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Bhavsar SV, Movahedi M, Cesta A, Pope JE, Bombardier C. Retention of triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine compared to combination methotrexate and leflunomide in rheumatoid arthritis. Joint Bone Spine 2024; 91:105732. [PMID: 38583692 DOI: 10.1016/j.jbspin.2024.105732] [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: 10/16/2023] [Revised: 03/05/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE There are various combination conventional synthetic disease-modifying-antirheumatic drug (csDMARD) treatment strategies used in rheumatoid arthritis (RA). A commonly used csDMARD combination is triple therapy with methotrexate (MTX), sulfasalazine (SSZ) and hydroxychloroquine (HCQ). Another approach is double therapy with MTX and leflunomide (LEF). We compared the real-world retention of these two treatment combinations. METHODS Patients with RA from the Ontario Best Practices Research Initiative (OBRI) who received triple or double therapy on or after OBRI enrolment were included. Retention rates were compared between these two groups. We also analyzed which medication in the combination was discontinued and the reasons for treatment discontinuation. Disease activity was assessed at baseline, 6 and 12 months after treatment initiation as well as at time of discontinuation. Risk factors for treatment discontinuation were also examined. RESULTS Six hundred and ninety-two patients were included (258 triple and 434 double therapy). There were 175 (67.8%) discontinuations in the triple therapy group and 287 (66.1%) discontinuations in patients on double therapy. The median survival for triple therapy was longer (15.1 months; 95% CI: 11.2-21.2) compared to double therapy (9.6 months; 95%CI: 7.03-12.2). However, this was not statistically significant. Disease activity at 6 and 12 months, measured by 28-joint count Disease Activity Score based on erythrocyte sedimentation rate (DAS28-ESR) was lower with triple therapy (mean DAS28 at 6 months 3.4 vs. 3.9, P<0.0001 and at 12 months 3.2 vs. 3.5, P=0.0005). CONCLUSION Patients on triple therapy remained on treatment longer than patients on double therapy. However, this difference was not statistically significant.
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Affiliation(s)
| | - Mohammad Movahedi
- Ontario Best Practices Research Initiative (OBRI), Toronto General Research Institute University Health Network, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Canada.
| | - Angela Cesta
- Ontario Best Practices Research Initiative (OBRI), Toronto General Research Institute University Health Network, Toronto, Canada
| | - Janet E Pope
- Saint-Joseph's Health Care, 268, Grosvenor St, London, ON, Canada
| | - Claire Bombardier
- Ontario Best Practices Research Initiative (OBRI), Toronto General Research Institute University Health Network, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Canada
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Avalos-Salgado FA, Gonzalez-Lopez L, Gonzalez-Vazquez S, Ponce-Guarneros JM, Santiago-Garcia AP, Amaya-Cabrera EL, Arellano-Cervantes R, Gutiérrez-Aceves JA, Alcaraz-Lopez MF, Nava-Valdivia CA, Gonzalez-Ponce F, Rodriguez-Jimenez NA, Macias-Islas MA, Valdivia-Tangarife ER, Saldaña-Cruz AM, Cardona-Muñoz EG, Gamez-Nava JI. Risk Factors Associated with Adverse Events Leading to Methotrexate Withdrawal in Elderly Rheumatoid Arthritis Patients: A Retrospective Cohort Study. J Clin Med 2024; 13:1863. [PMID: 38610627 PMCID: PMC11012848 DOI: 10.3390/jcm13071863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Rheumatoid arthritis (RA) in elderly population represents a challenge for physicians in terms of therapeutic management. Methotrexate (MTX) is the first-line treatment among conventional synthetic-disease-modifying anti-rheumatic drugs (cs-DMARDs); however, it is often associated with adverse events (AEs). Therefore, the objective of this study was to identify the incidence and risk factors of MTX discontinuation due to AEs in elderly patients with RA in a long-term retrospective cohort study. Methods: Clinical sheets from elderly RA patients taking MTX from an outpatient rheumatology consult in a university centre were reviewed. To assess MTX persistence, we used Kaplan-Meir curves and Cox regression models to identify the risk of withdrawing MTX due to adverse events. Results: In total, 198 elderly RA patients who reported using MTX were included. Of them, the rates of definitive suspension of MTX due to AEs were 23.0% at 5 years, 35.6% at 10 years and 51.7% at 15 years. The main organs and system involved were gastrointestinal (15.7%) and mucocutaneous (3.0%). Factors associated with withdrawing MTX due to AEs were MTX dose ≥ 15 mg/wk (adjusted HR: 2.46, 95% CI: 1.22-4.96, p = 0.012); instead, the folic acid supplementation was protective for withdrawal (adjusted HR: 0.28, 95% CI: 0.16-0.49, p < 0.001). Conclusions: Higher doses of MTX increase the risk of withdrawals in elderly RA, while folic acid supplementation reduces the risk. Therefore, physicians working in therapeutic management for elderly patients using MTX must focus on using lower MTX doses together with the concomitant prescription of folic acid.
