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Pitsigavdaki S, Nikoloudaki M, Garantziotis P, Silvagni E, Repa A, Marangoni A, Flouri I, Avgoustidis N, Parperis K, Fanouriakis A, Govoni M, Sidiropoulos P, Boumpas DT, Bortoluzzi A, Bertsias G. Pragmatic targets for moderate/severe SLE and their implications for clinical care and trial design: sustained DORIS or LLDAS for at least 6 months is sufficient while their attainment for at least 24 months ensures high specificity for damage-free progression. Ann Rheum Dis 2024; 83:464-474. [PMID: 38233103 PMCID: PMC10958283 DOI: 10.1136/ard-2023-224919] [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: 08/25/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVES Treatment targets in systemic lupus erythematosus (SLE) have been validated in unselected-in terms of severity-cohorts, which limits their generalisability. We assessed remission (Definition of Remission in SLE (DORIS)) and Lupus Low Disease Activity State (LLDAS) in a historical cohort of 348 patients with active moderate-to-severe disease and median follow-up of 5 years. METHODS Active SLE was defined as Physician Global Assessment ≥1.5 and/or SLE Disease Activity Index 2000 ≥6, requiring therapy intensification. DORIS/LLDAS, organ damage, flares and adverse events were monitored. Shared frailty survival, generalised linear models and K-means clustering were applied. RESULTS Sustained DORIS and LLDAS for ≥6 months occurred in 41.1% and 80.4%, respectively, and resulted in reduced damage accrual (HR: 0.58; 95% CI 0.36 to 0.93 and 0.61; 0.43 to 0.86) and severe flares (HR: 0.14; 0.08 to 0.27 and 0.19; 0.13 to 0.27). LLDAS without DORIS was also protective (HR: 0.65; 0.43 to 0.98 for damage, 0.49; 0.36 to 0.67 for flares). Models fitting increasing duration of targets showed that DORIS ≥50% and LLDAS ≥60% of time, or alternatively, ≥24 and ≥36 months, achieved optimal balance between feasibility (20.2-41.7%) and specificity (73.3-86.1%) for damage-free outcome. These targets were linked to reduced serious adverse events (risk ratio (RR): 0.56-0.71), hospitalisation (RR: 0.70) and mortality (RR: 0.06-0.13). Patients with predominant arthritis and mucocutaneous disease experienced reduced DORIS/LLDAS, compared with counterparts with major organ involvement. Conventional drugs were more frequently used in the former group, whereas potent immunosuppressive/biological agents in the latter. CONCLUSIONS In moderate-to-severe SLE, sustained DORIS/LLDAS for at least 6 months is sufficient, while attainment for at least 24 months ensures higher specificity for damage-free progression, thus facilitating treat-to-target strategies and clinical trials. Arthritis and skin disease represent unmet therapeutic needs that could benefit from novel biologics.
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Affiliation(s)
- Sofia Pitsigavdaki
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Myrto Nikoloudaki
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Panagiotis Garantziotis
- Laboratory of Autoimmunity and Inflammation, Centre of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg and University Hospital of Erlangen, Erlangen, Germany
| | - Ettore Silvagni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - Argyro Repa
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Antonio Marangoni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - Irini Flouri
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Nestor Avgoustidis
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Konstantinos Parperis
- Division of Rheumatology, Department of Medicine, University of Cyprus Medical School, Nicosia, Cyprus
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Marcello Govoni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - Prodromos Sidiropoulos
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
- Division of Immunity, Institute of Molecular Biology and Biotechnology-Foundation for Research and Technology - Hellas (FORTH), Heraklion, Greece
| | - Dimitrios T Boumpas
- Laboratory of Autoimmunity and Inflammation, Centre of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Alessandra Bortoluzzi
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
- Division of Immunity, Institute of Molecular Biology and Biotechnology-Foundation for Research and Technology - Hellas (FORTH), Heraklion, Greece
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Ruyssen-Witrand A, Guernec G, Dupont J, Lapuyade D, Lioté F, Vittecoq O, Degboé Y, Constantin A. Ten-year radiographic and functional outcomes in rheumatoid arthritis patients in remission compared to patients in low disease activity. Arthritis Res Ther 2023; 25:207. [PMID: 37864239 PMCID: PMC10588022 DOI: 10.1186/s13075-023-03176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/19/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND To compare the 10-year structural and functional prognosis between patients in sustained remission versus patients in sustained low disease activity (LDA) in early rheumatoid arthritis (RA). METHODS We included 256 patients from the ESPOIR cohort who fulfilled the 2010 ACR/EULAR criteria for RA and who were in sustained remission using the Simple Disease Activity Index (SDAI) score (n = 48), in sustained LDA (n = 139) or in sustained moderate to high disease activity (MDA or HDA, n = 69) over 10 years. The mTSSs progression over 10 years and the 10-year HAQ-DI scores were compared between the 3 groups. A longitudinal latent process mixed model was used to assess the independent effect of SDAI status over time on 10-year mTSS progression and HAQ-DI at 10 years. RESULTS Patients in sustained remission group were younger, had lower baseline HAQ-DI and mTSS scores and were less exposed to glucocorticoids, methotrexate or biologic disease-modifying anti-rheumatic drugs over 10 years. Patients in sustained remission had lower 10-year structural progression (variation of mTSS in the remission group: 4.06 (± 4.75) versus 14.59 (± 19.76) in the LDA group and 21.04 (± 24.08), p < 0.001 in the MDA or HDA groups) and lower 10-year HAQ-DI scores (10-year HAQ-DI in the remission group: 0.14 (± 0.33) versus 0.53 (± 0.49) in the LDA group and 1.20 (± 0.62) in the MDA or HDA groups, p < 0.001). The incidence of serious adverse events over 10 years was low, about 3.34/100 patient years, without any difference between the three groups. CONCLUSION RA patients in sustained SDAI remission have better long-term structural and functional outcomes in comparison to patients in sustained LDA.
