to March 2005, 55% (95% CI 52–58%); March 2005 to September 2008, 47% (45–49%); September 2008 to March 2012, 42% (39–45%); and March 2012 to October 2015, 39% (34–43%) (p < 0.001). Conventional synthetic disease-modifying anti-rheumatic drugs (OR 10.13; 95% CI 8.22–12.47), non-steroidal anti-inflammatory drugs (1.18; 1.02–1.37) and opioids (2.14; 1.84–2.48) were associated with GC current use, as were lower pain scores (0.94; 0.90–0.98), higher arthritis activity scores (1.09; 1.05–1.14) and poorer HAQ scores (1.52; 1.30–1.79). Use of biologic disease-modifying anti-rheumatic drugs (bDMARDs) was not associated with GC current use (0.98; 0.83–1.15) or GC cessation (HR 0.87; 95% CI 0.75–1.01), but it was associated with GC commencement (0.54; 0.47–0.62). Conclusions The probability of oral GC use decreased over time, with reduced commencement and increased cessation of GCs. The modest effect of bDMARDs on GC cessation was not statistically significant. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1461-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rachel J Black
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, Adelaide, 5000, Australia. .,Division of Medicine, The University of Adelaide, Adelaide, Australia.
| | - Susan Lester
- Division of Medicine, The University of Adelaide, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia.,Department of Epidemiology & Preventive Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | | | - Marissa Lassere
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Lyn March
- Northern Clinical School, Institute of Bone and Joint Research, University of Sydney, Department of Rheumatology, Royal North Shore Hospital, Sydney, Australia
| | - Samuel Whittle
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, Australia
| | - Catherine L Hill
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, Adelaide, 5000, Australia.,Division of Medicine, The University of Adelaide, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, Australia
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Rheumatoid arthritis patients treated in trial and real world settings: comparison of randomized trials with registries. Rheumatology (Oxford) 2017; 57:354-369. [DOI: 10.1093/rheumatology/kex394] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 12/18/2022] Open
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Abstract
The use of biologics such as anti-tumor necrosis factor and oral Janus kinase inhibitors have revolutionized the treatment of rheumatoid arthritis (RA). The risk of malignancies such as lymphomas, lung cancer, and nonmelanoma skin cancers (NMSCs) is greater in patients with RA compared with the general population. The incidence of all malignancy (excluding NMSC) was similar in tofacitinib users compared with the general population. The rates of overall and site-specific malignancies in patients with RA treated with tofacitinib are similar to what is expected in the RA population and not different from disease-modifying antirheumatic drugs and biologics.
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Affiliation(s)
- Padmapriya Sivaraman
- Department of Internal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA; Division of Rheumatology, Presbyterian Hospital, 8200 Walnut Hill Ln, Dallas, TX 75231, USA; Metroplex Clinical Research Center, 8144 Walnut Hill Ln, #800, Dallas, TX 75231, USA.