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Affiliation(s)
- Felipe Alexis Avalos-Salgado
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | - Laura Gonzalez-Lopez
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Programa de Maestria Salud Publica, Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Sergio Gonzalez-Vazquez
- Hospital General Regional 110, Instituto Mexicano del Seguro Social, Guadalajara 44716, Mexico
| | - Juan Manuel Ponce-Guarneros
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Instituto Mexicano del Seguro Social, Unidad de Medicina Familiar No. 97, Magdalena 46474, Mexico
| | - Aline Priscilla Santiago-Garcia
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | | | - Reynaldo Arellano-Cervantes
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Departamento de Ciencias del Movimiento Humano, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - J. Ahuixotl Gutiérrez-Aceves
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | - Miriam Fabiola Alcaraz-Lopez
- Departamento de Medicina Interna-Reumatología, Hospital General Regional Núm. 46, Instituto Mexicano del Seguro Social, Guadalajara 44910, Mexico
| | - Cesar Arturo Nava-Valdivia
- Departamento de Microbiología y Patología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Fabiola Gonzalez-Ponce
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
| | - Norma Alejandra Rodriguez-Jimenez
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Miguel Angel Macias-Islas
- Departamento de Neurociencias, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (M.A.M.-I.)
| | - Edgar Ricardo Valdivia-Tangarife
- Departamento de Neurociencias, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (M.A.M.-I.)
| | - Ana Miriam Saldaña-Cruz
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Ernesto German Cardona-Muñoz
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Jorge Ivan Gamez-Nava
- Programa de Doctorado en Farmacología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (F.A.A.-S.); (J.A.G.-A.)
- Research Group for Factors Related to Therapeutic Outcomes in Autoimmune Diseases, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico (F.G.-P.); (N.A.R.-J.); (E.G.C.-M.)
- Programa de Maestria Salud Publica, Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Instituto de Terapéutica Experimental y Clínica, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
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Sherbini AA, Sharma SD, Gwinnutt JM, Hyrich KL, Verstappen SMM. Prevalence and predictors of adverse events with methotrexate mono- and combination-therapy for rheumatoid arthritis: a systematic review. Rheumatology (Oxford) 2021; 60:4001-4017. [PMID: 33909898 PMCID: PMC8410011 DOI: 10.1093/rheumatology/keab304] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 03/21/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This systematic review aims to summarize rates of adverse events (AEs) in patients with RA or inflammatory arthritis starting MTX as monotherapy or in combination with other csDMARDs, and to identify reported predictors of AEs. METHODS Three databases were searched for studies reporting AEs in MTX-naïve patients with RA. Randomized controlled trials (RCTs) and observational cohort studies were included. Prevalence rates of AEs were pooled using random effects meta-analysis, stratified by study design. RESULTS Forty-six articles (34 RCTs and 12 observational studies) were identified. The pooled prevalence of total AEs was 80.1% in RCTs (95% CI: 73.5, 85.9), compared with 23.1% in observational studies (95% CI: 12.3, 36.0). The pooled prevalence of serious AEs was 9.5% in RCTs (95% CI: 7.4, 11.7), and 2.1% in observational studies (95% CI: 1.0, 3.4). MTX discontinuation due to AEs was higher in observational studies (15.5%, 95% CI: 9.6, 22.3) compared with RCTs (6.7%, 95% CI: 4.7, 8.9). Gastrointestinal events were the most commonly reported AEs (pooled prevalence: 32.7%, 95% CI: 18.5, 48.7). Five studies examined predictors of AEs. RF status, BMI and HAQ score were associated with MTX discontinuation due to AEs; ACPA negativity, smoking and elevated creatinine were associated with increased risk of elevated liver enzymes. CONCLUSION The review provides an up-to-date overview of the prevalence of AEs associated with MTX in patients with RA. The findings should be communicated to patients to help them make informed choices prior to commencing MTX.