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Affiliation(s)
- Adeline Ruyssen-Witrand
- Rheumatology Centre, Toulouse University Hospital, Centre d'Investigation Clinique de Toulouse CIC1436, Inserm, Team PEPSS "Pharmacologie En Population cohorteS Et biobanqueS, Purpan Teaching Hospital, University of Toulouse 3, 1 Place du Dr Baylac, 31059, Toulouse, Cedex 9, France.
| | - Gregory Guernec
- Inserm, Centre d'Epidémiologie Et de Recherche en Santé Des Populations, UMR1295, Inserm, Toulouse, France
| | - Julia Dupont
- Rheumatology Centre, Toulouse University Hospital, Toulouse, France
| | - Diane Lapuyade
- Rheumatology Centre, Toulouse University Hospital, Toulouse, France
| | - Frédéric Lioté
- Université Paris Cité and Inserm UMR1132 Bioscar Hôpital Lariboisière and Service de Rhumatologie, Hôpital Saint-Joseph, Paris, France
| | - Olivier Vittecoq
- Department of Rheumatology and CIC-CRB1404, Normandie Univ, UNIROUEN, Rouen University Hospital, 76000, Rouen, France
| | - Yannick Degboé
- Rheumatology Center, Toulouse University Hospital, INFINITY, Toulouse Institute for Infectious and Inflammatory Diseases, INSERM U1291, CNRS U5051, University Toulouse 3, Toulouse, France
| | - Arnaud Constantin
- Rheumatology Center, Toulouse University Hospital, INFINITY, Toulouse Institute for Infectious and Inflammatory Diseases, INSERM U1291, CNRS U5051, University Toulouse 3, Toulouse, France
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Deep Learning-Based Computer-Aided Diagnosis of Rheumatoid Arthritis with Hand X-ray Images Conforming to Modified Total Sharp/van der Heijde Score. Biomedicines 2022; 10:biomedicines10061355. [PMID: 35740376 PMCID: PMC9220074 DOI: 10.3390/biomedicines10061355] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction: Rheumatoid arthritis (RA) is a systemic autoimmune disease; early diagnosis and treatment are crucial for its management. Currently, the modified total Sharp score (mTSS) is widely used as a scoring system for RA. The standard screening process for assessing mTSS is tedious and time-consuming. Therefore, developing an efficient mTSS automatic localization and classification system is of urgent need for RA diagnosis. Current research mostly focuses on the classification of finger joints. Due to the insufficient detection ability of the carpal part, these methods cannot cover all the diagnostic needs of mTSS. Method: We propose not only an automatic label system leveraging the You Only Look Once (YOLO) model to detect the regions of joints of the two hands in hand X-ray images for preprocessing of joint space narrowing in mTSS, but also a joint classification model depending on the severity of the mTSS-based disease. In the image processing of the data, the window level is used to simulate the processing method of the clinician, the training data of the different carpal and finger bones of human vision are separated and integrated, and the resolution is increased or decreased to observe the changes in the accuracy of the model. Results: Integrated data proved to be beneficial. The mean average precision of the proposed model in joint detection of joint space narrowing reached 0.92, and the precision, recall, and F1 score all reached 0.94 to 0.95. For the joint classification, the average accuracy was 0.88, and the accuracy of severe, mild, and healthy reached 0.91, 0.79, and 0.9, respectively. Conclusions: The proposed model is feasible and efficient. It could be helpful for subsequent research on computer-aided diagnosis in RA. We suggest that applying the one-hand X-ray imaging protocol can improve the accuracy of mTSS classification model in determining mild disease if it is used in clinical practice.
