1
|
Kaur C, Mishra Y, Kumar R, Singh G, Singh S, Mishra V, Tambuwala MM. Pathophysiology, diagnosis, and herbal medicine-based therapeutic implication of rheumatoid arthritis: an overview. Inflammopharmacology 2024; 32:1705-1720. [PMID: 38528307 PMCID: PMC11136810 DOI: 10.1007/s10787-024-01445-8] [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: 12/04/2023] [Accepted: 02/10/2024] [Indexed: 03/27/2024]
Abstract
Rheumatoid arthritis (RA) stands as an autoimmune disorder characterized by chronic joint inflammation, resulting in profound physiological alterations within the body. Affecting approximately 0.4-1.3% of the global population, this condition poses significant challenges as current therapeutic approaches primarily offer symptomatic relief, with the prospect of complete recovery remaining elusive. This review delves into the contemporary advancements in understanding the pathophysiology, diagnosis, and the therapeutic potential of herbal medicine in managing RA. Notably, early diagnosis during the initial stages emerges as the pivotal determinant for successful recovery post-treatment. Utilizing tools such as Magnetic Resonance Imaging (MRI), anti-citrullinated peptide antibody markers, and radiography proves crucial in pinpointing the diagnosis of RA with precision. Unveiling the intricate pathophysiological mechanisms of RA has paved the way for innovative therapeutic interventions, incorporating plant extracts and isolated phytoconstituents. In the realm of pharmacological therapy for RA, specific disease-modifying antirheumatic drugs have showcased commendable efficacy. However, this conventional approach is not without its drawbacks, as it is often associated with various side effects. The integration of methodological strategies, encompassing both pharmacological and plant-based herbal therapies, presents a promising avenue for achieving substantive recovery. This integrated approach not only addresses the symptoms but also strives to tackle the underlying causes of RA, fostering a more comprehensive and sustainable path towards healing.
Collapse
Affiliation(s)
- Charanjit Kaur
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, 144411, Punjab, India
| | - Yachana Mishra
- School of Bioengineering and Biosciences, Lovely Professional University, Phagwara, 144411, Punjab, India
| | - Rajesh Kumar
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, 144411, Punjab, India
| | - Gurvinder Singh
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, 144411, Punjab, India
| | - Sukhraj Singh
- Department of Food Civil Supply and Consumer Affairs, Amritsar, 143001, Punjab, India
| | - Vijay Mishra
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, 144411, Punjab, India.
| | - Murtaza M Tambuwala
- Lincoln Medical School, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS, England, UK.
| |
Collapse
|
2
|
Kedra J, Dieudé P, Giboin C, Marotte H, Salliot C, Schaeverbeke T, Perdriger A, Soubrier M, Morel J, Constantin A, Dernis E, Royant V, Salmon JH, Pham T, Gottenberg JE, Pertuiset E, Dougados M, Devauchelle-Pensec V, Gaudin P, Cormier G, Goupille P, Mariette X, Berenbaum F, Alcaix D, Rouidi SA, Berthelot JM, Monnier A, Piroth C, Lioté F, Goëb V, Gaujoux-Viala C, Chary-Valckenaere I, Hajage D, Tubach F, Fautrel B. Towards the Lowest Efficacious Dose: Results From a Multicenter Noninferiority Randomized Open-Label Controlled Trial Assessing Tocilizumab or Abatacept Injection Spacing in Rheumatoid Arthritis in Remission. Arthritis Rheumatol 2024; 76:541-552. [PMID: 37942714 DOI: 10.1002/art.42752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE We assess the clinical and structural impact at two years of progressively spacing tocilizumab (TCZ) or abatacept (ABA) injections versus maintenance at full dose in patients with rheumatoid arthritis in sustained remission. METHODS This multicenter open-label noninferiority (NI) randomized clinical trial included patients with established rheumatoid arthritis in sustained remission receiving ABA or TCZ at a stable dose. Patients were randomized to treatment maintenance (M) at full dose (M-arm) or progressive injection spacing (S) driven by the Disease Activity Score in 28 joints every 3 months up to biologics discontinuation (S-arm). The primary end point was the evolution of disease activity according to the Disease Activity Score in 44 joints during the 2-year follow-up analyzed per protocol with a linear mixed-effects model, evaluated by an NI test based on the one-sided 95% confidence interval (95% CI) of the slope difference (NI margin 0.25). Other end points were flare incidence and structural damage progression. RESULTS Overall, 202 of the 233 patients included were considered for per protocol analysis (90 in S-arm and 112 in M-arm). At the end of follow-up, 16.2% of the patients in the S-arm could discontinue their biologic disease-modifying antirheumatic drug, 46.9% tapered the dose and 36.9% returned to a full dose. NI was not demonstrated for the primary outcome, with a slope difference of 0.10 (95% CI 0.10-0.31) between the two arms. NI was not demonstrated for flare incidence (difference 42.6%, 95% CI 30.0-55.1) or rate of structural damage progression at two years (difference 13.9%, 95% CI -6.7 to 34.4). CONCLUSION The Towards the Lowest Efficacious Dose trial failed to demonstrate NI for the proposed ABA or TCZ tapering strategy.
Collapse
Affiliation(s)
- Joanna Kedra
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Philippe Dieudé
- Université de Paris Cité, INSERM UMR 1152 and Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Caroline Giboin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Hubert Marotte
- Université Jean Monnet Saint-Étienne, Centre Hospitalier Universitaire de Saint-Etienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Étienne, France
| | | | | | | | - Martin Soubrier
- Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Jacques Morel
- Montpellier University Hospital and University of Montpellier, INSRM, CNRS, Montpellier, France
| | - Arnaud Constantin
- Pierre-Paul Riquet University Hospital, Toulouse III - Paul Sabatier University, and INSERM UMR 1291, Purpan University Hospital, Toulouse, France
| | | | | | - Jean-Hugues Salmon
- University of Reims Champagne-Ardenne, Faculty of Medicine, UR 3797 and Maison Blanche Hospital, Reims University Hospitals, Reims, France
| | - Thao Pham
- Sainte-Marguerite Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | | | | | - Maxime Dougados
- University of Paris, Hôpital Cochin. AP-HP, INSERM U1153, pôle de recherche et d'enseignement supérieur Sorbonne Paris-Cité, Paris, France
| | | | | | | | | | - Xavier Mariette
- Université Paris-Saclay, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Le Kremlin Bicêtre, France
| | - Francis Berenbaum
- Sorbonne University-INSERM Centre De Recherche scientifique Saint-Antoine, AP-HP Saint-Antoine Hospital, Paris, France
| | | | | | | | | | | | - Frédéric Lioté
- Université de Paris and INSERM UMR1132 Bioscar (Centre Viggo Petersen), Hôpital Lariboisière, AP-HP, Paris, France
| | - Vincent Goëb
- University Hospital of Amiens, Université de Picardie Jules Verne, Amiens, France
| | - Cécile Gaujoux-Viala
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, University of Montpellier, INSERM, Centre Hospitalier Universitaire de Nîmes, Montpellier, France
| | | | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno Fautrel
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| |
Collapse
|
3
|
Kameda H, Nishida K, Nanki T, Watanabe A, Oshima Y, Momohara S. Safety and effectiveness of certolizumab pegol in Japanese patients with rheumatoid arthritis: Up to 3-year results from a postmarketing surveillance study. Mod Rheumatol 2024:roae019. [PMID: 38619380 DOI: 10.1093/mr/roae019] [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: 08/28/2023] [Accepted: 02/22/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES To report up to 3-year safety and effectiveness of certolizumab pegol (CZP) in Japanese patients with rheumatoid arthritis from a postmarketing surveillance study. METHODS Patients enrolled previously completed 24 weeks of CZP in the 24-week postmarketing surveillance study. Adverse drug reactions (ADRs) were recorded for patients who received ≥1 CZP dose. Effectiveness outcomes were 28-joint Disease Activity Score with erythrocyte sedimentation rate and European Alliance of Associations for Rheumatology response. Week 24-156 safety and Week 0-52 effectiveness data are reported here. RESULTS A total of 781 patients were enrolled, with 735 and 376 patients evaluated for safety and effectiveness, respectively. Within the safety set, 17.8% (131/735) of patients reported ADRs; 9.4% (69/735) reported serious ADRs. Among patients with history of respiratory, thoracic, and mediastinal disorders, 38.4% (28/73) reported ADRs. The most frequent ADRs were infections and infestations (11.8%; 87/735); skin and subcutaneous tissue disorders (1.9%; 14/735); respiratory, thoracic, and mediastinal disorders (1.6%; 12/735). Mean 28-joint Disease Activity Score with erythrocyte sedimentation rate reduced from 4.6 (Week 0) to 2.8 (Week 52). At Week 52, 51.8% (161/311) of patients achieved European Alliance of Associations for Rheumatology Good response. CONCLUSIONS The long-term safety and effectiveness of CZP in the real-world setting in Japan were consistent with previously reported data; no new safety signals were identified.
Collapse
Affiliation(s)
- Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University (Ohashi Medical Center), Tokyo, Japan
| | - Keiichiro Nishida
- Department of Orthopaedic Surgery, Science of Functional Recovery and Reconstruction, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Toshihiro Nanki
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University (Omori Medical Center), Tokyo, Japan
| | - Akira Watanabe
- Research Division for Development of Anti-Infective Agents, Faculty of Medical Science and Welfare, Tohoku Bunka Gakuen University, Sendai, Japan
| | | | - Shigeki Momohara
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
4
|
Gao Y, Zhang Y, Liu X. Rheumatoid arthritis: pathogenesis and therapeutic advances. MedComm (Beijing) 2024; 5:e509. [PMID: 38469546 PMCID: PMC10925489 DOI: 10.1002/mco2.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 03/13/2024] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by the unresolved synovial inflammation for tissues-destructive consequence, which remains one of significant causes of disability and labor loss, affecting about 0.2-1% global population. Although treatments with disease-modifying antirheumatic drugs (DMARDs) are effective to control inflammation and decrease bone destruction, the overall remission rates of RA still stay at a low level. Therefore, uncovering the pathogenesis of RA and expediting clinical transformation are imminently in need. Here, we summarize the immunological basis, inflammatory pathways, genetic and epigenetic alterations, and metabolic disorders in RA, with highlights on the abnormality of immune cells atlas, epigenetics, and immunometabolism. Besides an overview of first-line medications including conventional DMARDs, biologics, and small molecule agents, we discuss in depth promising targeted therapies under clinical or preclinical trials, especially epigenetic and metabolic regulators. Additionally, prospects on precision medicine based on synovial biopsy or RNA-sequencing and cell therapies of mesenchymal stem cells or chimeric antigen receptor T-cell are also looked forward. The advancements of pathogenesis and innovations of therapies in RA accelerates the progress of RA treatments.
Collapse
Affiliation(s)
- Ying Gao
- Department of RheumatologyChanghai HospitalNaval Medical UniversityShanghaiChina
| | - Yunkai Zhang
- Naval Medical CenterNaval Medical UniversityShanghaiChina
| | - Xingguang Liu
- National Key Laboratory of Immunity & InflammationNaval Medical UniversityShanghaiChina
- Department of Pathogen BiologyNaval Medical UniversityShanghaiChina
| |
Collapse
|
5
|
Ward MM, Madanchi N, Yazdanyar A, Shah NR, Constantinescu F. Prevalence and predictors of sustained remission/low disease activity after discontinuation of induction or maintenance treatment with tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic and scoping review. Arthritis Res Ther 2023; 25:222. [PMID: 37986101 PMCID: PMC10659063 DOI: 10.1186/s13075-023-03199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND To determine the prevalence of sustained remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) after discontinuation of tumor necrosis factor inhibitors (TNFi), separately in induction treatment and maintenance treatment studies, and to identify predictors of successful discontinuation. METHODS We performed a systematic literature review of studies published from 2005 to May 2022 that reported outcomes after TNFi discontinuation among patients in remission/LDA. We computed prevalences of successful discontinuation by induction or maintenance treatment, remission criterion, and follow-up time. We performed a scoping review of predictors of successful discontinuation. RESULTS Twenty-two induction-withdrawal studies were identified. In pooled analyses, 58% (95% confidence interval (CI) 45, 70) had DAS28 < 3.2 (9 studies), 52% (95% CI 35, 69) had DAS28 < 2.6 (9 studies), and 40% (95% CI 18, 64) had SDAI ≤ 3.3 (4 studies) at 37-52 weeks after discontinuation. Among patients who continued TNFi, 62 to 85% maintained remission. Twenty-two studies of maintenance treatment discontinuation were also identified. At 37-52 weeks after TNFi discontinuation, 48% (95% CI 38, 59) had DAS28 < 3.2 (10 studies), and 47% (95% CI 33, 62) had DAS28 < 2.6 (6 studies). Heterogeneity among studies was high. Data on predictors in induction-withdrawal studies were limited. In both treatment scenarios, longer duration of RA was most consistently associated with less successful discontinuation. CONCLUSIONS Approximately one-half of patients with RA remain in remission/LDA for up to 1 year after TNFi discontinuation, with slightly higher proportions in induction-withdrawal settings than with maintenance treatment discontinuation.
Collapse
Affiliation(s)
- Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10CRC, Room 4-1339, 10 Center Drive, Bethesda, MD, 20892-1468, USA.
| | - Nima Madanchi
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Current address: Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, USA
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Current address: Division of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nehal R Shah
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | |
Collapse
|
6
|
van Esveld L, Cox JM, Kuijper TM, Bosch TM, Weel-Koenders AE. Cost-utility analysis of tapering strategies of biologicals in rheumatoid arthritis patients in the Netherlands. Ann Rheum Dis 2023; 82:1296-1306. [PMID: 37423648 DOI: 10.1136/ard-2023-224190] [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: 03/23/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Current guidelines recommend tapering biological disease-modifying antirheumatoid drugs (bDMARDs) in rheumatoid arthritis (RA) if the disease is under control. However, guidelines on tapering are lacking. Assessing cost-effectiveness of different tapering strategies might provide broader input for creating guidelines on how to taper bDMARDs in patients with RA. The aim of this study is to evaluate the long-term cost-effectiveness from a societal perspective of bDMARD tapering strategies in Dutch patients with RA, namely 50% dose reduction (tapering), discontinuation and a 50% dose reduction followed by discontinuation (de-escalation). METHODS Using a societal perspective, a Markov model with a life-time horizon of 30 years was used to simulate 3-monthly transitions between Disease Activity 28 (DAS28)-defined health states of remission (<2.6), low disease activity (2.63.2). Transition probabilities were estimated through literature search and random effects pooling. Incremental costs, incremental quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits for each tapering strategy were compared with continuation. Deterministic, probabilistic sensitivity analyses and multiple scenario analyses were performed. RESULTS After 30 years, the ICERs were €115 157/QALY lost, €74 226/QALY lost and €67 137/QALY lost for tapering, de-escalation and discontinuation, respectively; mainly driven by bDMARD cost savings and a 72.8% probability of a loss in quality of life. This corresponds to a 76.1%, 64.3% and 60.1% probability of tapering, de-escalation and discontinuation being cost-effective, provided a willingness-to-accept threshold of €50 000/QALY lost. CONCLUSIONS Based on these analyses, the 50% tapering approach saved the highest cost per QALY lost.