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Affiliation(s)
- Ahmad A Sherbini
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
| | - Seema D Sharma
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
| | - James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Cole M, Yap C, Buckley C, Ng WF, McInnes I, Filer A, Siebert S, Pratt A, Isaacs JD, Stocken DD. TRAFIC: statistical design and analysis plan for a pragmatic early phase 1/2 Bayesian adaptive dose escalation trial in rheumatoid arthritis. Trials 2021; 22:433. [PMID: 34229728 PMCID: PMC8259060 DOI: 10.1186/s13063-021-05384-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 11/19/2022] Open
Abstract
Background Adaptive model-based dose-finding designs have demonstrated advantages over traditional rule-based designs but have increased statistical complexity but uptake has been slow especially outside of cancer trials. TRAFIC is a multi-centre, early phase trial in rheumatoid arthritis incorporating a model-based design. Methods A Bayesian adaptive dose-finding phase I trial rolling into a single-arm, single-stage phase II trial. Model parameters for phase I were chosen via Monte Carlo simulation evaluating objective performance measures under clinically relevant scenarios and incorporated stopping rules for early termination. Potential designs were further calibrated utilising dose transition pathways. Discussion TRAFIC is an MRC-funded trial of a re-purposed treatment demonstrating that it is possible to design, fund and implement a model-based phase I trial in a non-cancer population within conventional research funding tracks and regulatory constraints. The phase I design allows borrowing of information from previous trials, all accumulated data to be utilised in decision-making, verification of operating characteristics through simulation, improved understanding for management and oversight teams through dose transition pathways. The rolling phase II design brings efficiencies in trial conduct including site and monitoring activities and cost. TRAFIC is the first funded model-based dose-finding trial in inflammatory disease demonstrating that small phase I/II trials can have an underlying statistical basis for decision-making and interpretation. Trial registration Trials Registration: ISRCTN, ISRCTN36667085. Registered on September 26, 2014.
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Affiliation(s)
- M Cole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - C Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, Sutton, UK
| | - C Buckley
- School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - W F Ng
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - I McInnes
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - A Filer
- School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - S Siebert
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - A Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - J D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - D D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
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Pratt AG, Siebert S, Cole M, Stocken DD, Yap C, Kelly S, Shaikh M, Cranston A, Morton M, Walker J, Frame S, Ng WF, Buckley CD, McInnes IB, Filer A, Isaacs JD. Targeting synovial fibroblast proliferation in rheumatoid arthritis (TRAFIC): an open-label, dose-finding, phase 1b trial. LANCET RHEUMATOLOGY 2021; 3:e337-e346. [PMID: 33928262 PMCID: PMC8062952 DOI: 10.1016/s2665-9913(21)00061-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Current rheumatoid arthritis therapies target immune inflammation and are subject to ceiling effects. Seliciclib is an orally available cyclin-dependent kinase inhibitor that suppresses proliferation of synovial fibroblasts—cells not yet targeted in rheumatoid arthritis. Part 1 of this phase 1b/2a trial aimed to establish the maximum tolerated dose of seliciclib in patients with active rheumatoid arthritis despite ongoing treatment with TNF inhibitors, and to evaluate safety and pharmacokinetics. Methods Phase 1b of the TRAFIC study was a non-randomised, open-label, dose-finding trial done in rheumatology departments in five UK National Health Service hospitals. Eligible patients (aged ≥18 years) fulfilled the 1987 American College of Rheumatology (ACR) or the 2010 ACR–European League Against Rheumatism classification criteria for rheumatoid