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Kishimoto Y, Kato Y, Uemura M, Kuranobu K. Can Intra-articular Injection of Glucocorticoids Be an Alternative Intervention to Achieve Remission in Patients With Rheumatoid Arthritis Exhibiting Low Disease Activity? A Single-Center Longitudinal Study. J Clin Rheumatol 2022; 28:e353-e358. [PMID: 35192592 DOI: 10.1097/rhu.0000000000001719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE This study aimed at investigating whether a single intra-articular (IA) injection of triamcinolone acetonide (TA) could facilitate to achieve clinical remission in patients with rheumatoid arthritis (RA) exhibiting low disease activity (LDA). METHODS This longitudinal study included 22 patients with RA exhibiting LDA involving wrist arthritis at our institution between April 2016 and March 2019. A single IA injection of 20 mg TA was administered into the symptomatic wrist joint. Efficacy was assessed by the primary end point of proportion of patients reaching clinical remission. Secondary end points included Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), Health Assessment Questionnaire Disability Index, adverse events, and ultrasonographic assessment of the injected wrist joints. RESULTS Remission rates were 40% and 50% at weeks 4 and 12, respectively, and were maintained at approximately 50% until week 24. The secondary outcomes of CDAI, SDAI, and Health Assessment Questionnaire Disability Index were improved significantly at week 4, and the improvements in CDAI and SDAI continued up to week 24. Ultrasonography showed that synovial hypertrophy, power Doppler signals, and the combined score were significantly reduced at weeks 4, 12, and 24 compared with the baseline. No patient developed severe, irreversible adverse events. CONCLUSIONS Approximately half of the patients with RA exhibiting LDA who received a single IA injection of TA into the wrist joints achieved clinical remission without serious adverse events in the midterm period, suggesting that IA injection of TA might be considered as an alternative intervention to achieve remission in patients with RA exhibiting LDA.
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Affiliation(s)
| | | | | | - Koji Kuranobu
- Rehabilitation, Japanese Red Cross Tottori Hospital, Tottori, Japan
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Value of Remission in Patients with Rheumatoid Arthritis: A Targeted Review. Adv Ther 2022; 39:75-93. [PMID: 34787822 PMCID: PMC8799574 DOI: 10.1007/s12325-021-01946-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/01/2021] [Indexed: 11/03/2022]
Abstract
The treat-to-target strategy, which defines clinical remission as the primary therapeutic goal for rheumatoid arthritis (RA), is a widely recommended treatment approach in clinical guidelines. Achieving remission has been associated with improved clinical outcomes, quality of life, and productivity. These benefits are likely to translate to reduced economic burden in terms of lower healthcare costs and resource utilization. As such, a literature review was conducted to better understand the economic value of remission. Despite the large heterogeneity found in RA-related economic outcomes across studies, patients in remission consistently had lower direct medical and indirect costs, less healthcare resource utilization, and greater productivity compared to those without remission. Remission was associated with 19–52% savings in direct medical costs and 37–75% savings in indirect costs. The economic value of remission should thus be considered in economic analyses of RA therapies to inform treatment and reimbursement decisions.
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Hèctor C, Millan AM, Diaz-Torne C. Rheumatoid Arthritis: Defining Clinical and Ultrasound Deep Remission. Mediterr J Rheumatol 2021; 31:384-388. [PMID: 33521569 PMCID: PMC7841096 DOI: 10.31138/mjr.31.4.384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 11/04/2022] Open
Abstract
The prognosis of patients with rheumatoid arthritis (RA) has improved substantially in the last two decades due to the appearance of biological therapies, but above all, due to the improvement in the strategy and management of the disease. Our goal in RA should be to achieve remission, or in its absence, the lowest inflammatory activity. Achieving remission will prevent from structural and functional damage highly associated with RA itself. Clinical remission is defined as the absence of significant signs and symptoms of inflammatory disease activity, as well as the abrogation of any signs of systemic inflammation. Currently, there are some controversies about remission. Which is the real remission? Which remission criteria should be used and when? Does clinical remission mean ultrasound remission? In the present review, we try to answer and put some light into it, focusing on clinical and ultrasound deep remission.