Collapse
Affiliation(s)
| | - Juul M Cox
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Tessa M Bosch
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
| | - Angelique Eam Weel-Koenders
- Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
7
|
Emery P, Tanaka Y, Bykerk VP, Huizinga TWJ, Citera G, Bingham CO, Banerjee S, Soule BP, Nys M, Connolly SE, Lozenski KL, Zhuo J, Wong R, Huang KHG, Fleischmann R. Sustained Remission and Outcomes with Abatacept plus Methotrexate Following Stepwise Dose De-escalation in Patients with Early Rheumatoid Arthritis. Rheumatol Ther 2023; 10:707-727. [PMID: 36869251 PMCID: PMC10140217 DOI: 10.1007/s40744-022-00519-9] [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: 03/08/2022] [Accepted: 12/02/2022] [Indexed: 03/05/2023] Open
Abstract
INTRODUCTION One target of rheumatoid arthritis (RA) treatment is to achieve early sustained remission; over the long term, patients in sustained remission have less structural joint damage and physical disability. We evaluated Simplified Disease Activity Index (SDAI) remission with abatacept + methotrexate versus abatacept placebo + methotrexate and impact of de-escalation (DE) in anti-citrullinated protein antibody (ACPA)-positive patients with early RA. METHODS The phase IIIb, randomized, AVERT-2 two-stage study (NCT02504268) evaluated weekly abatacept + methotrexate versus abatacept placebo + methotrexate. PRIMARY ENDPOINT SDAI remission (≤ 3.3) at week 24. Pre-planned exploratory endpoint: maintenance of remission in patients with sustained remission (weeks 40 and 52) who, from week 56 for 48 weeks (DE period), (1) continued combination abatacept + methotrexate, (2) tapered abatacept to every other week (EOW) + methotrexate for 24 weeks with subsequent abatacept withdrawal (abatacept placebo + methotrexate), or (3) withdrew methotrexate (abatacept monotherapy). RESULTS Primary study endpoint was not met: 21.3% (48/225) of patients in the combination and 16.0% (24/150) in the abatacept placebo + methotrexate arm achieved SDAI remission at week 24 (p = 0.2359). There were numerical differences favoring combination therapy in clinical assessments, patient-reported outcomes (PROs) and week 52 radiographic non-progression. After week 56, 147 patients in sustained remission with abatacept + methotrexate were randomized (combination, n = 50; DE/withdrawal, n = 50; abatacept monotherapy, n = 47) and entered DE. At DE week 48, SDAI remission (74%) and PRO improvements were mostly maintained with continued combination therapy; lower remission rates were observed with abatacept placebo + methotrexate (48.0%) and with abatacept monotherapy (57.4%). Before withdrawal, de-escalating to abatacept EOW + methotrexate preserved remission. CONCLUSIONS The stringent primary endpoint was not met. However, in patients achieving sustained SDAI remission, numerically more maintained remission with continued abatacept + methotrexate versus abatacept monotherapy or withdrawal. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02504268. Video abstract (MP4 62241 KB).
Collapse
Affiliation(s)
- Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and Leeds NIHR Biomedical Research Centre, Leeds, UK.
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Vivian P Bykerk
- Department of Rheumatology, Hospital for Special Surgery, New York City, NY, USA
| | - Thomas W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gustavo Citera
- Department of Rheumatology, Instituto de Rehabilitación Psicofísca, Buenos Aires, Argentina
| | - Clifton O Bingham
- Divisions of Rheumatology and Allergy, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Subhashis Banerjee
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Benjamin P Soule
- Fibrosis Business Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Marleen Nys
- Global Biometrics and Data Science, Bristol Myers Squibb, Braine-l'Alleud, Belgium
| | - Sean E Connolly
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Karissa L Lozenski
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Joe Zhuo
- Worldwide Health Economics and Outcomes Research, Bristol Myers Squibb, Princeton, NJ, USA
| | - Robert Wong
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Kuan-Hsiang Gary Huang
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Roy Fleischmann
- Division of Rheumatology, University of Texas Southwestern Medical Center and Metroplex Clinical Research Center, Dallas, TX, USA
| |
Collapse
|
8
|
Shin K, Kwon HM, Kim MJ, Yoon MJ, Chai HG, Kang SW, Park W, Park SH, Suh CH, Kim HA, Lee SG, Lee CK, Bae SC, Park YB, Song YW. Two-year clinical outcomes after discontinuation of long-term golimumab therapy in Korean patients with rheumatoid arthritis. Korean J Intern Med 2022; 37:1061-1069. [PMID: 34883551 PMCID: PMC9449209 DOI: 10.3904/kjim.2021.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/15/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to investigate long-term post-discontinuation outcomes in patients with rheumatoid arthritis (RA) who had been treated with tumor necrosis factor-α inhibitors (TNF-αi) which was then discontinued. METHODS Sixty Korean patients with RA who participated in a 5-year GO-BEFORE and GO-FORWARD extension trials were included in this retrospective study. Golimumab was deliberately discontinued after the extension study (baseline). Patients were then followed by their rheumatologists. We reviewed their medical records for 2 years (max 28 months) following golimumab discontinuation. Patients were divided into a maintained benefit (MB) group and a loss-of-benefit (LB) group based on treatment pattern after golimumab discontinuation. The LB group included patients whose conventional disease-modifying antirheumatic drug(s) were stepped-up or added/switched (SC) and those who restarted biologic therapy (RB). RESULTS The mean age of patients at baseline was 56.5 years and 55 (91.7%) were females. At the end of follow-up, 23 (38.3%) patients remained in the MB group. In the LB group, 75.7% and 24.3% were assigned into SC and RB subgroups, respectively. Fifty percent of patients lost MB after 23.3 months. Demographics and clinical variables at baseline were comparable between MB and LB groups except for age, C-reactive protein level, and corticosteroid use. Restarting biologic therapy was associated with swollen joint count (adjusted hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.01 to 3.55) and disease duration (adjusted HR, 1.12; 95% CI, 1.02 to 1.23) at baseline. CONCLUSION Treatment strategies after discontinuing TNF-αi are needed to better maintain disease control and quality of life of patients with RA.
Collapse
Affiliation(s)
- Kichul Shin
- Division of Rheumatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Hyun Mi Kwon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Min Jung Kim
- Division of Rheumatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Myung Jae Yoon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Hyun Gyung Chai
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Seong-Wook Kang
- Division of Rheumatology, Chungnam National University Hospital, Daejeon,
Korea
| | - Won Park
- Division of Rheumatology, Inha University Hospital, Incheon,
Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Chang Hee Suh
- Division of Rheumatology, Ajou University Hospital, Suwon,
Korea
| | - Hyun Ah Kim
- Division of Rheumatology, Hallym University Sacred Heart Hospital, Anyang,
Korea
| | - Seung-Geun Lee
- Division of Rheumatology, Pusan National University Hospital, Busan,
Korea
| | - Choong Ki Lee
- Division of Rheumatology, Yeungnam University Medical Center, Daegu,
Korea
| | - Sang-Cheol Bae
- Division of Rheumatology, Hanyang University Seoul Hospital, Seoul,
Korea
| | - Yong-Beom Park
- Division of Rheumatology, Severance Hospital, Yonsei University College of Medicine, Seoul,
Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine, Medical Research Center, Seoul National University, Seoul,
Korea
| |
Collapse
|
9
|
Lei S, Li Z, Zhang X, Zhou S. Efficacy and safety of progressively reducing biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis in persistent remission: a study protocol for a non-inferiority randomized, controlled, single-blind trial. Trials 2022; 23:600. [PMID: 35897052 PMCID: PMC9327307 DOI: 10.1186/s13063-022-06543-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background To compare the effects of two biologic disease-modifying antirheumatic drug (bDMARD) administration strategies on the maintenance effect and safety of patients with rheumatoid arthritis (RA) in remission, to analyze the effects of gradual drug reduction and dose maintenance treatment on clinical outcomes in patients who have achieved remission with different types of bDMARDs, to search and screen out people who may benefit from drug reduction strategies, and to provide references for drug reduction strategies and treatment options for patients with RA in remission, so as to help improve the safety of the treatment and reduce the economic burden. Methods The study will be a 24-month non-inferiority randomized, controlled, single-blind trial and is planned to be launched in our hospital from September 2021 to August 2023. Patients will be randomized in a ratio of 2:1 to two groups: maintenance or injection spacing by 50%/gradual reduction of dosage every 3 months up to complete stop. When the patient relapses, return to the last effective dose. If the remission can be maintained, the medication of bDMARDs can be stopped 9 months after enrollment. The primary outcome will be the persistent flare rate. Discussion Our study may provide a reference for the selection of drug reduction strategies and treatment options for patients with RA in remission, so as to help improve the safety of the treatment and reduce the economic burden. Trial registration Chinese Clinical Trial Registry ChiCTR2100044751. Registered on 26 March 2021
Collapse
Affiliation(s)
- Shangwen Lei
- Department of Rheumatology, Gansu Provincial People's Hospital, 204 Donggang West Road, Lanzhou, 730000, People's Republic of China.
| | - Zijia Li
- Department of Rheumatology, Gansu Provincial People's Hospital, 204 Donggang West Road, Lanzhou, 730000, People's Republic of China
| | - Xiaoli Zhang
- Department of Thoracic surgery, Gansu Provincial People's Hospital, Lanzhou, 730000, People's Republic of China
| | - Shuhong Zhou
- Department of Rheumatology, Gansu Provincial People's Hospital, 204 Donggang West Road, Lanzhou, 730000, People's Republic of China
| |
Collapse
|
10
|
He B, Li Y, Luo WW, Cheng X, Xiang HR, Zhang QZ, He J, Peng WX. The Risk of Adverse Effects of TNF-α Inhibitors in Patients With Rheumatoid Arthritis: A Network Meta-Analysis. Front Immunol 2022; 13:814429. [PMID: 35250992 PMCID: PMC8888889 DOI: 10.3389/fimmu.2022.814429] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/24/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives To evaluate the safety of each anti-TNF therapy for patients with rheumatoid arthritis (RA) and then make the best choice in clinical practice. Methods We searched PUBMED, EMBASE, and the Cochrane Library. The deadline for retrieval is August 2021. The ORs, Confidence Intervals (CIs), and p values were calculated by STATA.16.0 software for assessment. Result 72 RCTs involving 28332 subjects were included. AEs were more common with adalimumab combined disease-modifying anti-rheumatic drugs (DMARDs) compared with placebo (OR = 1.60, 95% CI: 1.06, 2.42), DMARDs (1.28, 95% CI: 1.08, 1.52), etanercept combined DMARDs (1.32, 95% CI: 1.03, 1.67); certolizumab combined DMARDs compared with placebo (1.63, 95% CI: 1.07, 2.46), DMARDs (1.30, 95% CI: 1.10, 1.54), etanercept combined DMARDs (1.34, 95% CI: 1.05, 1.70). In SAEs, comparisons between treatments showed adalimumab (0.20, 95% CI: 0.07, 0.59), etanercept combined DMARDs (0.39, 95% CI: 0.15, 0.96), golimumab (0.19, 95% CI: 0.05, 0.77), infliximab (0.15, 95% CI: 0.03,0.71) decreased the risk of SAEs compared with golimumab combined DMARDs. In infections, comparisons between treatments showed adalimumab combined DMARDs (0.59, 95% CI: 0.37, 0.95), etanercept (0.49, 95% CI: 0.28, 0.88), etanercept combined DMARDs (0.56, 95% CI: 0.35, 0.91), golimumab combined DMARDs (0.51, 95% CI: 0.31, 0.83) decreased the risk of infections compared with infliximab combined DMARDs. No evidence indicated that the use of TNF-α inhibitors influenced the risk of serious infections, malignant tumors. Conclusion In conclusion, we regard etanercept monotherapy as the optimal choice for RA patients in clinical practice when the efficacy is similar. Conversely, certolizumab + DMARDs therapy is not recommended. Systematic Review Registration identifier PROSPERO CRD42021276176.
Collapse
Affiliation(s)
- Bei He
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yun Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wen-Wen Luo
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xuan Cheng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Huai-Rong Xiang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qi-Zhi Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jie He
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wen-Xing Peng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| |
Collapse
|
11
|
Defining the Optimal Strategies for Achieving Drug-Free Remission in Rheumatoid Arthritis: A Narrative Review. Healthcare (Basel) 2021; 9:healthcare9121726. [PMID: 34946453 PMCID: PMC8701994 DOI: 10.3390/healthcare9121726] [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: 10/05/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Background: It is now accepted that the optimum treatment goal for rheumatoid arthritis (RA) is sustained remission, as this has been shown to be associated with the best patient outcomes. There is little guidance on how to manage patients once remission is achieved; however, it is recommended that patients can taper therapy, with a view to discontinuing and achieving drug-free remission if treatment goals are maintained. This narrative review aims to present the current literature on drug-free remission in rheumatoid arthritis, with a view to identifying which strategies are best for disease-modifying anti-rheumatic drug (DMARD) tapering and to highlight areas of unmet clinical need. Methods: We performed a narrative review of the literature, which included research articles, meta-analyses and review papers. The key search terms included were rheumatoid arthritis, remission, drug-free remission, b-DMARDS/biologics, cs-DMARDS and tapering. The databases that were searched included PubMed and Google Scholar. For each article, the reference section of the paper was reviewed to find additional relevant articles. Results: It has been demonstrated that DFR is possible in a proportion of RA patients achieving clinically defined remission (both on cs and b-DMARDS). Immunological, imaging and clinical associations with/predictors of DFR have all been identified, including the presence of autoantibodies, absence of Power Doppler (PD) signal on ultrasound (US), lower disease activity according to composite scores of disease activity and lower patient-reported outcome scores (PROs) at treatment cessation. Conclusions: DFR in RA may be an achievable goal in certain patients. This carries importance in reducing medication-induced side-effects and potential toxicity, the burden of taking treatment if not required and cost effectiveness, specifically for biologic therapy. Prospective studies of objective biomarkers will help facilitate the prediction of successful treatment discontinuation.