arthritis and had moderate to severe disease activity (a Disease Activity Score for 28 joints [DAS28] of ≥3·2) despite stable treatment with anti-TNF therapy for at least 3 months before enrolment. Participants were recruited sequentially to a maximum of seven cohorts of three participants each, designated to receive seliciclib 200 mg, 400 mg, 600 mg, 800 mg, or 1000 mg administered in 200 mg oral capsules. Sequential cohorts received doses determined by a restricted, one-stage Bayesian continual reassessment model, which determined the maximum tolerated dose (the primary outcome) based on a target dose-limiting toxicity rate of 35%. Seliciclib maximum concentration (Cmax) and area under the plasma concentration time curve 0–6 h (AUC0–6) were measured. This study is registered with ISRCTN, ISRCTN36667085. Findings Between Oct 8, 2015, and Aug 15, 2017, 37 patients were screened and 15 were enrolled to five cohorts and received seliciclib, after which the trial steering committee and the data monitoring committee determined that the maximum tolerated dose could be defined. In addition to a TNF inhibitor, ten (67%) enrolled patients were taking conventional synthetic disease modifying antirheumatic drugs. The maximum tolerated dose of seliciclib was 400 mg, with an estimated dose-limiting toxicity probability of 0·35 (90% posterior probability interval 0·18–0·52). Two serious adverse events occurred (one acute kidney injury in a patient receiving the 600 mg dose and one drug-induced liver injury in a patient receiving the 400 mg dose), both considered to be related to seliciclib and consistent with its known safety profile. 65 non-serious adverse events occurred during the trial, 50 of which were considered to be treatment related. Most treatment-related adverse events were mild; 20 of the treatment-related non-serious adverse events contributed to dose-limiting toxicities. There were no deaths. Average Cmax and AUC0–6 were two-times higher in participants developing dose-limiting toxicities. Interpretation The maximum tolerated dose of seliciclib has been defined for rheumatoid arthritis refractory to TNF blockade. No unexpected safety concerns were identified to preclude ongoing clinical evaluation in a formal efficacy trial. Funding UK Medical Research Council, Cyclacel, Research into Inflammatory Arthritis Centre (Versus Arthritis), and the National Institute of Health Research Newcastle and Birmingham Biomedical Research Centres and Clinical Research Facilities.
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Affiliation(s)
- Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Michael Cole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Christina Yap
- Clinical Trial and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Stephen Kelly
- Department of Rheumatology, Barts Health NHS Trust, London, UK
| | - Muddassir Shaikh
- Department of Rheumatology, James Cook University Hospital, Middlesbrough, UK
| | - Amy Cranston
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Miranda Morton
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jenn Walker
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Wan-Fai Ng
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Christopher D Buckley
- National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Andrew Filer
- National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Yan D, Borucki R, Sontheimer RD, Werth VP. Candidate drug replacements for quinacrine in cutaneous lupus erythematosus. Lupus Sci Med 2020; 7:7/1/e000430. [PMID: 33082164 PMCID: PMC7577055 DOI: 10.1136/lupus-2020-000430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/22/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is a disfiguring and potentially disabling disease that causes significant morbidity in patients. Antimalarials are an important class of medication used to treat this disease and have been the first-line systemic therapy since the 1950s. Quinacrine, in particular, is used as an adjuvant therapy to other antimalarials for improved control of CLE. Quinacrine is currently unavailable in the USA, which has taken away an important component of the treatment regimen of patients with CLE. This paper reviews the evidence of available local and systemic therapies in order to assist providers in choosing alternative treatments for patients who previously benefited from quinacrine therapy.