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Affiliation(s)
- Corominas Hèctor
- Arthritis Unit, Rheumatology and Autoimmune Diseases Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ana Milena Millan
- Arthritis Unit, Rheumatology and Autoimmune Diseases Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cesar Diaz-Torne
- Arthritis Unit, Rheumatology and Autoimmune Diseases Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
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Ji L, Xie W, Li G, Zhang Z. Maintenance to target was associated with radiological outcomes in patients with rheumatoid arthritis: a real-world observational cohort study. Clin Rheumatol 2020; 40:1307-1315. [PMID: 32897479 DOI: 10.1007/s10067-020-05385-w] [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] [Received: 05/22/2020] [Revised: 07/22/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the effect of different maintenance to target on radiologic outcomes in patients with rheumatoid arthritis (RA) in real-world setting. METHODS RA patients enrolled were screened from a longitudinal cohort. The radiographies were evaluated at baseline, after 1-2 years and thereafter every 2 years. An increase of mTSS > 3 from baseline was taken as the primary outcome and accelerated annual radiological progression as the secondary outcome of radiological progression. The maintenance rate (MR) to target was calculated as the proportion of the year fulfilling preset criteria of target over the whole follow-up period. COX regression and logistic analysis were used to determine the effect of variables on radiological outcomes. RESULTS Two hundred forty-three patients were enrolled, with median follow-up of 2 years (3.00). Radiological progression was observed in 43 (17.7%) patients, with annual increase of mTSS 0.20 (1.33). In multivariate analysis, MR was the only independent protective factor of both primary and secondary radiological outcomes in two models [HR 0.09, 95% CI (0.04, 0.22), p < 0.001, model 1; OR 0.21, 95% CI (0.09, 0.49), p < 0.001, model 2]. ACPA positivity was another independent risk factor of secondary outcome [OR 2.96, 95% CI (1.27, 6.86), p = 0.012]. Higher MR was also associated with less radiological progression in established RA patients. Partial MR was not inferior to full maintenance within 4 years in terms of halting radiological progression. CONCLUSION Low MR and ACPA positivity were independent risk factors of poor radiological outcomes in RA patients. No significant difference in radiological progression could be detected between partial and full maintenance group within 4 years in daily practice. KEY POINTS • The first study showing that maintenance to target is beneficial to bone protection in established RA patients in real-world setting • No difference in radiological outcomes between partial and full maintenance group within 4 years.
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Affiliation(s)
- Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China
| | - Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China.
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Michaud K, Pope J, van de Laar M, Curtis JR, Kannowski C, Mitchell S, Bell J, Workman J, Paik J, Cardoso A, Taylor PC. Systematic Literature Review of Residual Symptoms and an Unmet Need in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2020; 73:1606-1616. [PMID: 32619340 PMCID: PMC8596735 DOI: 10.1002/acr.24369] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 06/25/2020] [Indexed: 12/11/2022]
Abstract
Objective To evaluate the nature and burden of residual disease in rheumatoid arthritis (RA) in patients who meet treatment targets. Second, for those who did not meet targets, to evaluate how much is due to patient symptoms. Methods Prospective and retrospective studies were searched in Medline, Embase, and Cochrane Library in the English language from January 1, 2008 to April 18, 2018; conference abstracts (from January 2016 to April 2018) and reference lists of relevant studies were also screened. Results Of 8,339 records identified, 55 were included in the review; 53 were unique studies, including 10 randomized controlled trials. Of these, 48 reported on patients who achieved low disease activity (LDA) or remission. Studies varied in population, treatment goals, and outcome reporting. The proportions of patients with residual symptoms in these studies varied by the definitions used for LDA or remission and were more often reported in patients with LDA than those in remission. The most commonly reported outcome measures were functional disability (n = 34 studies), tender or swollen joints (n = 18), pain (n = 17), patient global assessment (n = 15), and fatigue (n = 14). However, few studies reported the percentage of patients achieving a specific threshold, which could then be used to easily define the presence of residual symptoms. Conclusion Residual symptoms are present in some patients despite their achieving LDA or remission, highlighting an unmet need, especially with respect to improving pain, fatigue, and function. Standardized reporting in future observational studies would facilitate better understanding of this issue in defined RA populations.