| | - Stanley B Cohen
- Department of Internal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA; Division of Rheumatology, Presbyterian Hospital, 8200 Walnut Hill Ln, Dallas, TX 75231, USA; Metroplex Clinical Research Center, 8144 Walnut Hill Ln, #800, Dallas, TX 75231, USA
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Ito S. Weekly subcutaneous injection of tocilizumab in patients with rheumatoid arthritis. Mod Rheumatol 2017; 28:17-19. [PMID: 29043870 DOI: 10.1080/14397595.2017.1386838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Satoshi Ito
- a Department of Rheumatology , Niigata Rheumatic Center , Shibata City , Niigata , Japan
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21
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Real-world experience of tocilizumab in rheumatoid arthritis: sub-analysis of data from the Italian biologics’ register GISEA. Clin Rheumatol 2017; 37:315-321. [DOI: 10.1007/s10067-017-3846-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/31/2017] [Accepted: 09/18/2017] [Indexed: 12/28/2022]
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Shimizu Y, Tanaka E, Inoue E, Shidara K, Sugimoto N, Seto Y, Nakajima A, Momohara S, Taniguchi A, Yamanaka H. Reduction of methotrexate and glucocorticoids use after the introduction of biological disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis in daily practice based on the IORRA cohort. Mod Rheumatol 2017; 28:461-467. [DOI: 10.1080/14397595.2017.1369926] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Yoko Shimizu
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Eiichi Tanaka
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Eisuke Inoue
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kumi Shidara
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Naoki Sugimoto
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yohei Seto
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Ayako Nakajima
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Shigeki Momohara
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Atsuo Taniguchi
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo, Japan
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Georgakopoulou E, Scully C. Biological agents: what they are, how they affect oral health and how they can modulate oral healthcare. Br Dent J 2017; 218:671-7. [PMID: 26114697 DOI: 10.1038/sj.bdj.2015.439] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 12/17/2022]
Abstract
Biological agents - biologics, biologicals or biopharmaceuticals - are any medicinal product manufactured in, or extracted from, a biological source. They are often generated by DNA recombinant biotechnology and several dozen therapeutic monoclonal antibodies (mAbs) are now marketed for a variety of indications, increasingly in the management of inflammatory immune-mediated disorders, transplantation rejection and cancer treatments. Immunomodulatory mAbs are expensive, must be given by injection or infusion and can have adverse effects but are increasingly used and can be highly effective agents. This paper reviews these agents and their increasing relevance to oral science and healthcare.
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Affiliation(s)
- E Georgakopoulou
- Department of Histology and Embryology, School of Medicine, University of Athens, Greece
| | - C Scully
- 1] WHO Collaborating Centre for Oral Health-General Health Co-Director London [2] Royal College of Surgeons of Edinburgh King James IV Professor London [3] UCL Emeritus Professor, London
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24
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Farah Z, Ali S, Price-Kuehne F, Mackworth-Young CG. Tocilizumab in refractory rheumatoid arthritis: long-term efficacy, safety, and tolerability beyond 2 years. Biologics 2016; 10:59-66. [PMID: 27069354 PMCID: PMC4818059 DOI: 10.2147/btt.s101289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objectives To evaluate the long-term efficacy and safety of tocilizumab (TCZ) in clinical patients with rheumatoid arthritis (RA) refractory to synthetic disease-modifying antirheumatic drugs, anti-tumor necrosis factor agents, and B-cell depletion therapy with rituximab (RTX). Methods We conducted a single-center retrospective study of 22 patients with RA treated with TCZ. We collected data including demographics and medication histories. We recorded clinical parameters including tender joint counts and swollen joint counts, and laboratory parameters including inflammatory makers and lipid profiles over regular intervals of TCZ treatment. Results In all, 22 patients with RA were included, 20 of whom were female. The median age at the first dose of TCZ was 62 years (range: 35–75 years). The mean duration of the disease from diagnosis with RA to May 2015 was 15.7 years (range: 6–30 years). A total of 15 out of 22 patients remained on TCZ at the end of the study, and in all, there was an improvement in markers of disease activity following initiating TCZ. The effect was sustained for a mean of 35 months (SD±15.5 months, range: 9–72 months). Of the 17 patients who failed to respond to RTX previously, 12 patients remained on TCZ. In all, eight out of 22 patients developed adverse events, five of whom discontinued TCZ. In contrast to previously documented short-term data, TCZ did not result in a statistically significant (P<0.05) long-term deterioration in lipid profile for any of the lipid parameters measured in our cohort (mean ± SD at initiation of TCZ to most recent follow-up: total cholesterol 5.25±1.05 to 5.28±0.77 mmol/L, high-density lipoprotein 1.72±0.54 to 1.67±0.43 mmol/L, low-density lipoprotein 3.05±0.98 to 2.98±0.81 mmol/L, and cholesterol to high-density lipoprotein ratio 3.41±1.23 to 3.40±1.22). Conclusion The efficacy of TCZ in patients with RA refractory to disease-modifying drugs, including anti-tumor necrosis factor blockade and RTX, is sustained over 3 years. TCZ confers a good safety profile in the long term even in patients who previously developed adverse events to other rheumatic drugs. In the long run, there is no statistically significant deterioration in lipid profile during treatment with TCZ.