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Affiliation(s)
- Daisy Yan
- Department of Dermatology, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert Borucki
- Department of Dermatology, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Richard D Sontheimer
- Department of Dermatology, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Victoria P Werth
- Department of Dermatology, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA .,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Update on the Pathomechanism, Diagnosis, and Treatment Options for Rheumatoid Arthritis. Cells 2020; 9:cells9040880. [PMID: 32260219 PMCID: PMC7226834 DOI: 10.3390/cells9040880] [Citation(s) in RCA: 395] [Impact Index Per Article: 98.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/28/2020] [Accepted: 03/30/2020] [Indexed: 12/18/2022] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease that involves multiple joints bilaterally. It is characterized by an inflammation of the tendon (tenosynovitis) resulting in both cartilage destruction and bone erosion. While until the 1990s RA frequently resulted in disability, inability to work, and increased mortality, newer treatment options have made RA a manageable disease. Here, great progress has been made in the development of disease-modifying anti-rheumatic drugs (DMARDs) which target inflammation and thereby prevent further joint damage. The available DMARDs are subdivided into (1) conventional synthetic DMARDs (methotrexate, hydrochloroquine, and sulfadiazine), (2) targeted synthetic DMARDs (pan-JAK- and JAK1/2-inhibitors), and (3) biologic DMARDs (tumor necrosis factor (TNF)-α inhibitors, TNF-receptor (R) inhibitors, IL-6 inhibitors, IL-6R inhibitors, B cell depleting antibodies, and inhibitors of co-stimulatory molecules). While DMARDs have repeatedly demonstrated the potential to greatly improve disease symptoms and prevent disease progression in RA patients, they are associated with considerable side-effects and high financial costs. This review summarizes our current understanding of the underlying pathomechanism, diagnosis of RA, as well as the mode of action, clinical benefits, and side-effects of the currently available DMARDs.
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Lee EM, Vasudevan AR, Wee IYJ, Yeow SD, Dinh VTU. Effectiveness and safety of physician–pharmacist collaborative care for rheumatoid arthritis patients: The Changi General Hospital’s experience. PROCEEDINGS OF SINGAPORE HEALTHCARE 2019. [DOI: 10.1177/2010105819839078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Increasing demand for follow-up of rheumatoid arthritis has encouraged pharmacists to collaborate with physicians to assist with patient care. Objective: The aim of this study was to assess the effectiveness and safety of the collaborative care model in a rheumatoid arthritis clinic. Methods: We performed a retrospective review of patient case notes and medication records from March 2013 to February 2016. The effectiveness and safety of collaborative care was examined in pre-implementation (standard care) versus post-implementation (collaborative care) cohorts. All patients were assessed for 12 months. Effectiveness of clinic was measured using the percentage of patients that achieved optimal doses of non-biologic disease-modifying anti-rheumatic drugs (nb-DMARDs). Clinic safety performance was evaluated based on the percentage of patients in each cohort that achieved compliance to in-house hospital guidelines on nb-DMARD monitoring. Other clinic safety factors monitored included the incidence and characteristics of nb-DMARD-associated adverse drug events. Results: Thirty-eight patients who had received standard care and collaborative care were reviewed. More patients receiving collaborative care achieved nb-DMARD dose optimization within a year of initiation of therapy (68.4% vs 39.5%; p-value < 0.05). Compliance to safety recommendations from hospital guidelines on nb-DMARD monitoring was significantly higher in the collaborative care group (70.6% vs 44.1%; p-value < 0.05). Collaborative care resulted in a higher incidence of nb-DMARD-associated adverse drug events being detected (26.3% vs 18.4%; p-value < 0.05). The most common adverse drug events were gastrointestinal (29.4%), dermatological (17.6%), and hematologic (17.6%), the majority being mild in severity. Conclusion: Collaborative rheumatoid arthritis care contributed to improvements in nb-DMARD dose optimization, compliance to hospital guidelines on monitoring, and the detection of nb-DMARD-related adverse drug events.
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9
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An in vitro test system for compounds that modulate human inflammatory macrophage polarization. Eur J Pharmacol 2018; 833:328-338. [DOI: 10.1016/j.ejphar.2018.06.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 12/22/2022]
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10
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Betancourt BY, Biehl A, Katz JD, Subedi A. Pharmacotherapy Pearls in Rheumatology for the Care of Older Adult Patients: Focus on Oral Disease-Modifying Antirheumatic Drugs and the Newest Small Molecule Inhibitors. Rheum Dis Clin North Am 2018; 44:371-391. [PMID: 30001781 DOI: 10.1016/j.rdc.2018.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Providing safe and effective pharmacotherapy to geriatric patients with rheumatologic disorders is challenging. Multidisciplinary care involving rheumatologists, primary care physicians, and other specialties can optimize benefit and reduce adverse outcomes. Oral disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the small molecule inhibitors tofacitinib and apremilast have distinctive monitoring requirements and specific adverse reaction profiles. This article provides clinically relevant pearls for use of these interventions in older patients.