Collapse
|
12
|
Axelrod H, Adams M. Biologic Agents and Secondary Immune Deficiency. Immunol Allergy Clin North Am 2021; 41:639-652. [PMID: 34602234 DOI: 10.1016/j.iac.2021.07.006] [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: 11/30/2022]
Abstract
Biologics are protein-based pharmaceuticals derived from living organisms or their proteins. We discuss the mechanism of action for currently approved biologics and a give summary of the studies on immune suppression from biologics. Most of these studies have been conducted with rheumatology patients, and many in adults. Their relevance for children is explored and existing gaps in data for children are highlighted.
Collapse
Affiliation(s)
- Heather Axelrod
- Department of Pediatrics (PGY3), Children's Hospital of Michigan, Detroit, MI, USA
| | - Matthew Adams
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
| |
Collapse
|
13
|
Tsuchiya H, Fujio K. Title Current Status of the Search for Biomarkers for Optimal Therapeutic Drug Selection for Patients with Rheumatoid Arthritis. Int J Mol Sci 2021; 22:ijms22179534. [PMID: 34502442 PMCID: PMC8431405 DOI: 10.3390/ijms22179534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 08/28/2021] [Accepted: 08/28/2021] [Indexed: 12/19/2022] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease characterized by destructive synovitis. It is significantly associated with disability, impaired quality of life, and premature mortality. Recently, the development of biological agents (including tumor necrosis factor-α and interleukin-6 receptor inhibitors) and Janus kinase inhibitors have advanced the treatment of RA; however, it is still difficult to predict which drug will be effective for each patient. To break away from the current therapeutic approaches that could be described as a “lottery,” there is an urgent need to establish biomarkers that stratify patients in terms of expected therapeutic responsiveness. This review deals with recent progress from multi-faceted analyses of the synovial tissue in RA, which is now bringing new insights into diverse features at both the cellular and molecular levels and their potential links with particular clinical phenotypes.
Collapse
|
14
|
Luurssen-Masurel N, Weel AEAM, Hazes JMW, de Jong PHP. The impact of different (rheumatoid) arthritis phenotypes on patients' lives. Rheumatology (Oxford) 2021; 60:3716-3726. [PMID: 33237330 PMCID: PMC8328508 DOI: 10.1093/rheumatology/keaa845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/21/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives To compare patient-reported outcome (PRO) domains between three arthritis phenotypes [undifferentiated arthritis (UA), autoantibody-negative RA (RA−) and autoantibody-positive RA (RA+)] at diagnosis, after 2 years and over time. Methods All UA (n = 130), RA− (n = 176) and RA+ (n = 331) patients from the tREACH trial, a stratified single-blinded trial with a treat-to-target approach, were used. PRO comparisons between phenotypes at baseline and after 2 years were performed with analysis of variance, while a linear mixed model compared them over time. Effect sizes were weighted against the minimal clinically important differences (MCIDs) for each PRO. Results RA− patients had a higher disease burden compared with RA+ and UA. At baseline and after 2 years, RA− patients had more functional impairment and a poorer Physical Component Summary (PCS) compared with the other phenotypes, while they only scored worse for general health and morning stiffness duration at baseline. The MCIDs were exceeded at baseline, except for functional ability between RA+ and UA, while after 2 years only the MCID of the PCS was exceeded by RA− compared with UA and RA. After 2 years the PROs of all phenotypes improved, but PROs measuring functioning were still worse compared with the general population, even when patients had low disease activity. Conclusion RA− patients had the highest disease burden of all phenotypes. Although most patients have low disease activity after treatment, all clinical phenotypes still have a similar significant impact on patients’ lives, which is mainly physical. Therefore it is important to assess and address PROs in daily practice because of persistent disease burden despite low disease activity. Trial registration ISRCTN26791028.
Collapse
Affiliation(s)
| | - Angelique Elisabeth Adriana Maria Weel
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands.,Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
| | | | | | | |
Collapse
|
15
|
Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| |
Collapse
|
16
|
Arnold S, Jaeger VK, Scherer A, Ciurea A, Walker UA, Kyburz D. Discontinuation of biologic DMARDs in a real-world population of patients with rheumatoid arthritis in remission: outcome and risk factors. Rheumatology (Oxford) 2021; 61:131-138. [PMID: 33848332 DOI: 10.1093/rheumatology/keab343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Data from randomized controlled trials have shown the feasibility of discontinuation of bDMARD therapy in patients with RA that have reached remission. Criteria for selecting patients that are likely to remain in remission are still incompletely defined.We aimed to identify predictors of successful discontinuation of bDMARD therapy in the Swiss Clinical Quality Management (SCQM) registry, a real-world cohort of RA patients. METHODS RA patients in DAS28-ESR remission who stopped bDMARD/tsDMARD treatment were included. Loss of remission was defined as a DAS28-ESR > 2.6 or restart of a bDMARD/tsDMARD. Time to loss of remission was the main outcome. Kaplan-Meier methods were applied and cox regression was used for multivariable analyses adjusting for confounding factors. Missing data were imputed using multiple imputation. RESULTS 318 patients in a bDMARD/tsDMARD-free remission were followed between 1997 and 2017. 241 patients (76%) lost remission after a median time of 0.9 years (95%CI 0.7-1.0). The time to loss of remission was shorter in women, in patients with a longer disease duration >4yrs and in patients who did not meet CDAI remission criteria at baseline. Remission was longer in patients with csDMARD therapy during b/tsDMARD free remission (HR 0.8, p= 0.05, 95%CI 0.6-1.0). CONCLUSION In a real-world patient population the majority of patients who discontinued b/tsDMARD treatment lost remission within <1 year. Our study confirms that fulfilment of more rigorous remission criteria and csDMARD treatment increases the chance of maintaining b/tsDMARD free remission.
Collapse
Affiliation(s)
- Simone Arnold
- Department of Rheumatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Veronika K Jaeger
- Department of Rheumatology, University Hospital Basel and University of Basel, Basel, Switzerland.,Institute for Epidemiology and Social Medicine, University of Münster, Germany
| | - Almut Scherer
- Swiss Clinical Quality Management Foundation, Zurich, Switzerland
| | - Adrian Ciurea
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ulrich A Walker
- Department of Rheumatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Diego Kyburz
- Department of Rheumatology, University Hospital Basel and University of Basel, Basel, Switzerland
| |
Collapse
|
17
|
Dos Santos JBR, da Silva MRR, Kakehasi AM, Acurcio FA, Almeida AM, Alves de Oliveira Junior H, Pimenta PRK, Alvares-Teodoro J. FIRST LINE OF SUBCUTANEOUS ANTI-TNF THERAPY FOR RHEUMATOID ARTHRITIS: A PROSPECTIVE COHORT STUDY. Expert Rev Clin Immunol 2020; 16:1217-1225. [PMID: 33203248 DOI: 10.1080/1744666x.2021.1850271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objectives: This study aims to evaluate and compare the use of subcutaneous anti-TNF for RA in a Brazilian real-life setting. Methods: A prospective cohort of biological disease-modifying antirheumatic drug (bDMARD)-naïve patients treated with adalimumab, etanercept, golimumab, and certolizumab was developed. Medication persistence, disease activity by the Clinical Disease Activity Index (CDAI), functionality by the Health Assessment Questionnaire (HAQ), quality of life by the European Quality of Life 5 Dimensions (EQ-5D), and safety were evaluated at 6 and 12 months. Results: In a total of 327 individuals, 211 (64.5%) were persistent at 12 months. Patients improved after the use of anti-TNF, with a reduction in the mean of CDAI and HAQ, in addition to an increase in the mean of EQ-5D (p < 0.05). The number of patients who achieved the clinical response was 114 (34.86%) by CDAI, 212 (64.83%) by HAQ, and 215 (65.75%) by EQ-5D at 12 months. There were no statistically significant differences among the drugs (p > 0.05). The anti-TNF was well tolerated. Conclusion: Anti-TNF reduced disease activity, in addition to improving patients' functionality and quality of life. Additional pharmacotherapeutic monitoring can be essential to achieve better results.
Collapse
Affiliation(s)
- Jéssica Barreto Ribeiro Dos Santos
- Health Assessment, Technology, and Economy Group, Center for Exact, Natural and Health Sciences, Federal University of Espírito Santo , Alegre, Brazil.,Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais , President Antônio Carlos Avenue, 6627, Campus Pampulha, Belo Horizonte, Brazil
| | - Michael Ruberson Ribeiro da Silva
- Health Assessment, Technology, and Economy Group, Center for Exact, Natural and Health Sciences, Federal University of Espírito Santo , Alegre, Brazil.,Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais , President Antônio Carlos Avenue, 6627, Campus Pampulha, Belo Horizonte, Brazil
| | | | - Franciscode Assis Acurcio
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais , President Antônio Carlos Avenue, 6627, Campus Pampulha, Belo Horizonte, Brazil.,Medicine School, Federal University of Minas Gerais , Belo Horizonte, Brazil
| | - Alessandra Maciel Almeida
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais , President Antônio Carlos Avenue, 6627, Campus Pampulha, Belo Horizonte, Brazil.,Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brasil
| | | | - Pedro Ricardo Kömel Pimenta
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais , President Antônio Carlos Avenue, 6627, Campus Pampulha, Belo Horizonte, Brazil
| | - Juliana Alvares-Teodoro
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais , President Antônio Carlos Avenue, 6627, Campus Pampulha, Belo Horizonte, Brazil
| |
Collapse
|
18
|
Vollert J, Cook NR, Kaptchuk TJ, Sehra ST, Tobias DK, Hall KT. Assessment of Placebo Response in Objective and Subjective Outcome Measures in Rheumatoid Arthritis Clinical Trials. JAMA Netw Open 2020; 3:e2013196. [PMID: 32936297 PMCID: PMC7495232 DOI: 10.1001/jamanetworkopen.2020.13196] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
Importance Large placebo responses in randomized clinical trials may keep effective medication from reaching the market. Primary outcome measures of clinical trials have shifted from patient-reported to objective outcomes, partly because response to randomized placebo treatment is thought to be greater in subjective compared with objective outcomes. However, a direct comparison of placebo response in subjective and objective outcomes in the same patient population is missing. Objective To assess whether subjective patient-reported (pain severity) and objective inflammation (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]) outcomes differ in placebo response. Design, Setting, and Participants The placebo arms of 5 double-blind, randomized, placebo-controlled clinical trials were included in this cross-sectional study. These trials were conducted internationally for 24 weeks or longer between 2005 and 2009. All patients with rheumatoid arthritis randomized to placebo (N = 788) were included. Analysis of data from these trials was conducted from March 27 to December 31, 2019. Intervention Placebo injection. Main Outcomes and Measures The difference (with 95% CIs) from baseline at week 12 and week 24 on a 0- to 100-mm visual analog scale to evaluate the severity of pain, CRP level, and ESR. Results Of the 788 patients included in the analysis, 644 were women (82%); mean (SD) age was 51 (13) years. There was a statistically significant decrease in patient-reported pain intensity (week 12: -14 mm; 95% CI, -12 to -16 mm and week 24: -20 mm; 95% CI, -16 to -22 mm). Similarly, significant decreases were noted in the CRP level (week 12: -0.51 mg/dL; 95% CI, -0.47 to -0.56 mg/dL and week 24: -1.16 mg/dL; 95% CI, -1.03 to -1.30 mg/dL) and ESR (week 12: -11 mm/h; 95% CI, -10 to 12 mm/h and week 24: -25 mm/h; 95% CI, -12 to -26 mm/h) (all P < .001). Conclusions and Relevance The findings of this study suggest that improvements in clinical outcomes among participants randomized to placebo were not limited to subjective outcomes. Even if these findings could largely demonstrate a regression to the mean, they should be considered for future trial design, as unexpected favorable placebo responses may result in a well-designed trial becoming underpowered to detect the treatment difference needed in clinical drug development.
Collapse
Affiliation(s)
- Jan Vollert
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Nancy R. Cook
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ted J. Kaptchuk
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shiv T. Sehra
- Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts
| | - Deirdre K. Tobias
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathryn T. Hall
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
19
|
Schlager L, Loiskandl M, Aletaha D, Radner H. Predictors of successful discontinuation of biologic and targeted synthetic DMARDs in patients with rheumatoid arthritis in remission or low disease activity: a systematic literature review. Rheumatology (Oxford) 2020; 59:324-334. [PMID: 31325305 DOI: 10.1093/rheumatology/kez278] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/29/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To systematically review possible predictors of successful discontinuation of biologic or targeted synthetic DMARDs (b/tsDMARDs) in RA patients in remission or low disease activity. METHODS MEDLINE database and Cochrane Library were scanned for studies that discontinued b/tsDMARDs in remission/low disease activity and searched for predictors of successful discontinuation. Additionally, EULAR and ACR meeting abstracts were hand searched. RESULTS Thirty-four studies with a total of 5724 patients were included. Predictors of successful b/tsDMARD discontinuation were (number of studies): low disease activity (n = 13), better physical function (n = 6), low or absence of rheumatoid factor (n = 5) or ACPA (n = 3), low levels of CRP (n = 3) or ESR (n = 3), shorter disease duration (n = 3), low signals of disease activity by ultrasound (n = 3). Only one study with high risk of bias was identified on tsDMARD discontinuation. CONCLUSION Several predictors of successful bDMARD discontinuation were identified. Although studies are heterogeneous, these predictors may inform clinical decision making in patients who are considered for a potential bDMARD discontinuation.