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Affiliation(s)
- Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Janet Pope
- University of Western Ontario, London, Ontario, Canada
| | | | | | | | | | | | | | - Jim Paik
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - Peter C Taylor
- Botnar Research Centre, University of Oxford, Oxford, UK
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Norvang V, Brinkmann GH, Yoshida K, Lillegraven S, Aga AB, Sexton J, Tedeschi SK, Lyu H, Norli ES, Uhlig T, Kvien TK, Mjaavatten MD, Solomon DH, Haavardsholm EA. Achievement of remission in two early rheumatoid arthritis cohorts implementing different treat-to-target strategies. Arthritis Rheumatol 2020; 72:1072-1081. [PMID: 32090491 DOI: 10.1002/art.41232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/06/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To compare achievement of remission in two early rheumatoid arthritis (RA) treat-to-target (TTT) cohorts, one tight control cohort targeting stringent remission in a randomized controlled strategy trial and one observational cohort targeting a looser definition of remission in clinical practice. METHODS We analyzed data from the ARCTIC trial and the NOR-VEAC observational study. Both were Norwegian multicenter studies including disease modifying anti-rheumatic drug (DMARD)-naïve RA-patients and implementing TTT. The target in ARCTIC was remission defined as a Disease Activity Score (DAS44) <1.6 plus 0 of 44 swollen joint count, while the target in NOR-VEAC was the less stringent remission of DAS28<2.6. We assessed achievement of the study-specific targets and compared achievement of the ACR/ EULAR Boolean remission during two years of follow-up. RESULTS We included 189 patients from ARCTIC and 330 patients from NOR-VEAC. More than half in each cohort had reached the study-specific target at 6 months, increasing to more than 60% at 12 and 24 months. The odds of reaching ACR/EULAR Boolean remission during follow-up were higher in ARCTIC than in NOR-VEAC, with statistically significant differences at 3 months (OR 1.73; 95% CI 1.03-2.89), 12 months (OR 1.97; 95% CI 1.21-3.20) and 24 months (OR 1.82; 95% CI 1.05 - 3.16). CONCLUSION A majority of patients in both cohorts reached the study-specific treatment targets. More patients in ARCTIC than in NOR-VEAC achieved ACR/EULAR Boolean remission during follow-up, suggesting that targeting a more stringent definition of remission provide further potential for favorable outcomes of a TTT strategy.
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Affiliation(s)
- Vibeke Norvang
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Kazuki Yoshida
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women´s Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Siri Lillegraven
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Joseph Sexton
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Sara K Tedeschi
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women´s Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Houchen Lyu
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ellen S Norli
- Department of Rheumatology, Martina Hansens Hospital, Sandvika, Norway
| | - Till Uhlig
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Daniel H Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women´s Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
- Department of Rheumatology, Østfold Hospital, Grålum, Norway
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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.
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Affiliation(s)
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Tuen Mun, Hong Kong, China.
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Mota LMHD, Kakehasi AM, Gomides APM, Duarte ALBP, Cruz BA, Brenol CV, de Albuquerque CP, Castelar Pinheiro GDR, Laurindo IMM, Pereira IA, Bertolo MB, Ubirajara Silva de Souza MPG, de Freitas MVC, Louzada-Júnior P, Xavier RM, Giorgi RDN. 2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis. Adv Rheumatol 2018; 58:2. [PMID: 30657071 DOI: 10.1186/s42358-018-0005-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 12/29/2022] Open
Abstract
The objective of this document is to provide a comprehensive update of the recommendations of Brazilian Society of Rheumatology on drug treatment of rheumatoid arthritis (RA), based on a systematic literature review and on the opinion of a panel of rheumatologists. Four general principles and eleven recommendations were approved. General principles: RA treatment should (1) preferably consist of a multidisciplinary approach coordinated by a rheumatologist, (2) include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record, (3) be based on decisions shared by the patient and the physician after clarification about the disease and the available therapeutic options; (4) the goal is sustained clinical remission or, when this is not feasible, low disease activity. Recommendations: (1) the first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established; (2) methotrexate (MTX) is the first-choice csDMARD; (3) the combination of two or more csDMARDs, including MTX, may be used as the first line of treatment; (4) after failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone; (5) after failure of two schemes with csDMARDs, a bDMARD may be preferably used or, alternatively a tsDMARD, preferably combined, in both cases, with a csDMARD; (6) the different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost; (7) the combination of a bDMARD and MTX is preferred over the use of a bDMARD alone; (8) in case of failure of an initial treatment scheme with a bDMARD, a scheme with another bDMARD can be used; in cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe; (9) tofacitinib can be used to treat RA after failure of bDMARD; (10) corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered; (11) reducing or spacing out bDMARD doses is possible in patients in sustained remission.
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Affiliation(s)
- Licia Maria Henrique da Mota
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina- Universidade de Brasília; Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil. .,Rheos, Centro Médico Lúcio Costa, SGAS 610, bloco 1, salas T50- T51, L2 Sul, Asa Sul, Brasília, DF, 70200700, Brazil.