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Affiliation(s)
- Blas Y Betancourt
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA.
| | - Ann Biehl
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, FDA, 10001 New Hampshire Avenue, Hillandale Building, 4th Floor Silver Spring, MD 20993, USA
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
| | - Ananta Subedi
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
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11
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High burden of adverse events is associated with reduced remission rates in early rheumatoid arthritis. Clin Rheumatol 2017; 37:1689-1694. [DOI: 10.1007/s10067-017-3958-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/09/2017] [Accepted: 12/14/2017] [Indexed: 12/01/2022]
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12
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Wabe N, Wojciechowski J, Wechalekar MD, Cleland LG, McWilliams L, Lee A, Proudman S, Wiese MD. Disease activity trajectories in early rheumatoid arthritis following intensive DMARD therapy over 3 years: association with persistence to therapy. Int J Rheum Dis 2017; 20:1447-1456. [PMID: 28952204 DOI: 10.1111/1756-185x.13184] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify the disease activity trajectories during intensive triple disease modifying anti-rheumatic drug (DMARD) therapy over 3 years in rheumatoid arthritis (RA) patients and to evaluate the association with treatment persistence. METHODS Disease Activity Score in 28 joints, baseline risk factors and medication usage were obtained from a longitudinal observational cohort of early RA patients, most of whom were treated with combination DMARD therapy consisting of methotrexate, sulfasalazine and hydroxychloroquine. Persistence of each DMARD was defined as the duration of time from initiation to cessation. A group-based trajectory modelling technique was used to identify disease activity trajectories. RESULT Three disease activity trajectories (good [43.8%], moderate [39.7%] and poor [16.5%]) were identified in a cohort of 297 patients. Most baseline risk factors, medication usage, the rate of treatment persistence and the effect of persistence on disease activity differed among patients in each of the three trajectories. Although the rate of persistence was higher in the trajectory with a good outcome, the association with persistence was more pronounced among patients who were in the poor outcome trajectory. Persistence with at least two or all three baseline DMARDs was associated with a decrease in disease activity to a broadly similar degree in all trajectories. CONCLUSION After correction for other baseline prognostic factors, persistence with initial DMARDs contributes to heterogeneity in disease activity trajectory and there was an association between persistence with initial DMARD therapy and lower long-term disease activity.
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Affiliation(s)
- Nasir Wabe
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia
| | - Jessica Wojciechowski
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia.,Australian Centre for Pharmacometrics, University of South Australia, Adelaide, South Australia, Australia
| | - Mihir D Wechalekar
- Rheumatology Unit, Repatriation General Hospital, Adelaide, South Australia, Australia
| | - Leslie G Cleland
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Leah McWilliams
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Anita Lee
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael D Wiese
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia
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Biehl AJ, Katz JD. Pharmacotherapy Pearls for the Geriatrician: Focus on Oral Disease-Modifying Antirheumatic Drugs Including Newer Agents. Clin Geriatr Med 2016; 33:1-15. [PMID: 27886691 DOI: 10.1016/j.cger.2016.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Providing safe and effective pharmacotherapy to the geriatric patients with rheumatological disorders is an ongoing struggle for the rheumatologist and geriatrician alike. Cohesive communication and partnership can improve the care of these patients and subvert adverse outcomes. Disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the newest oral agent for treatment of rheumatoid arthritis, tofacitinib, have distinctive monitoring and adverse effect profiles. This article provides the general practitioner or geriatrician with clinically relevant pearls regarding the use of these interventions in older patients.
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Affiliation(s)
- Ann J Biehl
- Department of Pharmacy, National Institutes of Health Clinical Center, 10 Center Drive, Room 1C240, Bethesda, MD 20892-1196, USA.
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 6N-216F, Building 10, 9000 Rockville Pike, Bethesda, MD 20892, USA
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