Collapse
Affiliation(s)
- Lukas Schlager
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Michaela Loiskandl
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Helga Radner
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| |
Collapse
|
20
|
Mankia K, Di Matteo A, Emery P. Prevention and cure: The major unmet needs in the management of rheumatoid arthritis. J Autoimmun 2020; 110:102399. [DOI: 10.1016/j.jaut.2019.102399] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 01/01/2023]
|
21
|
Emery P, Burmester GR, Naredo E, Sinigaglia L, Lagunes I, Koenigsbauer F, Conaghan PG. Adalimumab dose tapering in patients with rheumatoid arthritis who are in long-standing clinical remission: results of the phase IV PREDICTRA study. Ann Rheum Dis 2020; 79:1023-1030. [PMID: 32404343 PMCID: PMC7392484 DOI: 10.1136/annrheumdis-2020-217246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To investigate the association between baseline disease activity and the occurrence of flares after adalimumab tapering or withdrawal in patients with rheumatoid arthritis (RA) in sustained remission. METHODS The PREDICTRA phase IV, randomised, double-blind (DB) study (ImPact of Residual Inflammation Detected via Imaging TEchniques, Drug Levels, and Patient Characteristics on the Outcome of Dose TaperIng of Adalimumab in Clinical Remission Rheumatoid ArThritis (RA) Patients) enrolled patients with RA receiving adalimumab 40 mg every other week who were in sustained remission ≥6 months. After a 4-week, open-label lead-in (OL-LI) period, patients were randomised 5:1 to DB adalimumab taper (every 3 weeks) or withdrawal (placebo) for 36 weeks. The primary endpoint was the association between DB baseline hand and wrist MRI-detected inflammation with flare occurrence. RESULTS Of 146 patients treated during the OL-LI period, 122 were randomised to taper (n=102) or withdrawal (n=20) arms. Patients had a mean 12.9 years of active disease and had received adalimumab for a mean of 5.4 years (mean 2.2 years in sustained remission). Overall, 37 (36%) and 9 (45%) patients experienced a flare in the taper and withdrawal arms, respectively (time to flare, 18.0 and 13.3 weeks). None of the DB baseline disease characteristics or adalimumab concentration was associated with flare occurrence after adalimumab tapering. Approximately half of the patients who flared regained clinical remission after 16 weeks of open-label rescue adalimumab. The safety profile was consistent with previous studies. CONCLUSIONS Approximately one-third of patients who tapered adalimumab versus half who withdrew adalimumab experienced a flare within 36 weeks. Time to flare was numerically longer in the taper versus withdrawal arm. Baseline MRI inflammation was not associated with flare occurrence. TRIAL REGISTRATION NUMBER NCT02198651, EudraCT 2014-001114-26.
Collapse
Affiliation(s)
- Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK .,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin, Berlin, Germany
| | - Esperanza Naredo
- Department of Rheumatology, Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Luigi Sinigaglia
- Department of Rheumatology and Medical Sciences, Centro Specialistico Ortopedico Traumatologico Pini-CTO, Milan, Italy
| | - Ivan Lagunes
- Global Medical Affairs Rheumatology, AbbVie Inc, North Chicago, Illinois, USA
| | | | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| |
Collapse
|
22
|
Clinical characteristics associated with drug-free sustained remission in patients with rheumatoid arthritis: Data from Korean Intensive Management of Early Rheumatoid Arthritis (KIMERA). Semin Arthritis Rheum 2020; 50:1414-1420. [PMID: 32241617 DOI: 10.1016/j.semarthrit.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There is limited information on treatment withdrawal in patients with rheumatoid arthritis (RA). This study investigated the clinical course after stopping disease-modifying anti-rheumatic drugs (DMARDs) in patients with well-controlled RA and the clinical features associated with disease flare. METHODS Among patients in the Korean Intensive Management of Early Rheumatoid Arthritis (KIMERA) cohort, discontinuation of DMARDs was determined by a shared decision between patient and rheumatologist. Drug-free remission was defined as (1) non-use of DMARDs and corticosteroids, (2) Disease Activity Score in 28 joints (DAS28) <2.6, and (3) no evidence of synovitis. The maintenance rate of drug-free remission and the predictors for flare were evaluated using Cox proportional hazard models. RESULTS Of 234 patients, 50 patients discontinued DMARDs. All but one using etanercept were treated with conventional synthetic DMARDs. The median follow-up duration was 30 months, and 31 patients (62%) experienced disease flare after stopping DMARDs. The maintenance rate of drug-free remission was 94.0%, 86.7%, and 46.1% at 12, 24, and 48 months, respectively. Disease flare was correlated with longer time to remission, failure of initial DMARDs, and longer duration of disease and higher disease activity at DMARD withdrawal (P = 0.001, 0.022, 0.010 and 0.037, respectively). In multivariate analyses, longer duration of disease (>24 months) and higher disease activity (DAS28 >2.26) at DMARD withdrawal was independently associated with disease flare. CONCLUSION Drug-free remission was feasible in selected patients with well-controlled RA. Patients with early RA and lower disease activity at DMARD withdrawal are more likely to maintain the drug-free remission.
Collapse
|
23
|
Abstract
Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) are two common autoimmune rheumatic diseases that vary in severity, clinical presentation, and disease course between individuals. Molecular and genetic studies of both diseases have identified candidate genes and molecular pathways that are linked to various disease outcomes and treatment responses. Currently, patients can be grouped into molecular subsets in each disease, and these molecular categories should enable precision medicine approaches to be applied in rheumatic diseases. In this article, we will review key lessons learned about disease heterogeneity and molecular characterization in rheumatology, which we hope will lead to personalized therapeutic strategies.
Collapse
Affiliation(s)
| | - Jaqueline L. Paredes
- Colton Center for Autoimmunity, New York University School of Medicine, New York, NY, USA
| | - Simone Appenzeller
- Rheumatology Unit, Department of Medicine, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
| | - Timothy B. Niewold
- Colton Center for Autoimmunity, New York University School of Medicine, New York, NY, USA
| |
Collapse
|
24
|
Ladhari C, Le Blay P, Vincent T, Larbi A, Rubenstein E, Lopez RF, Jorgensen C, Pers YM. Successful long-term remission through tapering tocilizumab infusions: a single-center prospective study. BMC Rheumatol 2020; 4:5. [PMID: 32161846 PMCID: PMC7047400 DOI: 10.1186/s41927-019-0109-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/10/2019] [Indexed: 02/07/2023] Open
Abstract
Background Strategic drug therapy for rheumatoid arthritis (RA) patients with prolonged remission is not well defined. According to recent guidelines, tapering biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) may be considered. We aimed to evaluate the effectiveness of long-term maintenance of tocilizumab (TCZ) treatment after the progressive tapering of infusions. Methods We conducted an exploratory, prospective, single-center, open-label study, on RA patients with sustained remission of at least 3 months and treated with TCZ infusions every 4 weeks. The initial re-treatment interval was extended to 6 weeks for the first 3 months. Thereafter, the spacing between infusions was determined by the clinician. Successful long-term maintenance following the tapering of TCZ infusions was defined by patients still treated after two years by TCZ with a minimum dosing interval of 5 weeks. Results Thirteen patients were enrolled in the study. Eight out of thirteen were still treated by TCZ after two years. Successful long-term maintenance was possible in six patients, with four patients maintaining a re-treatment interval of 8-weeks or more. We observed 5 patients with TCZ withdrawal: one showing adverse drug reaction (neutropenia) and four with secondary failure. Patients achieving successful long-term maintenance with TCZ were significantly younger than those with secondary failure (p < 0.05). In addition, RA patients with positive rheumatoid factor and anti-citrullinated peptide antibodies, experienced a significantly greater number of flares during our 2-year follow-up (p < 0.01). Conclusions A progressive tapering of TCZ infusions may be possible for many patients. However, larger studies, including more patients, are needed to confirm this therapeutic option. Trial registration NCT02909998. Date of registration: October 2008.
Collapse
Affiliation(s)
- Chayma Ladhari
- 1IRMB, University of Montpellier, Inserm U1183, CHU Montpellier, 371, avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Pierre Le Blay
- 1IRMB, University of Montpellier, Inserm U1183, CHU Montpellier, 371, avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Thierry Vincent
- Department of Immunology, Saint Eloi University Hospital, 80 rue Augustin Fliche, 34295 Montpellier Cedex 5, France
| | - Ahmed Larbi
- 3Department of Radiology, CHU Nimes, Place du Pr R. Debré, 30029 Nîmes Cedex 9, France
| | - Emma Rubenstein
- 1IRMB, University of Montpellier, Inserm U1183, CHU Montpellier, 371, avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Rosanna Ferreira Lopez
- 1IRMB, University of Montpellier, Inserm U1183, CHU Montpellier, 371, avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Christian Jorgensen
- 1IRMB, University of Montpellier, Inserm U1183, CHU Montpellier, 371, avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Yves-Marie Pers
- 1IRMB, University of Montpellier, Inserm U1183, CHU Montpellier, 371, avenue du doyen Gaston Giraud, 34295 Montpellier, France
| |
Collapse
|
25
|
Strand V, Schiff M, Tundia N, Friedman A, Meerwein S, Pangan A, Ganguli A, Fuldeore M, Song Y, Pope J. Effects of upadacitinib on patient-reported outcomes: results from SELECT-BEYOND, a phase 3 randomized trial in patients with rheumatoid arthritis and inadequate responses to biologic disease-modifying antirheumatic drugs. Arthritis Res Ther 2019; 21:263. [PMID: 31791386 PMCID: PMC6889334 DOI: 10.1186/s13075-019-2059-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 11/08/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) are important when evaluating treatment benefits in rheumatoid arthritis (RA). We compared upadacitinib, an oral, selective JAK-1 inhibitor, with placebo to assess clinically meaningful improvements in PROs in patients with RA who have had inadequate responses to biologic disease-modifying antirheumatic drugs (bDMARD-IR). METHODS PRO responses between upadacitinib 15 mg or 30 mg and placebo were evaluated at week 12 from the SELECT-BEYOND trial. Improvement was determined by measuring Patient Global Assessment of Disease Activity (PtGA), pain, Health Assessment Questionnaire Disability Index (HAQ-DI), Short Form-36 Health Survey (SF-36), duration and severity of morning (AM) stiffness, and Insomnia Severity Index (ISI). Least squares mean changes and percentage of patients reporting improvements ≥ minimum clinically important differences (MCID) and scores greater than or equal to normative values were determined. The number needed to treat (NNT) to achieve clinically meaningful improvements was calculated. RESULTS In 498 patients, both upadacitinib doses resulted in statistically significant changes from baseline versus placebo in PtGA, pain, HAQ-DI, SF-36 Physical Component Summary (PCS), 7 of 8 SF-36 domains (15 mg), 6 of 8 SF-36 domains (30 mg), and AM stiffness duration and severity. Compared with placebo, more upadacitinib-treated patients reported improvements ≥ MCID in PtGA, pain, HAQ-DI, SF-36 PCS, 7 of 8 SF-36 domains (15 mg), 5 of 8 SF-36 domains (30 mg), AM stiffness duration and severity, and ISI (30 mg) and scores ≥ normative values in HAQ-DI and SF-36 domains. Across most PROs, NNTs to achieve MCID with upadacitinib ranged from 4 to 7 patients. CONCLUSIONS In bDMARD-IR RA patients, upadacitinib (15 mg or 30 mg) improved multiple aspects of quality of life, and more patients reached clinically meaningful improvements approaching normative values compared with placebo. TRIAL REGISTRATION The trial is registered with ClinicalTrials.gov (NCT02706847), registered 6 March 2016.
Collapse
Affiliation(s)
- Vibeke Strand
- Stanford University, 306 Ramona Road, Portola Valley, CA 94028 USA
| | - Michael Schiff
- University of Colorado School of Medicine, Denver, CO 80045 USA
| | - Namita Tundia
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL 60064 USA
| | - Alan Friedman
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL 60064 USA
| | - Sebastian Meerwein
- AbbVie Deutschland GmbH & Co., KG, Mainzer Strasse 81, 65189 Wiesbaden, Germany
| | - Aileen Pangan
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL 60064 USA
| | - Arijit Ganguli
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL 60064 USA
| | - Mahesh Fuldeore
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL 60064 USA
| | - Yan Song
- Analysis Group Inc., 14th Floor, 111 Huntington Avenue, Boston, MA 02199 USA
| | - Janet Pope
- University of Western Ontario, St. Joseph’s Health Care, 268 Grosvenor Street, London, ON N6A 4V2 Canada
| |
Collapse
|
26
|
Cavalli G, Favalli EG. Biologic discontinuation strategies and outcomes in patients with rheumatoid arthritis. Expert Rev Clin Immunol 2019; 15:1313-1322. [PMID: 31663390 DOI: 10.1080/1744666x.2020.1686976] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease, which affects joints as well as extra-articular tissues. In the last decades, increasing targeted therapeutic options dramatically improved RA management by doubling the rate of patients achieving clinical remission. Currently, there is a need for management strategies aimed at limiting treatment-related adverse events and costs in good responders.Areas covered: Data on de-escalation of biologic drugs (especially for anti-TNF agents) are mainly available from post-hoc analyses of randomized controlled trials and from registry-based observational studies. This narrative review illustrates the rationales for dose tapering and expands to provide an overview of the efficacy of the different available strategies for reducing the exposure to biologic drugs in patients achieving a sustained clinical response. Selected studies are discussed as illustrative examples.Expert opinion: Withdrawal of biologic therapy might be attempted in limited patients with very early RA; conversely, established RA is more suitably managed with a progressive decrease of drug regimen, by either dose reduction or injection/infusion spacing. Further studies investigating potential factors predicting post-tapering disease relapse are warranted, in order to better identify the best candidates for a decreased-dose approach.