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Affiliation(s)
- Ziad Farah
- Department of Rheumatology, Charing Cross Hospital, London, UK
| | - Sabreen Ali
- Department of Rheumatology, Charing Cross Hospital, London, UK
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Black RJ, Joseph RM, Brown B, Movahedi M, Lunt M, Dixon WG. Half of U.K. patients with rheumatoid arthritis are prescribed oral glucocorticoid therapy in primary care: a retrospective drug utilisation study. Arthritis Res Ther 2015; 17:375. [PMID: 26702817 PMCID: PMC4718024 DOI: 10.1186/s13075-015-0895-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/10/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) have shared care between rheumatologists and general practitioners (GPs). Rheumatologists guide immunosuppressive therapy, whilst GPs rely on analgesia and glucocorticoid (GC) therapy to manage active disease. The objective of this study was to describe patterns of GC prescribing for patients with RA in primary care and to determine the influence of patient characteristics and prescriber. METHODS Incident RA patients were identified within the Clinical Practice Research Datalink, a United Kingdom (UK) primary care research database. Descriptive statistics identified patterns of oral GC prescribing. Prescribers were categorised by their tendency to prescribe GCs (high/low). Logistic regression was used to identify baseline characteristics associated with GC prescriptions during follow-up and to examine whether baseline characteristics influenced prescribing differently in high versus low prescribers. RESULTS A total of 7777 patients (47%) received ≥1 GC prescription during follow-up. The average daily dose was 7.5 mg (IQR 5-15.3 mg). Of those who received GCs, >50% were prescribed >10 mg/day and 20 % >30 mg/day. The median proportion of time spent on GCs was 26.3% (IQR 3.8-70.0%). Age and cardiovascular disease (CVD) were associated with increased likelihood of receiving GCs. High prescribers more commonly prescribed GC therapy in older patients and patients with hypertension. CONCLUSIONS Half of patients with incident RA received GCs in primary care. Average GC use was 7.5 mg for 25% of the time, perhaps higher usage than rheumatologists and GPs might expect. GCs were prescribed more commonly in certain high-risk populations, including older patients and those with CVD.
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Affiliation(s)
- Rachel J Black
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,Department of Medicine, The University of Adelaide, Adelaide, SA, 5005, Australia. .,Department of Rheumatology, The Basil Hetzel Institute for Translational Health Research, Woodville Rd, Woodville South, SA, 5011, Australia.
| | - Rebecca M Joseph
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, 29 Grafton Street, Manchester, M13 9WU, UK.
| | - Benjamin Brown
- Health e-Research Centre, Farr Institute for Health Informatics Research, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Mohammad Movahedi
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK.
| | - Mark Lunt
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK.
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, 29 Grafton Street, Manchester, M13 9WU, UK. .,Health e-Research Centre, Farr Institute for Health Informatics Research, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK. .,Department of Rheumatology, Salford Royal NHS Foundation Trust , Stott Lane, Salford, M6 8HD, UK.
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Besada E. Comment on: tocilizumab induces corticosteroid sparing in rheumatoid arthritis patients in clinical practice. Rheumatology (Oxford) 2015; 54:751. [PMID: 25602064 DOI: 10.1093/rheumatology/keu467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Emilio Besada
- Bone and Joint Research Group, Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
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Fortunet C, Maillefert JF. Comment on: tocilizumab induces corticosteroid sparing in rheumatoid arthritis patients in clinical practice: reply. Rheumatology (Oxford) 2015; 54:751-2. [PMID: 25602063 DOI: 10.1093/rheumatology/keu468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Clémentine Fortunet
- Department of Rheumatology, Dijon University Hospital, Dijon and INSERM U1093, UFR Médecine, University of Burgundy, France
| | - Jean Francis Maillefert
- Department of Rheumatology, Dijon University Hospital, Dijon and INSERM U1093, UFR Médecine, University of Burgundy, France. Department of Rheumatology, Dijon University Hospital, Dijon and INSERM U1093, UFR Médecine, University of Burgundy, France.
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