| | - Adriana Maria Kakehasi
- Disciplina de Reumatologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ana Paula Monteiro Gomides
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina- Universidade de Brasília; Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil.,Centro Universitário de Brasília- UniCEUB, Brasília, Brazil
| | | | | | - Claiton Viegas Brenol
- Serviço de Reumatologia, Departamento de Medicina Interna, Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | | | - Manoel Barros Bertolo
- Disciplina de Reumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | | | | | - Paulo Louzada-Júnior
- Disciplina de Reumatologia, Faculdade de Medicina de Universidade de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Ricardo Machado Xavier
- Serviço de Reumatologia, Departamento de Medicina Interna, Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rina Dalva Neubarth Giorgi
- Serviço de Reumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual, São Paulo, Brazil
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12
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Further Treatment Intensification in Undifferentiated and Rheumatoid Arthritis Patients Already in Low Disease Activity has Limited Benefit towards Physical Functioning. Arthritis Res Ther 2017; 19:220. [PMID: 28962586 PMCID: PMC5622576 DOI: 10.1186/s13075-017-1425-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is recommended to optimise treatment as long as a predefined treatment target is not met, but should the aim be remission if patients are in low disease activity (LDA)? The aim of this study was to assess if, in patients with rheumatoid arthritis (RA) or patients with undifferentiated arthritis (UA) with Disease Activity Score (DAS) ≤ 2.4 (LDA), treatment intensification results in better functional ability. METHODS In the IMPROVED study 610 patients with early RA or UA were treated with methotrexate + tapered high-dose prednisone. After 4 months, patients with DAS ≥ 1.6 were randomised to either of two treatment strategies. Patients with DAS < 1.6 tapered treatment. Over 5 years, patients with DAS ≥ 1.6 required treatment intensification, but protocol violations occurred, which allowed us to test the effect of treatment intensification regardless of subsequent DAS. A linear mixed model was used to test, in patients in LDA, the relationship between treatment intensification and functional ability (Health Assessment Questionnaire [HAQ]) over time. RESULTS The number of patients in LDA per visit ranged from 88 to 146. Per visit, 27-74% of the patients in LDA had treatment intensification. We found a statistically significant effect of treatment intensification on ΔHAQ, corrected for baseline HAQ, age, sex and treatment strategy (β = -0.085, 95% CI -0.13 to -0.044). When ΔDAS was added, the effect of treatment intensification was partly explained by ΔDAS, and the association with HAQ was no longer statistically significant (β = -0.022, 95% CI -0.060 to 0.016). When the interaction between treatment intensification and time in follow-up was added, a statistically significant interaction was found (β = 0.0098, 95% CI 0.0010 to 0.019), indicating lesser improvement in HAQ after treatment intensification if follow-up time increased. CONCLUSIONS For patients with early RA and patients with UA already in LDA, further treatment intensification aimed at DAS remission does not result in meaningful functional improvement. TRIAL REGISTRATION ISRCTN, 11916566 . Registered on 28 December 2006. EudraCT, 2006-006186-16 . Registered on 16 July 2007.
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13
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Caporali R, Smolen JS. Back to the future: forget ultrasound and focus on clinical assessment in rheumatoid arthritis management. Ann Rheum Dis 2017; 77:18-20. [PMID: 28768630 DOI: 10.1136/annrheumdis-2017-211458] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 11/03/2022]
Abstract
Ultrasound (US) unquestionably improves many aspects of rheumatoid arthritis (RA) diagnosis and management, but no consensus has been reached regarding the optimal US methodology that should be used, and high levels of standardisation have not yet been attained. Current evidence from two randomised controlled trials does not support the US in directing treatment decisions. A return to the endorsement of clinical assessment and the adoption of T2T strategies aiming at ACR/EULAR remission still represent the standard of care for RA and should be pursued through appropriate educational programmes. Thus, for now, the major application of sonography in arthritis should have a focus on diagnostic and especially differential diagnostic aspects.
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Affiliation(s)
- Roberto Caporali
- Division of Rheumatology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
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14
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Hirano F, Yokoyama W, Yamazaki H, Amano K, Kawakami A, Hayashi T, Tamura N, Yasuda S, Dobashi H, Fujii T, Ito S, Kaneko Y, Matsui T, Okuda Y, Saito K, Suzuki F, Yoshimi R, Sakai R, Koike R, Kohsaka H, Miyasaka N, Harigai M. Achieving simplified disease activity index remission in patients with active rheumatoid arthritis is associated with subsequent good functional and structural outcomes in a real-world clinical setting under a treat-to-target strategy. Mod Rheumatol 2016; 27:811-819. [DOI: 10.1080/14397595.2016.1265726] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Fumio Hirano
- Department of Pharmacovigilance
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
| | - Waka Yokoyama
- Department of Pharmacovigilance
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
| | - Hayato Yamazaki
- Department of Pharmacovigilance
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Atsushi Kawakami
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Taichi Hayashi
- Department of Rheumatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Bunkyō, Japan
| | - Shinsuke Yasuda
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Takamatsu, Japan,
| | - Takao Fujii
- Department of the Control for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Minato, Japan
| | - Toshihiro Matsui
- Department of Rheumatology, Sagamihara National Hospital, National Hospital Organization, Sagamihara, Japan
| | - Yasuaki Okuda
- Department of Internal Medicine, Center for Rheumatic Diseases, Dohgo Spa Hospital, Matsuyama, Japan
| | - Kazuyoshi Saito
- The First Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Fumihito Suzuki
- Department of Rheumatology, Soka Municipal Hospital, Saitama, Japan
| | - Ryusuke Yoshimi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Ryoko Sakai
- Department of Pharmacovigilance
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
| | - Ryuji Koike