Collapse
Affiliation(s)
- Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Milan, Italy
| | | |
Collapse
|
27
|
Can we wean patients with inflammatory arthritis from biological therapies? Autoimmun Rev 2019; 18:102399. [PMID: 31639516 DOI: 10.1016/j.autrev.2019.102399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 05/30/2019] [Indexed: 12/17/2022]
Abstract
Biological therapies have represented a cornerstone in the treatment of immune-mediated inflammatory diseases. Their advent combined with implementation of a treat-to-target approach has meant that remission or low disease activity are now realistic targets for treatment achieved by a significant number of patients. However, biologicals are not risk free and their elevated costs continue to present an important economic burden to national healthcare services. "Can we wean patients with inflammatory arthritis from biological therapies?" Over the last decade this question has become increasingly important as to define the best management strategies in terms of efficacy, safety and economic outcomes. Not surprisingly this has generated an interesting debate as to whether reasons to taper biologics outweigh reasons not to taper and evidence in support of either of these schools of thought is persistently growing. AIM: In this article we reviewed the contents of the relevant session from the 2019 Controversies in Rheumatology and Autoimmunity meeting in Florence.
Collapse
|
28
|
Law ST, Taylor PC. Role of biological agents in treatment of rheumatoid arthritis. Pharmacol Res 2019; 150:104497. [PMID: 31629903 DOI: 10.1016/j.phrs.2019.104497] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/26/2019] [Accepted: 10/14/2019] [Indexed: 12/20/2022]
Abstract
Advances in understanding of the pathophysiology of rheumatoid arthritis with concurrent advances in protein engineering led to the development of biological disease-modifying antirheumatic drugs which have dramatically revolutionized the treatment of this condition. This review article focuses on the role of biological agents currently employed in the treatment of rheumatoid arthritis, as well as novel biological agents in development.
Collapse
Affiliation(s)
- Shing T Law
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK.
| |
Collapse
|
29
|
Abstract
Biologics are protein-based pharmaceuticals derived from living organisms or their proteins. We discuss the mechanism of action for currently approved biologics and a give summary of the studies on immune suppression from biologics. Most of these studies have been conducted with rheumatology patients, and many in adults. Their relevance for children is explored and existing gaps in data for children are highlighted.
Collapse
Affiliation(s)
- Heather Axelrod
- Department of Pediatrics (PGY3), Children's Hospital of Michigan, Detroit, MI, USA
| | - Matthew Adams
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
| |
Collapse
|
30
|
Ho CTK, Mok CC, Cheung TT, Kwok KY, Yip RML. Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology. Clin Rheumatol 2019; 38:3331-3350. [PMID: 31485846 DOI: 10.1007/s10067-019-04761-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022]
Abstract
The expanding range of treatment options for rheumatoid arthritis (RA), from conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to biological DMARDs (bDMARDs), biosimilar bDMARDs, and targeted synthetic DMARDs, has improved patient outcomes but increased the complexity of treatment decisions. These updated consensus recommendations from the Hong Kong Society of Rheumatology provide guidance on the management of RA, with a focus on how to integrate newly available DMARDs into clinical practice. The recommendations were developed based on evidence from the literature along with local expert opinion. Early diagnosis of RA and prompt initiation of effective therapy remain crucial and we suggest a treat-to-target approach to guide optimal sequencing of DMARDs in RA patients to achieve tight disease control. Newly available DMARDs are incorporated in the treatment algorithm, resulting in a greater range of second-line treatment options. In the event of treatment failure or intolerance, switching to another DMARD with a similar or different mode of action may be considered. Given the variety of available treatments and the heterogeneity of patients with RA, treatment decisions should be tailored to the individual patient taking into consideration prognostic factors, medical comorbidities, drug safety, cost of treatment, and patient preference.
Collapse
Affiliation(s)
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Tuen Mun, Hong Kong, China.
| | | | | | | |
Collapse
|
31
|
Castagné B, Viprey M, Martin J, Schott AM, Cucherat M, Soubrier M. Cardiovascular safety of tocilizumab: A systematic review and network meta-analysis. PLoS One 2019; 14:e0220178. [PMID: 31369575 PMCID: PMC6675055 DOI: 10.1371/journal.pone.0220178] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/10/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Our objective was to compare the cardiovascular safety of tocilizumab and other biological disease-modifying antirheumatic drugs (bDMARD) in rheumatoid arthritis using a network meta-analysis (NMA). METHODS A systematic literature search through May 2018 identified randomized controlled trials (RCT) or observational studies (cohort only) reporting cardiovascular outcomes of tocilizumab (TCZ) and/or abatacept (ABA) and/or rituximab (RTX) and/or tumor necrosis factor inhibitors (TNFi) in rheumatoid arthritis patients. The composite primary outcome was the rate of major adverse cardiovascular outcomes (MACE, myocardial infarction (MI), peripheral artery disease (PAD) and cardiac heart failure (CHF)). RESULTS 19 studies were included in the NMA, including 11 RCTs and 8 cohort studies. We found less events with RTX (5.41 [1.70;17.26]. We found no difference between TCZ and other treatments. Concerning MI, we found no difference between TCZ and csDMARD (4.23 [0.22;80.64]), no difference between TCZ and TNFi (2.00 [0.18;21.84]). There was no difference between TCZ and csDMARD (1.51[0.02;103.50] and between TCZ and TNFi (1.00 [0.06;15.85]) for stroke event. With cohorts and RCT NMA, we found no difference between TCZ and other treatments for MACE (0.66 [0.42;1.03] with ABA, 1.04 [0.60;1.81] with RTX, 0.78[0.53;1.16] and 0.91 [0.54;1.51] with csDMARD), but the risk of myocardial infarction was lower with TCZ compared to ABA (0.67 [0.47;0.97]). We lacked data to compare TCZ and other bDMARD for stoke and MI. Not enough data was available to perform a NMA for CHF and PAD. CONCLUSIONS Despite an increase in cholesterol levels, TCZ has safe cardiovascular outcomes compared to other bDMARD.
Collapse
Affiliation(s)
- Benjamin Castagné
- Rheumatology Department, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
- HESPER EA 7425, University of Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Marie Viprey
- HESPER EA 7425, University of Lyon, Claude Bernard University Lyon 1, Lyon, France
- Public Health Centre, Hospices Civils de Lyon, Lyon, France
| | - Julie Martin
- HESPER EA 7425, University of Lyon, Claude Bernard University Lyon 1, Lyon, France
- Public Health Centre, Hospices Civils de Lyon, Lyon, France
| | - Anne-Marie Schott
- HESPER EA 7425, University of Lyon, Claude Bernard University Lyon 1, Lyon, France
- Public Health Centre, Hospices Civils de Lyon, Lyon, France
| | - Michel Cucherat
- University Lyon, UMR 5558, Laboratory of Biometry and Evolutionary Biology, CNRS, Villeurbanne, France
- Department of Pharmacology and Toxicology, Hospices Civils de Lyon, Lyon, France
| | - Martin Soubrier
- Rheumatology Department, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| |
Collapse
|
32
|
Tanaka Y, Smolen JS, Jones H, Szumski A, Marshall L, Emery P. The effect of deep or sustained remission on maintenance of remission after dose reduction or withdrawal of etanercept in patients with rheumatoid arthritis. Arthritis Res Ther 2019; 21:164. [PMID: 31277720 PMCID: PMC6610967 DOI: 10.1186/s13075-019-1937-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 06/10/2019] [Indexed: 12/27/2022] Open
Abstract
Background Biologic disease-modifying antirheumatic drugs (bDMARDs) are important options for managing rheumatoid arthritis (RA). Once patients achieve disease control, clinicians may consider dose reduction or withdrawal of the bDMARD. Results from published studies indicate that some patients will maintain remission; however, others will flare. We analyzed data from three etanercept down-titration studies in patients with RA to determine what extent of remission provides the greatest predictability of maintaining remission following dose reduction or discontinuation. Methods Patients with moderate to severe RA from the PRESERVE, PRIZE, and Treat-to-Target (T2T) randomized controlled trials were included. We determined the proportion of patients achieving remission with etanercept at the last time point in the induction period, and sustained remission (last two time points), according to the Disease Activity Score 28-joints (DAS28), the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean criteria, and the clinical disease activity index (CDAI). We also calculated the proportion achieving DAS28 deep remission (DAS28 ≤ 1.98), sustained deep remission (last two time points), and low disease activity (LDA), and LDA according to the CDAI. Then, we evaluated whether they maintained remission or LDA following etanercept dose reduction or withdrawal. Results Patients achieving sustained and/or deep remission were more likely than patients achieving remission or LDA to maintain remission/LDA after etanercept dose reduction or withdrawal. In PRESERVE, the proportions of patients with DAS28 sustained deep remission, deep remission, sustained remission, remission, and LDA who maintained remission following etanercept dose reduction were 81%, 67%, 58%, 56%, and 36%, respectively, P < 0.001 for trend. In PRESERVE, this trend was significant when etanercept was discontinued and when ACR/EULAR Boolean and CDAI remission criteria were used. Although some sample sizes were small, the PRIZE and T2T studies also demonstrated response trends according to ACR/EULAR Boolean and CDAI remission criteria, and T2T demonstrated response trends according to DAS28. Conclusions These results suggest that patients achieving disease control according to a stringent definition, such as sustained ACR/EULAR Boolean or CDAI remission, or a new definition of sustained deep remission by DAS28, have a higher probability of remaining in remission or LDA following etanercept dose reduction or withdrawal. Trial registration PRESERVE: ClinicalTrials.gov identifier: NCT00565409, registered 30 November 2007; PRIZE: ClinicalTrials.gov identifier: NCT00913458, registered 4 June 2009; T2T: ClinicalTrials.gov identifier: NCT01578850, registered 17 April 2012 Electronic supplementary material The online version of this article (10.1186/s13075-019-1937-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahata-nishi, Kitakyushu, 807-8555, Japan.
| | | | | | | | | | - Paul Emery
- Leeds Biomedical Research Centre, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| |
Collapse
|
33
|
Orange DE, Agius P, DiCarlo EF, Mirza SZ, Pannellini T, Szymonifka J, Jiang CS, Figgie MP, Frank MO, Robinson WH, Donlin LT, Rozo C, Gravallese EM, Bykerk VP, Goodman SM. Histologic and Transcriptional Evidence of Subclinical Synovial Inflammation in Patients With Rheumatoid Arthritis in Clinical Remission. Arthritis Rheumatol 2019; 71:1034-1041. [PMID: 30835943 DOI: 10.1002/art.40878] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/28/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) in clinical remission may have subclinical synovial inflammation. This study was undertaken to determine the proportion of patients with RA in remission or with low disease activity at the time of arthroplasty who had histologic or transcriptional evidence of synovitis, and to identify clinical features that distinguished patients as having subclinical synovitis. METHODS We compared Disease Activity Score in 28 joints (DAS28) to synovial histologic features in 135 patients with RA undergoing arthroplasty. We also compared DAS28 scores to RNA-Seq data in a subset of 35 patients. RESULTS Fourteen percent of patients met DAS28 criteria for clinical remission (DAS28 <2.6), and another 15% met criteria for low disease activity (DAS28 <3.2). Histologic analysis of synovium revealed synovitis in 27% and 31% of samples from patients in remission and patients with low disease activity, respectively. Patients with low disease activity and synovitis also exhibited increased C-reactive protein (CRP) (P = 0.0006) and increased anti-cyclic citrullinated peptide (anti-CCP) antibody levels (P = 0.03) compared to patients without synovitis. Compared to patients with a "low inflammatory synovium" subtype, 183 genes were differentially expressed in the synovium of patients with subclinical synovitis. The majority of these genes (86%) were also differentially expressed in the synovium of patients with clinically active disease (DAS28 ≥3.2). CONCLUSION Thirty-one percent of patients with low clinical disease activity exhibited histologic evidence of subclinical synovitis, which was associated with increased CRP and anti-CCP levels. Our findings suggest that synovial gene expression signatures of clinical synovitis are present in patients with subclinical synovitis.
Collapse
Affiliation(s)
- Dana E Orange
- Hospital for Special Surgery and Rockefeller University, New York, New York
| | | | | | | | | | | | | | | | | | - William H Robinson
- Stanford University, Stanford, California, and VA Palo Alto Health Care System, Palo Alto, California
| | | | | | | | | | | |
Collapse
|
34
|
Ebina K, Hashimoto M, Yamamoto W, Hirano T, Hara R, Katayama M, Onishi A, Nagai K, Son Y, Amuro H, Yamamoto K, Maeda Y, Murata K, Jinno S, Takeuchi T, Hirao M, Kumanogoh A, Yoshikawa H. Drug tolerability and reasons for discontinuation of seven biologics in 4466 treatment courses of rheumatoid arthritis-the ANSWER cohort study. Arthritis Res Ther 2019; 21:91. [PMID: 30971306 PMCID: PMC6458752 DOI: 10.1186/s13075-019-1880-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background The aim of this study is to evaluate the retention rates and reasons for discontinuation for seven biological disease-modifying antirheumatic drugs (bDMARDs) in a real-world setting of patients with rheumatoid arthritis (RA). Methods This multi-center, retrospective study assessed 4466 treatment courses of 2494 patients with bDMARDs from 2009 to 2017 (females, 82.4%; baseline age, 57.4 years; disease duration 8.5 years; rheumatoid factor positivity 78.6%; Disease Activity Score in 28 joints using erythrocyte sedimentation rate, 4.3; concomitant prednisolone (PSL) 2.7 mg/day (43.1%) and methotrexate (MTX) 5.0 mg/week (61.8%); and 63.6% patients were bio-naïve). Treatment courses included tocilizumab (TCZ; n = 895), etanercept (ETN; n = 891), infliximab (IFX; n = 748), abatacept (ABT; n = 681), adalimumab (ADA; n = 558), golimumab (GLM; n = 464), and certolizumab pegol (CZP; n = 229). Drug retention rates and discontinuation reasons were estimated at 36 months using the Kaplan-Meier method and adjusted for potential confounders (age, sex, disease duration, concomitant PSL and MTX, and switched number of bDMARDs) using Cox proportional hazards modeling. Results A total of 56.9% of treatment courses were stopped, with 25.8% stopping due to lack of effectiveness, 12.7% due to non-toxic reasons, 11.9% due to toxic adverse events, and 6.4% due to disease remission. Drug retention rates for each discontinuation reason were as follows: lack of effectiveness [from 65.5% (IFX) to 81.7% (TCZ); with significant differences between groups (Cox P < 0.001)], toxic adverse events [from 81.8% (IFX) to 94.0% (ABT), Cox P < 0.001], and remission [from 92.4% (ADA and IFX) to 97.7% (ETN), Cox P < 0.001]. Finally, overall retention rates excluding non-toxic reasons and remission for discontinuation ranged from 53.4% (IFX) to 75.5% (ABT) (Cox P < 0.001). Conclusions TCZ showed the lowest discontinuation rate by lack of effectiveness, ABT showed the lowest discontinuation rate by toxic adverse events, ADA and IFX showed the highest discontinuation rate by remission, and ABT showed the highest overall retention rates (excluding non-toxic reasons and remission) among seven bDMARDs in the adjusted model.
Collapse
Affiliation(s)
- Kosuke Ebina
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan.
| | - Motomu Hashimoto
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Wataru Yamamoto
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Health Information Management, Kurashiki Sweet Hospital, Kurashiki, Japan
| | - Toru Hirano
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryota Hara
- The Center for Rheumatic Diseases, Nara Medical University, Nara, Japan
| | - Masaki Katayama
- Department of Rheumatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akira Onishi
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koji Nagai
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - Yonsu Son
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Hideki Amuro
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Keiichi Yamamoto
- Department of Medical Informatics, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yuichi Maeda
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Murata
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sadao Jinno
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - Makoto Hirao
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
35
|
Mueller RB, Spaeth M, von Restorff C, Ackermann C, Schulze-Koops H, von Kempis J. Superiority of a Treat-to-Target Strategy over Conventional Treatment with Fixed csDMARD and Corticosteroids: A Multi-Center Randomized Controlled Trial in RA Patients with an Inadequate Response to Conventional Synthetic DMARDs, and New Therapy with Certolizumab Pegol. J Clin Med 2019; 8:jcm8030302. [PMID: 30832414 PMCID: PMC6462919 DOI: 10.3390/jcm8030302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/19/2019] [Accepted: 02/27/2019] [Indexed: 02/07/2023] Open
Abstract
Background: Treatment of rheumatoid arthritis (RA) includes the use of conventional (cs), biologic (b) disease-modifying anti-rheumatic drugs (DMARDs) and oral, intramuscularly, intravenous, or intraarticular (IA) glucocorticoids (GCs). In this paper, we analysed whether a treat-to-target (T2T) strategy optimizing csDMARD, oral, and IA-GC treatment as an adjunct new therapy to a new certolizumab pegol (CZP) therapy improves the effectivity in RA patients. Methods: 43 patients with active RA (≥6 tender, ≥6 swollen joints, ESR ≥ 20 mm/h or CRP ≥ 7mg/L) despite csDMARD treatment for ≥ 3 months and naïve to bDMARDs were randomized to CZP (200 mg/2 weeks after loading with 400 mg at weeks 0–2–4) plus a treat-to-target strategy (T2T, n = 21), or to CZP added to the established csDMARD therapy (fixed regimen, n = 22). The T2T strategy consisted of changing the baseline csDMARD therapy (1) SC-methotrexate (dose: 15 ≥ 20 ≥ 25 mg/week, depending on the initial dose) ≥ leflunomide (20 mg/d) ≥ sulphasalazine (2 × 1000 mg/d) plus (2) oral GCs (prednisolone 20–15–12.5–10–7.5–5–2.5–0 mg/d tapered every five days) and (3) injections of ≤5 affected joints with triamcinolone. DMARD modification and an addition of oral GCs were initiated, depending on the achievement of low disease activity (DAS 28 < 3.2). The primary objective was defined as the ACR 50 response at week 24. Results: ACR 50 was achieved in 76.2% of the T2T, as compared to 36.4% of the fixed regimen patients (p = 0.020). ACR 20 and 70 responses were achieved in 90.5% and 71.4% of the T2T patients and 59.1% and 27.3% of the fixed regimen patients, respectively (p = 0.045 and p = 0.010, respectively). The adverse event rate was similar for both groups (T2T n = 51; fixed regimen n = 55). Conclusion: Treat-to-target management with the optimization of csDMARDs, oral, and IA-GCs of RA patients in parallel to a newly established CZP treatment was safe and efficacious in comparison to a fixed regimen of csDMARDs background therapy.
Collapse
Affiliation(s)
- Ruediger B Mueller
- Division of Rheumatology and Immunology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland.
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig-Maximilians-University Munich, 80336 Munich, Germany.
- Division of Rheumatology, Medical University Department, Kantonsspital Aarau, CH-5001 Aarau, Switzerland.
| | - Michael Spaeth
- Division of Rheumatology, Spital Linth, 8730 Uznach, Switzerland.
| | | | | | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig-Maximilians-University Munich, 80336 Munich, Germany.
| | - Johannes von Kempis
- Division of Rheumatology and Immunology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland.
| |
Collapse
|
36
|
Daien C, Hua C, Gaujoux-Viala C, Cantagrel A, Dubremetz M, Dougados M, Fautrel B, Mariette X, Nayral N, Richez C, Saraux A, Thibaud G, Wendling D, Gossec L, Combe B. Update of French society for rheumatology recommendations for managing rheumatoid arthritis. Joint Bone Spine 2019; 86:135-150. [DOI: 10.1016/j.jbspin.2018.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
|
37
|
Yoshida S, Kotani T, Kimura Y, Matsumura Y, Yoshikawa A, Tokai N, Ozaki T, Nagai K, Takeuchi T, Makino S, Arawaka S. Efficacy of abatacept tapering therapy for sustained remission in patients with rheumatoid arthritis: Prospective single-center study. Int J Rheum Dis 2019; 22:81-89. [DOI: 10.1111/1756-185x.13384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 07/12/2018] [Accepted: 08/09/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Shuzo Yoshida
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Takuya Kotani
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Yuko Kimura
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Yoko Matsumura
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Ayaka Yoshikawa
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Nao Tokai
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Takuro Ozaki
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Koji Nagai
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Toru Takeuchi
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Shigeki Makino
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| | - Shigeki Arawaka
- Department of Internal Medicine (IV); Osaka Medical College; Osaka Japan
| |
Collapse
|
38
|
Emery P, Pedersen R, Bukowski J, Marshall L. Predictors of Remission Maintenance after Etanercept Tapering or Withdrawal in Early Rheumatoid Arthritis: Results from the PRIZE Study. Open Rheumatol J 2018. [DOI: 10.2174/1874312901812010179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:
To explore the influence of early treatment response to etanercept-methotrexate therapy on sustained remission after tapering/withdrawal of etanercept in methotrexate/biologic-naïve patients with early rheumatoid arthritis in the PRIZE study (ClinicalTrials.gov: NCT00913458).
Method:
In the initial 52-week open-label phase, enrolled patients received once-weekly etanercept 50 mg plus methotrexate. Patients who achieved DAS28 ≤3.2 at week 39 and <2.6 at week 52 were randomized to etanercept 25 mg plus methotrexate, methotrexate monotherapy, or placebo once weekly for 39 weeks in the double-blind phase. The relationships between responses in the open-label phase and sustained remission (DAS28 <2.6 at weeks 76 and 91, without glucocorticoid rescue therapy from weeks 52 to 64) in the double-blind phase were analyzed.
Results:
In the open-label phase, 70% of patients achieved DAS28 remission at week 52. In the double-blind phase, 63%, 40%, and 23% of patients had sustained DAS28 remission in the reduced-dose combination-therapy, methotrexate-monotherapy, and placebo groups, respectively. In patients receiving reduced-dose combination therapy, sustained remission was more likely in those who achieved DAS28 remission (p = 0.005) or low disease activity (p=0.044) in a shorter time, and who had a lower DAS28 (p = 0.016) or achieved ACR/EULAR Boolean remission (p < 0.05) at the end of the open-label phase. In patients receiving methotrexate monotherapy, sustained remission was associated with a lower acute-phase response (C-reactive protein, p = 0.007; erythrocyte sedimentation rate, p = 0.016) at the end of the open-label phase.
Conclusion:
Fast response and suppression of inflammation with etanercept-methotrexate therapy may predict successful etanercept tapering/withdrawal in patients with early rheumatoid arthritis.
Collapse
|
39
|
Hughes CD, Scott DL, Ibrahim F. Intensive therapy and remissions in rheumatoid arthritis: a systematic review. BMC Musculoskelet Disord 2018; 19:389. [PMID: 30376836 PMCID: PMC6208111 DOI: 10.1186/s12891-018-2302-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 10/11/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We systematically reviewed the effectiveness of intensive treatment strategies in achieving remission in patients with both early and established Rheumatoid Arthritis (RA). METHODS A systematic literature review and meta-analysis evaluated trials and comparative studies reporting remission in RA patients treated intensively with disease modifying anti-rheumatic drugs (DMARDs), biologics and Janus Kinase (JAK) inhibitors. Analysis used RevMan 5.3 to report relative risks (RR) in random effects models with 95% confidence intervals (CI). RESULTS We identified 928 publications: 53 studies were included (48 superiority studies; 6 head-to-head trials). In the superiority studies 3013/11259 patients achieved remission with intensive treatment compared with 1211/8493 of controls. Analysis of the 53 comparisons showed a significant benefit for intensive treatment (RR 2.23; 95% CI 1.90, 2.61). Intensive treatment increased remissions in both early RA (23 comparisons; RR 1.56; 1.38, 1.76) and established RA (29 comparisons RR 4.21, 2.92, 6.07). All intensive strategies (combination DMARDs, biologics, JAK inhibitors) increased remissions. In the 6 head-to-head trials 317/787 patients achieved remission with biologics compared with 229/671 of patients receiving combination DMARD therapies and there was no difference between treatment strategies (RR 1.06; 0.93. 1.21). There were differences in the frequency of remissions between early and established RA. In early RA the frequency of remissions with active treatment was 49% compared with 34% in controls. In established RA the frequency of remissions with active treatment was 19% compared with 6% in controls. CONCLUSIONS Intensive treatment with combination DMARDs, biologics or JAK inhibitors increases the frequency of remission compared to control non-intensive strategies. The benefits are seen in both early and established RA.
Collapse
Affiliation(s)
- Catherine D Hughes
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, Cutcombe Road, London, SE5 9RJ, UK.
| | - David L Scott
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, Cutcombe Road, London, SE5 9RJ, UK
| | - Fowzia Ibrahim
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, Cutcombe Road, London, SE5 9RJ, UK
| |
Collapse
|
40
|
Ruscitti P, Sinigaglia L, Cazzato M, Grembiale RD, Triolo G, Lubrano E, Montecucco C, Giacomelli R. Dose adjustments and discontinuation in TNF inhibitors treated patients: when and how. A systematic review of literature. Rheumatology (Oxford) 2018; 57:vii23-vii31. [PMID: 30289540 DOI: 10.1093/rheumatology/key132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives To review the available evidence concerning the possibility of discontinuing and/or tapering the dosage of TNF inhibitors (TNFi) in RA patients experiencing clinical remission or low disease activity. Methods A systematic review of the literature concerning the low dosage and discontinuation of TNFi in disease-controlled RA patients was performed by evaluation of reports published in indexed international journals (Medline via PubMed, EMBASE), in the time frame from 8 April 2013 to 15 January 2016. Results We analysed the literature evaluating the efficacy and the safety of two different strategies using TNFi, decreasing dosage or discontinuation, in patients experiencing clinical remission or low disease activity. After the analysis of online databases, 25 references were considered potentially relevant and 16 references were selected. The majority of data concerned etanercept and adalimumab. Results suggested the induction of stable clinical remission or low disease activity by using TNFi followed by a dosage tapering and/or discontinuation of such drugs may be associated with the maintenance of a good clinical response in a subset of patients affected by early disease. Conclusion RA patients treated early with TNFi and achieving their therapeutic clinical targets seem to maintain their clinical response after tapering or discontinuing TNFi. These data may allow physicians a more dynamic and tailored management of RA patients.
Collapse
Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | | | | | | | - Giovanni Triolo
- Department of Internal Medicine, University of Palermo, Palermo
| | - Ennio Lubrano
- Department of Medicine and Health Science 'Vincenzo Tiberio', University of Molise, Campobasso
| | - Carlomaurizio Montecucco
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Biologic Therapy Unit, IRCCS Policlinico San Matteo Foundation/University of Pavia, Pavia, Italy
| | - Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| |
Collapse
|
41
|
Simpson E, Hock E, Stevenson M, Wong R, Dracup N, Wailoo A, Conaghan P, Estrach C, Edwards C, Wakefield R. What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-258. [PMID: 29712616 PMCID: PMC5949573 DOI: 10.3310/hta22200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US). OBJECTIVE To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness. DATA SOURCES Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015. REVIEW METHODS A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken. MATHEMATICAL MODEL A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated. RESULTS Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used. LIMITATIONS Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed. CONCLUSION Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017216. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Philip Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
| | - Cristina Estrach
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christopher Edwards
- National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Richard Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
| |
Collapse
|
42
|
Ebina K, Hashimoto M, Yamamoto W, Ohnishi A, Kabata D, Hirano T, Hara R, Katayama M, Yoshida S, Nagai K, Son Y, Amuro H, Akashi K, Fujimura T, Hirao M, Yamamoto K, Shintani A, Kumanogoh A, Yoshikawa H. Drug retention and discontinuation reasons between seven biologics in patients with rheumatoid arthritis -The ANSWER cohort study. PLoS One 2018; 13:e0194130. [PMID: 29543846 PMCID: PMC5854351 DOI: 10.1371/journal.pone.0194130] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/26/2018] [Indexed: 11/18/2022] Open
Abstract
The purpose of this study was to evaluate the retention and discontinuation reasons of seven biological disease-modifying antirheumatic drugs (bDMARDs) in a real-world setting of patients with rheumatoid arthritis (RA). 1,037 treatment courses with bDMARDs from 2009 to 2016 [female, 81.8%; baseline age, 59.6 y; disease duration 7.8 y; rheumatoid factor positivity 81.5%; Disease Activity Score in 28 joints using erythrocyte sedimentation rate (DAS28-ESR), 4.4; concomitant prednisolone 43.5% and methotrexate 68.6%; Bio-naïve, 57.1%; abatacept (ABT), 21.3%; tocilizumab (TCZ), 20.7%; golimumab (GLM), 16.9%; etanercept (ETN), 13.6%; adalimumab (ADA), 11.1%; infliximab (IFX), 8.5%; certolizumab pegol (CZP), 7.9%] were included in this multi-center, retrospective study. Drug retention and discontinuation reasons at 36 months were estimated using the Kaplan-Meier method and adjusted by potent confounders using Cox proportional hazards modeling. As a result, 455 treatment courses (43.9%) were stopped, with 217 (20.9%) stopping due to inefficacy, 113 (10.9%) due to non-toxic reasons, 86 (8.3%) due to toxic adverse events, and 39 (3.8%) due to remission. Drug retention rates in the adjusted model were as follows: total retention (ABT, 60.7%; ADA, 32.7%; CZP, 43.3%; ETN, 51.9%; GLM, 45.4%; IFX, 31.1%; and TCZ, 59.2%; P < 0.001); inefficacy (ABT, 81.4%; ADA, 65.7%; CZP, 60.7%; ETN, 71.3%; GLM, 68.5%; IFX, 65.0%; and TCZ, 81.4%; P = 0.015), toxic adverse events (ABT, 89.8%; ADA, 80.5%; CZP, 83.9%; ETN, 89.2%; GLM, 85.5%; IFX, 75.6%; and TCZ, 77.2%; P = 0.50), and remission (ABT, 95.5%; ADA, 88.1%; CZP, 91.1%; ETN, 97.5%; GLM, 94.7%; IFX, 86.4%; and TCZ, 98.4%; P < 0.001). In the treatment of RA, ABT and TCZ showed higher overall retention, and TCZ showed lower inefficacy compared to IFX, while IFX showed higher discontinuation due to remission compared to ABT, ETN, GLM, and TCZ in adjusted modeling.