- Department of Pharmacovigilance
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
| | - Nobuyuki Miyasaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
| | - Masayoshi Harigai
- Department of Pharmacovigilance
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyō, Japan
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15
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Combe B, Landewe R, Daien CI, Hua C, Aletaha D, Álvaro-Gracia JM, Bakkers M, Brodin N, Burmester GR, Codreanu C, Conway R, Dougados M, Emery P, Ferraccioli G, Fonseca J, Raza K, Silva-Fernández L, Smolen JS, Skingle D, Szekanecz Z, Kvien TK, van der Helm-van Mil A, van Vollenhoven R. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2016. [PMID: 27979873 DOI: 10.1136/annrheumdis-2016-210602 10.1136/annrheumdis-2016-210602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Since the 2007 recommendations for the management of early arthritis have been presented, considerable research has been published in the field of early arthritis, mandating an update of the 2007 European League Against Rheumatism (EULAR) recommendations for management of early arthritis. METHODS In accordance with the 2014 EULAR Standardised Operating Procedures, the expert committee pursued an approach that was based on evidence in the literature and on expert opinion. The committee involved 20 rheumatologists, 2 patients and 1 healthcare professional representing 12 European countries. The group defined the focus of the expert committee and target population, formulated a definition of 'management' and selected the research questions. A systematic literature research (SLR) was performed by two fellows with the help of a skilled librarian. A set of draft recommendations was proposed on the basis of the research questions and the results of the SLR. For each recommendation, the categories of evidence were identified, the strength of recommendations was derived and the level of agreement was determined through a voting process. RESULTS The updated recommendations comprise 3 overarching principles and 12 recommendations for managing early arthritis. The selected statements involve the recognition of arthritis, referral, diagnosis, prognostication, treatment (information, education, pharmacological and non-pharmacological interventions), monitoring and strategy. Eighteen items were identified as relevant for future research. CONCLUSIONS These recommendations provide rheumatologists, general practitioners, healthcare professionals, patients and other stakeholders with an updated EULAR consensus on the entire management of early arthritis.
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Affiliation(s)
- Bernard Combe
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Robert Landewe
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology Center, Amsterdam and Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Claire I Daien
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Charlotte Hua
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Jose María Álvaro-Gracia
- Biological Therapies Unit, Servicio de Reumatología. Hospital Universitario de la Princesa, IIS-IP, Madrid, Spain
| | - Margôt Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Berlin, Germany
| | - Catalin Codreanu
- Department of Rheumatology, Center for Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Richard Conway
- Department of Rheumatology, Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Dublin, Ireland
| | - Maxime Dougados
- Medicine Faculty, APHP, Rheumatology B Department, Paris Descartes University, Cochin Hospital, Paris, France
| | - Paul Emery
- Leeds NIHR Musculoskeletal Biomedical Research Unit, LTHT, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Gianfranco Ferraccioli
- Fondazione Policlinico Gemelli Academic Hospital, Catholic University School of Medicine, Rome, Italy
| | - Joao Fonseca
- Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon.,Instituto de Medicina Molecular, Faculdade de Medicina Universidade de Lisboa, Portugal
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Lucía Silva-Fernández
- Rheumatology Department, Complexo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Diana Skingle
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Zoltan Szekanecz
- Faculty of Medicine, Department of Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ronald van Vollenhoven
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, Amsterdam, The Netherlands
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16
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Combe B, Landewe R, Daien CI, Hua C, Aletaha D, Álvaro-Gracia JM, Bakkers M, Brodin N, Burmester GR, Codreanu C, Conway R, Dougados M, Emery P, Ferraccioli G, Fonseca J, Raza K, Silva-Fernández L, Smolen JS, Skingle D, Szekanecz Z, Kvien TK, van der Helm-van Mil A, van Vollenhoven R. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2016; 76:948-959. [PMID: 27979873 DOI: 10.1136/annrheumdis-2016-210602] [Citation(s) in RCA: 315] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/24/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Since the 2007 recommendations for the management of early arthritis have been presented, considerable research has been published in the field of early arthritis, mandating an update of the 2007 European League Against Rheumatism (EULAR) recommendations for management of early arthritis. METHODS In accordance with the 2014 EULAR Standardised Operating Procedures, the expert committee pursued an approach that was based on evidence in the literature and on expert opinion. The committee involved 20 rheumatologists, 2 patients and 1 healthcare professional representing 12 European countries. The group defined the focus of the expert committee and target population, formulated a definition of 'management' and selected the research questions. A systematic literature research (SLR) was performed by two fellows with the help of a skilled librarian. A set of draft recommendations was proposed on the basis of the research questions and the results of the SLR. For each recommendation, the categories of evidence were identified, the strength of recommendations was derived and the level of agreement was determined through a voting process. RESULTS The updated recommendations comprise 3 overarching principles and 12 recommendations for managing early arthritis. The selected statements involve the recognition of arthritis, referral, diagnosis, prognostication, treatment (information, education, pharmacological and non-pharmacological interventions), monitoring and strategy. Eighteen items were identified as relevant for future research. CONCLUSIONS These recommendations provide rheumatologists, general practitioners, healthcare professionals, patients and other stakeholders with an updated EULAR consensus on the entire management of early arthritis.