Collapse
Affiliation(s)
- Kosuke Ebina
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
- * E-mail:
| | - Motomu Hashimoto
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Wataru Yamamoto
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Health Information Management, Kurashiki Sweet Hospital, Kurashiki, Japan
| | - Akira Ohnishi
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toru Hirano
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Ryota Hara
- The Center for Rheumatic Diseases, Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Masaki Katayama
- Department of Rheumatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Shuzo Yoshida
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - Koji Nagai
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - Yonsu Son
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Hideki Amuro
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Kengo Akashi
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takanori Fujimura
- The Center for Rheumatic Diseases, Nara Medical University, Nara, Japan
| | - Makoto Hirao
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Keiichi Yamamoto
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
43
|
Stevenson M, Archer R, Tosh J, Simpson E, Everson-Hock E, Stevens J, Hernandez-Alava M, Paisley S, Dickinson K, Scott D, Young A, Wailoo A. Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for the treatment of rheumatoid arthritis not previously treated with disease-modifying antirheumatic drugs and after the failure of conventional disease-modifying antirheumatic drugs only: systematic review and economic evaluation. Health Technol Assess 2018; 20:1-610. [PMID: 27140438 DOI: 10.3310/hta20350] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increasing disability, reduced quality of life and substantial costs (as a result of both intervention acquisition and hospitalisation). The objective was to assess the clinical effectiveness and cost-effectiveness of seven biologic disease-modifying antirheumatic drugs (bDMARDs) compared with each other and conventional disease-modifying antirheumatic drugs (cDMARDs). The decision problem was divided into those patients who were cDMARD naive and those who were cDMARD experienced; whether a patient had severe or moderate to severe disease; and whether or not an individual could tolerate methotrexate (MTX). DATA SOURCES The following databases were searched: MEDLINE from 1948 to July 2013; EMBASE from 1980 to July 2013; Cochrane Database of Systematic Reviews from 1996 to May 2013; Cochrane Central Register of Controlled Trials from 1898 to May 2013; Health Technology Assessment Database from 1995 to May 2013; Database of Abstracts of Reviews of Effects from 1995 to May 2013; Cumulative Index to Nursing and Allied Health Literature from 1982 to April 2013; and TOXLINE from 1840 to July 2013. Studies were eligible for inclusion if they evaluated the impact of a bDMARD used within licensed indications on an outcome of interest compared against an appropriate comparator in one of the stated population subgroups within a randomised controlled trial (RCT). Outcomes of interest included American College of Rheumatology (ACR) scores and European League Against Rheumatism (EULAR) response. Interrogation of Early Rheumatoid Arthritis Study (ERAS) data was undertaken to assess the Health Assessment Questionnaire (HAQ) progression while on cDMARDs. METHODS Network meta-analyses (NMAs) were undertaken for patients who were cDMARD naive and for those who were cDMARD experienced. These were undertaken separately for EULAR and ACR data. Sensitivity analyses were undertaken to explore the impact of including RCTs with a small proportion of bDMARD experienced patients and where MTX exposure was deemed insufficient. A mathematical model was constructed to simulate the experiences of hypothetical patients. The model was based on EULAR response as this is commonly used in clinical practice in England. Observational databases, published literature and NMA results were used to populate the model. The outcome measure was cost per quality-adjusted life-year (QALY) gained. RESULTS Sixty RCTs met the review inclusion criteria for clinical effectiveness, 38 of these trials provided ACR and/or EULAR response data for the NMA. Fourteen additional trials contributed data to sensitivity analyses. There was uncertainty in the relative effectiveness of the interventions. It was not clear whether or not formal ranking of interventions would result in clinically meaningful differences. Results from the analysis of ERAS data indicated that historical assumptions regarding HAQ progression had been pessimistic. The typical incremental cost per QALY of bDMARDs compared with cDMARDs alone for those with severe RA is > £40,000. This increases for those who cannot tolerate MTX (£50,000) and is > £60,000 per QALY when bDMARDs were used prior to cDMARDs. Values for individuals with moderate to severe RA were higher than those with severe RA. Results produced using EULAR and ACR data were similar. The key parameter that affected the results is the assumed HAQ progression while on cDMARDs. When historic assumptions were used typical incremental cost per QALY values fell to £38,000 for those with severe disease who could tolerate MTX. CONCLUSIONS bDMARDs appear to have cost per QALY values greater than the thresholds stated by the National Institute for Health and Care Excellence for interventions to be cost-effective. Future research priorities include: the evaluation of the long-term HAQ trajectory while on cDMARDs; the relationship between HAQ direct medical costs; and whether or not bDMARDs could be stopped once a patient has achieved a stated target (e.g. remission). STUDY REGISTRATION This study is registered as PROSPERO CRD42012003386. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rachel Archer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jon Tosh
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Everson-Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Suzy Paisley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kath Dickinson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David Scott
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Adam Young
- Department of Rheumatology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| |
Collapse
|
44
|
Emery P, Burmester GR, Naredo E, Zhou Y, Hojnik M, Conaghan PG. Design of a phase IV randomised, double-blind, placebo-controlled trial assessing the Im Pact of Residual Inflammation Detected via Imaging T Echniques, Drug Levels and Patient Characteristics on the Outcome of Dose Taper Ing of Adalimumab in Clinical Remission Rheumatoid Ar Thritis ( RA) patients (PREDICTRA). BMJ Open 2018; 8:e019007. [PMID: 29490959 PMCID: PMC5855387 DOI: 10.1136/bmjopen-2017-019007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The current American College of Rheumatology and European League Against Rheumatism treatment recommendations advise tapering biological disease-modifying antirheumatic drug (bDMARD) therapy in patients with rheumatoid arthritis (RA) who achieve stable clinical remission while receiving bDMARDs. However, not all patients maintain remission or low disease activity after tapering or discontinuation of bDMARDs. The aim of the ImPact of Residual Inflammation Detected via Imaging TEchniques, Drug Levels and Patient Characteristics on the Outcome of Dose TaperIng of Adalimumab in Clinical Remission Rheumatoid ArThritis (RA) study, or PREDICTRA, is to generate data on patient and disease characteristics that may predict the clinical course of a fixed dose-tapering regimen with the bDMARD adalimumab. METHODS AND ANALYSIS PREDICTRA is an ongoing, multicentre, phase IV, randomised, double-blind, parallel-group study of adalimumab dose tapering controlled by withdrawal in participants with RA who achieved stable clinical remission while receiving adalimumab. The study includes a screening period, a 4-week lead-in period with open-label adalimumab 40 mg every other week and a subsequent 36-week double-blind period during which participants are randomised 5:1 to adalimumab 40 mg every 3 weeks (taper arm) or placebo (withdrawal arm). The primary explanatory efficacy variables are lead-in baseline hand and wrist MRI-detected synovitis and bone marrow oedema scores, as well as a composite of both scores; the dependent variable is the occurrence of flare up to week 40. Additional efficacy variables, safety, pharmacokinetics, biomarkers and immunogenicity will also be assessed, and an ultrasound substudy will be conducted. ETHICS AND DISSEMINATION The study is conducted in accordance with the International Conference on Harmonisation guidelines, local laws and the ethical principles of the Declaration of Helsinki. All participants are required to sign a written informed consent statement before the start of any study procedures. TRIAL REGISTRATION NUMBER EudraCT 2014-001114-26 and NCT02198651; Pre-results.
Collapse
Affiliation(s)
- Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Esperanza Naredo
- Department of Rheumatology, Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Yijie Zhou
- Data and Statistical Sciences, AbbVie, North Chicago, Illinois, USA
| | - Maja Hojnik
- Global Medical Affairs Rheumatology, AbbVie, North Chicago, Illinois, USA
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
45
|
Mok CC. EULAR recommendations for the management of rheumatoid arthritis: what is new in 2017 and its applicability in our local setting. HONG KONG BULLETIN ON RHEUMATIC DISEASES 2017. [DOI: 10.1515/hkbrd-2017-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Rheumatoid arthritis (RA) is the most common rheumatic disease being managed by the rheumatologists. With the emergence of the biologic and targeted synthetic disease modifying anti-rheumatic drugs (b/tsDMARDs), the prognosis of RA has improved substantially. However, these novel agents are associated with high cost and untoward effects. International consensus statements for the drug management of RA have been published to guide the practice of rheumatologists. In this article, updates from the 2016 EULAR management recommendations for RA are reviewed and discussed within the context of our local situation in Hong Kong.
Collapse
Affiliation(s)
- Chi Chiu Mok
- Department of Medicine , Tuen Mun Hospital , Hong Kong , SAR China
| |
Collapse
|
46
|
Ruiz Garcia V, Burls A, Cabello JB, Vela Casasempere P, Bort‐Marti S, Bernal JA. Certolizumab pegol (CDP870) for rheumatoid arthritis in adults. Cochrane Database Syst Rev 2017; 9:CD007649. [PMID: 28884785 PMCID: PMC6483724 DOI: 10.1002/14651858.cd007649.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Tumour necrosis factor (TNF)-alpha inhibitors are beneficial for the treatment of rheumatoid arthritis (RA) for reducing the risk of joint damage, improving physical function and improving the quality of life. This review is an update of the 2014 Cochrane Review of the treatment of RA with certolizumab pegol. OBJECTIVES To assess the clinical benefits and harms of certolizumab pegol (CZP) in people with RA who have not responded well to conventional disease-modifying anti-rheumatic drugs (DMARDs). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL: Cochrane Library 2016, Issue 9), MEDLINE, Embase, Web of Knowledge, reference lists of articles, clinicaltrials.gov and ICTRP of WHO. The searches were updated from 2014 (date of the last search for the previous version) to 26 September 2016. SELECTION CRITERIA Randomised controlled trials that compared certolizumab pegol with any other agent, including placebo or methotrexate (MTX), in adults with active RA, regardless of current or prior treatment with conventional disease-modifying anti-rheumatic drugs (DMARDs), such as MTX. DATA COLLECTION AND ANALYSIS Two review authors independently checked search results, extracted data and assessed trial quality. We resolved disagreements by discussion or referral to a third review author. MAIN RESULTS We included 14 trials in this update, three more than previously. Twelve trials (5422 participants) included measures of benefit. We pooled 11 of them, two more than previously. Thirteen trials included information on harms, (5273 participants). The duration of follow-up varied from 12 to 52 weeks and the range of doses of certolizumab pegol varied from 50 to 400 mg given subcutaneously. In Phase III trials, the comparator was placebo plus MTX in seven trials and placebo in five. In the two Phase II trials the comparator was only placebo.The approved dose of certolizumab pegol, 200 mg every other week, produced clinically important improvements at 24 weeks for the following outcomes:- American College of Rheumatology (ACR) 50% improvement (pain, function and other symptoms of RA): 25% absolute improvement (95% confidence interval (CI) 20% to 33%); number need to treat for an additional beneficial outcome (NNTB) of 4 (95% CI 3 to 5); risk ratio (RR) 3.80 (95% CI 2.42 to 5.95), 1445 participants, 5 studies.- The Health Assessment Questionnaire (HAQ): -12% absolute improvement (95% CI -9% to -14%); NNTB of 8 (95% CI 7 to 11); mean difference (MD) - 0.35 (95% CI -0.43 to -0.26; 1268 participants, 4 studies) (scale 0 to 3; lower scores mean better function).- Proportion of participants achieving remission (Disease Activity Score (DAS) < 2.6) absolute improvement 10% (95% CI 8% to 16%); NNTB of 8 (95% CI 6 to 12); risk ratio (RR) 2.94 (95% CI 1.64 to 5.28), 2420 participants, six studies.- Radiological changes: erosion score (ES) absolute improvement -0.29% (95% CI -0.42% to -0.17%); NNTB of 6 (95% CI 4 to 10); MD -0.67 (95% CI -0.96 to -0.38); 714 participants, two studies (scale 0 to 230), but not a clinically important difference.-Serious adverse events (SAEs) were statistically but not clinically significantly more frequent for certolizumab pegol (200 mg every other week) with an absolute rate difference of 3% (95% CI 1% to 4%); number needed to treat for an additional harmful outcome (NNTH) of 33 (95% CI 25 to 100); Peto odds ratio (OR) 1.47 (95% CI 1.13 to 1.91); 3927 participants, nine studies.There was a clinically significant increase in all withdrawals in the placebo groups (for all doses and at all follow-ups) with an absolute rate difference of -29% (95% CI -16% to -42%), NNTH of 3 (95% CI 2 to 6), RR 0.47 (95% CI 0.39 to 0.56); and there was a clinically significant increase in withdrawals due to adverse events in the certolizumab groups (for all doses and at all follow-ups) with an absolute rate difference of 2% (95% CI 0% to 3%); NNTH of 58 (95% CI 28 to 329); Peto OR 1.45 (95% CI 1.09 to 1.94) 5236 participants Twelve studies.We judged the quality of evidence to be high for ACR50, DAS remission, SAEs and withdrawals due to adverse events, and moderate for HAQ and radiological changes, due to concerns about attrition bias. For all withdrawals we judged the quality of evidence to be moderate, due to inconsistency. AUTHORS' CONCLUSIONS The results and conclusions did not change from the previous review. There is a moderate to high certainty of evidence from randomised controlled trials that certolizumab pegol, alone or combined with methotrexate, is beneficial in the treatment of RA for improved ACR50 and health-related quality of life, an increased chance of remission of RA, and reduced joint damage as seen on x-ray. Fewer people stopped taking their treatment, but most of these who did stopped due to serious adverse events. Adverse events were more frequent with active treatment. We found a clinically but not statistically significant risk of serious adverse events.
Collapse
Affiliation(s)
- Vicente Ruiz Garcia
- La Fe University HospitalHospital at Home Unit, Tower C, Floor 1 Office 5 & CASPe SpainAv Fernando Abril Martorell nº 106ValenciaSpain46026
| | - Amanda Burls
- City University LondonSchool of Health SciencesMyddleton StreetLondonUKEC1V 0HB
| | - Juan B Cabello
- Hospital General Universitario de AlicanteDepartment of Cardiology & CASP SpainPintor Baeza 12AlicanteAlicanteSpain03010
| | - Paloma Vela Casasempere
- Hospital General Universitario AlicanteDepartment of RheumatologyMaestro Alonso, 109AlicanteSpain03010
| | | | - José A Bernal
- Hospital General Universitario AlicanteDepartment of RheumatologyMaestro Alonso, 109AlicanteSpain03010
| | | |
Collapse
|
47
|
Abstract
Management and therapy of rheumatoid arthritis (RA) has been revolutionized by the development and approval of the first biological disease-modifying antirheumatic drugs (bDMARDs) targeting tumor necrosis factor (TNF) α at the end of the last century. Today, numerous efficacious agents with different modes of action are available and achievement of clinical remission or, at least, low disease activity is the target of therapy. Early therapeutic interventions aiming at a defined goal of therapy (treat to target) are supposed to halt inflammation, improving symptoms and signs, and preserving structural integrity of the joints in RA. Up to now, bDMARDs approved for therapy in RA include agents with five different modes of action: TNF inhibition, T cell co-stimulation blockade, IL-6 receptor inhibition, B cell depletion, and interleukin 1 inhibition. Furthermore, targeted synthetic DMARDs (tsDMARDs) inhibiting Janus kinase (JAK) and biosimilars also are approved for RA. The present review focuses on bDMARDs and tsDMARDS regarding similarities and possible drug-specific advantages in the treatment of RA. Furthermore, compounds not yet approved in RA and biosimilars are discussed. Following the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) recommendations, specific treatment of the disease will be discussed with respect to safety and efficacy. In particular, we discuss the question of favoring specific bDMARDs or tsDMARDs in the two settings of insufficient response to methotrexate and to the first bDMARD, respectively.
Collapse
|
48
|
Liu D, Yuan N, Yu G, Song G, Chen Y. Can rheumatoid arthritis ever cease to exist: a review of various therapeutic modalities to maintain drug-free remission? Am J Transl Res 2017; 9:3758-3775. [PMID: 28861167 PMCID: PMC5575190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/20/2017] [Indexed: 06/07/2023]
Abstract
Therapies for rheumatoid arthritis (RA) were mostly aimed at reducing the pain, stiffness and further progression of joint destruction. However, with the advent of biologic agents that act against specific inflammatory cytokines contributing to RA pathogenesis (treat-to-target strategy), the degree of remission achieved has been remarkably impressive. In particular, inhibition of tumor necrosis factor α (TNFα), interleukins-1 and -6 and receptor-activator of nuclear kappa B ligand by neutralizing antibodies in early diagnosed RA patients has resulted in lowering of disease activity to levels that enable them to function as in the pre-disease stage. There are other biologic approaches such as depletion of B cells and blocking T-cell co-stimulators that have been included successfully in RA therapy under the class of disease-modifying anti-rheumatic drugs (DMARD). Given the excellent clinical outcomes of biologic DMARDs when initiated early in RA, discontinuation or dose tapering is practised. Because biologic DMARDs are expensive and also known to make users vulnerable to viral infections, dose reduction and drug holiday are reasonable steps when sustained good clinical response has been achieved. Majority clinical studies have been done with TNF inhibitors and data suggest that sustained remission of RA is achieved in several multi-centric studies carried out worldwide. However, high flare rate and reappearance of disease has been reported in several cases. This review critically discusses response predictors of biologic DMARDs, the case for treatment relaxation, strategizing drug tapering considering patient eligibility and timing in light of available clinical practice guidelines of RA.
Collapse
Affiliation(s)
- Di Liu
- Department of Rheumatology, The Affiliated Hospital to Changchun University of Chinese MedicineChangchun, China
| | - Na Yuan
- Department of Rheumatology, The Affiliated Hospital to Changchun University of Chinese MedicineChangchun, China
| | - Guimei Yu
- Department of Rheumatology, The Affiliated Hospital to Changchun University of Chinese MedicineChangchun, China
| | - Ge Song
- Department of Neurology, The First Hospital of Jilin UniversityJilin, China
| | - Yan Chen
- Department of Hematology, The First Clinical Hospital of Jilin Province Academy of Traditional Chinese MedicineJilin, China
| |
Collapse
|
49
|
Alam J, Jantan I, Bukhari SNA. Rheumatoid arthritis: Recent advances on its etiology, role of cytokines and pharmacotherapy. Biomed Pharmacother 2017; 92:615-633. [PMID: 28582758 DOI: 10.1016/j.biopha.2017.05.055] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 05/01/2017] [Accepted: 05/10/2017] [Indexed: 01/13/2023] Open
Abstract
An autoimmune disease is defined as a clinical syndrome resulted from an instigation of both T cell and B cell or individually, in the absence of any present infection or any sort of distinguishable cause. Clonal deletion of auto reactive cells remains the central canon of immunology for decades, keeping the role of T cell and B cell aside, which are actually the guards to recognize the entry of foreign body. According to NIH, 23.5 million Americans are all together affected by these diseases. They are rare, but with the exception of RA. Rheumatoid arthritis is chronic and systemic autoimmune response to the multiple joints with unknown ethology, progressive disability, systemic complications, early death and high socioeconomic costs. Its ancient disease with an old history found in North American tribes since 1500 BCE, but its etiology is yet to be explored. Current conventional and biological therapies used for RA are not fulfilling the need of the patients but give only partial responses. There is a lack of consistent and liable biomarkers of prognosis therapeutic response, and toxicity. Rheumatoid arthritis is characterized by hyperplasic synovium, production of cytokines, chemokines, autoantibodies like rheumatoid factor (RF) and anticitrullinated protein antibody (ACPA), osteoclastogensis, angiogenesis and systemic consequences like cardiovascular, pulmonary, psychological, and skeletal disorders. Cytokines, a diverse group of polypeptides, play critical role in the pathogenesis of RA. Their involvement in autoimmune diseases is a rapidly growing area of biological and clinical research. Among the proinflammatory cytokines, IL-1α/β and TNF-α trigger the intracellular molecular signalling pathway responsible for the pathogenesis of RA that leads to the activation of mesenchymal cell, recruitment of innate and adaptive immune system cells, activation of synoviocytes which in term activates various mediators including tumour necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), interleukin-6 (IL-6) and interleukin-8 (IL-8), resulting in inflamed synovium, increase angiogenesis and decrease lymphangiogensis. Their current pharmacotherapy should focus on their three phases of progression i.e. prearthritis phase, transition phase and clinical phase. In this way we will be able to find a way to keep the balance between the pro and anti-inflammatory cytokines that is believe to be the dogma of pathogenesis of RA. For this we need to explore new agents, whether from synthetic or natural source to find the answers for unresolved etiology of autoimmune diseases and to provide a quality of life to the patients suffering from these diseases specifically RA.
Collapse
Affiliation(s)
- Javaid Alam
- Drug and Herbal Research Centre, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Ibrahim Jantan
- Drug and Herbal Research Centre, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Syed Nasir Abbas Bukhari
- Drug and Herbal Research Centre, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia.
| |
Collapse
|
50
|
Singh JA, Hossain A, Mudano AS, Tanjong Ghogomu E, Suarez‐Almazor ME, Buchbinder R, Maxwell LJ, Tugwell P, Wells GA. Biologics or tofacitinib for people with rheumatoid arthritis naive to methotrexate: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2017; 5:CD012657. [PMID: 28481462 PMCID: PMC6481641 DOI: 10.1002/14651858.cd012657] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Biologic disease-modifying anti-rheumatic drugs (biologics) are highly effective in treating rheumatoid arthritis (RA), however there are few head-to-head biologic comparison studies. We performed a systematic review, a standard meta-analysis and a network meta-analysis (NMA) to update the 2009 Cochrane Overview. This review is focused on the adults with RA who are naive to methotrexate (MTX) that is, receiving their first disease-modifying agent. OBJECTIVES To compare the benefits and harms of biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib versus comparator (methotrexate (MTX)/other DMARDs) in people with RA who are naive to methotrexate. METHODS In June 2015 we searched for randomized controlled trials (RCTs) in CENTRAL, MEDLINE and Embase; and trials registers. We used standard Cochrane methods. We calculated odds ratios (OR) and mean differences (MD) along with 95% confidence intervals (CI) for traditional meta-analyses and 95% credible intervals (CrI) using a Bayesian mixed treatment comparisons approach for network meta-analysis (NMA). We converted OR to risk ratios (RR) for ease of interpretation. We also present results in absolute measures as risk difference (RD) and number needed to treat for an additional beneficial or harmful outcome (NNTB/H). MAIN RESULTS Nineteen RCTs with 6485 participants met inclusion criteria (including five studies from the original 2009 review), and data were available for four TNF biologics (adalimumab (six studies; 1851 participants), etanercept (three studies; 678 participants), golimumab (one study; 637 participants) and infliximab (seven studies; 1363 participants)) and two non-TNF biologics (abatacept (one study; 509 participants) and rituximab (one study; 748 participants)).Less than 50% of the studies were judged to be at low risk of bias for allocation sequence generation, allocation concealment and blinding, 21% were at low risk for selective reporting, 53% had low risk of bias for attrition and 89% had low risk of bias for major baseline imbalance. Three trials used biologic monotherapy, that is, without MTX. There were no trials with placebo-only comparators and no trials of tofacitinib. Trial duration ranged from 6 to 24 months. Half of the trials contained participants with early RA (less than two years' duration) and the other half included participants with established RA (2 to 10 years). Biologic + MTX versus active comparator (MTX (17 trials (6344 participants)/MTX + methylprednisolone 2 trials (141 participants))In traditional meta-analyses, there was moderate-quality evidence downgraded for inconsistency that biologics with MTX were associated with statistically significant and clinically meaningful benefit versus comparator as demonstrated by ACR50 (American College of Rheumatology scale) and RA remission rates. For ACR50, biologics with MTX showed a risk ratio (RR) of 1.40 (95% CI 1.30 to 1.49), absolute difference of 16% (95% CI 13% to 20%) and NNTB = 7 (95% CI 6 to 8). For RA remission rates, biologics with MTX showed a RR of 1.62 (95% CI 1.33 to 1.98), absolute difference of 15% (95% CI 11% to 19%) and NNTB = 5 (95% CI 6 to 7). Biologics with MTX were also associated with a statistically significant, but not clinically meaningful, benefit in physical function (moderate-quality evidence downgraded for inconsistency), with an improvement of HAQ scores of -0.10 (95% CI -0.16 to -0.04 on a 0 to 3 scale), absolute difference -3.3% (95% CI -5.3% to -1.3%) and NNTB = 4 (95% CI 2 to 15).We did not observe evidence of differences between biologics with MTX compared to MTX for radiographic progression (low-quality evidence, downgraded for imprecision and inconsistency) or serious adverse events (moderate-quality evidence, downgraded for imprecision). Based on low-quality evidence, results were inconclusive for withdrawals due to adverse events (RR of 1.32, but 95% confidence interval included possibility of important harm, 0.89 to 1.97). Results for cancer were also inconclusive (Peto OR 0.71, 95% CI 0.38 to 1.33) and downgraded to low-quality evidence for serious imprecision. Biologic without MTX versus active comparator (MTX 3 trials (866 participants)There was no evidence of statistically significant or clinically important differences for ACR50, HAQ, remission, (moderate-quality evidence for these benefits, downgraded for imprecision), withdrawals due to adverse events,and serious adverse events (low-quality evidence for these harms, downgraded for serious imprecision). All studies were for TNF biologic monotherapy and none for non-TNF biologic monotherapy. Radiographic progression was not measured. AUTHORS' CONCLUSIONS In MTX-naive RA participants, there was moderate-quality evidence that, compared with MTX alone, biologics with MTX was associated with absolute and relative clinically meaningful benefits in three of the efficacy outcomes (ACR50, HAQ scores, and RA remission rates). A benefit regarding less radiographic progression with biologics with MTX was not evident (low-quality evidence). We found moderate- to low-quality evidence that biologic therapy with MTX was not associated with any higher risk of serious adverse events compared with MTX, but results were inconclusive for withdrawals due to adverse events and cancer to 24 months.TNF biologic monotherapy did not differ statistically significantly or clinically meaningfully from MTX for any of the outcomes (moderate-quality evidence), and no data were available for non-TNF biologic monotherapy.We conclude that biologic with MTX use in MTX-naive populations is beneficial and that there is little/inconclusive evidence of harms. More data are needed for tofacitinib, radiographic progression and harms in this patient population to fully assess comparative efficacy and safety.
Collapse
Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterDepartment of MedicineFaculty Office Tower 805B510 20th Street SouthBirminghamALUSA35294
| | - Alomgir Hossain
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | - Amy S Mudano
- University of Alabama at BirminghamDepartment of Medicine ‐ RheumatologyBirminghamUSA
| | | | - Maria E Suarez‐Almazor
- The University of Texas, MD Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
| | | |
Collapse
|