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Affiliation(s)
- Bernard Combe
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Robert Landewe
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology Center, Amsterdam and Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Claire I Daien
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Charlotte Hua
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Jose María Álvaro-Gracia
- Biological Therapies Unit, Servicio de Reumatología. Hospital Universitario de la Princesa, IIS-IP, Madrid, Spain
| | - Margôt Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Berlin, Germany
| | - Catalin Codreanu
- Department of Rheumatology, Center for Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Richard Conway
- Department of Rheumatology, Centre for Arthritis and Rheumatic Diseases, St Vincent's University Hospital, Dublin Academic Medical Centre, Dublin, Ireland
| | - Maxime Dougados
- Medicine Faculty, APHP, Rheumatology B Department, Paris Descartes University, Cochin Hospital, Paris, France
| | - Paul Emery
- Leeds NIHR Musculoskeletal Biomedical Research Unit, LTHT, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Gianfranco Ferraccioli
- Fondazione Policlinico Gemelli Academic Hospital, Catholic University School of Medicine, Rome, Italy
| | - Joao Fonseca
- Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon.,Instituto de Medicina Molecular, Faculdade de Medicina Universidade de Lisboa, Portugal
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Lucía Silva-Fernández
- Rheumatology Department, Complexo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Diana Skingle
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Zoltan Szekanecz
- Faculty of Medicine, Department of Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ronald van Vollenhoven
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, Amsterdam, The Netherlands
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17
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Salaffi F, Carotti M, Ciapetti A, Di Carlo M, Gasparini S, Farah S, Gutierrez M. Effectiveness of a telemonitoring intensive strategy in early rheumatoid arthritis: comparison with the conventional management approach. BMC Musculoskelet Disord 2016; 17:146. [PMID: 27038788 PMCID: PMC4818962 DOI: 10.1186/s12891-016-1002-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 03/30/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The advent of Internet and World Wide Web has created new perspectives toward interaction between patients and healthcare professionals. Telemonitoring patients with rheumatoid arthritis (RA) is an emerging concept to guide the collaborative management treatment and improve outcomes in patients. The objective of this study was to investigate whether an intensive treatment strategy, according to a telemonitoring protocol, is more effective than conventional management strategy in reaching remission and comprehensive disease control (CDC) after 1 year in early rheumatoid arthritis (ERA) patients. METHODS Forty-four ERA patients were randomly allocated into two groups: the telemonitoring intensive strategy (TIS) group (group 1) or the conventional strategy (CS) group (group 2). Three patients refused to participate. In group 1 (n = 21), a remote monitoring system of disease activity, in combination with protocolised treatment adjustments aiming for remission was applied. In group 2 (n = 20), patients were treated according to daily clinical practice, with regular evaluation of disease activity, but without protocolised treatment adjustments. A telemedical care called "REmote TElemonitoring for MAnaging Rheumatologic Condition and HEaltcare programmes" (RETE-MARCHE), was developed to perform the remote monitoring. RESULTS A higher percentage of patients in the TIS group achieved CDAI remission vs patients in the CS group (38.1 % vs 25 % at year 1, p <0.01). Time to achieve remission was significantly shorter in the group 1 than in the group 2, with a median of 20 weeks vs a median over 36-weeks (p <0.001). Concordantly, the patients in group 1 showed a greater improvement (p <0.001), compared with group 2 in terms of functional impairment (71.4 % vs 35 %) and radiological damage progression (23.8 % vs 10 %), resulting in a greater rate of CDC (19.4 % vs 5 %). CONCLUSIONS According to our results, an intensive treatment strategy by telemonitoring leads to more effective disease remission and more rapid CDC than treatment according to conventional management strategy in ERA. TRIAL REGISTRATION TRIAL REGISTRATION NUMBER ISRCTN13142685 Date of registration: March, 17(th) 2016.
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Affiliation(s)
- Fausto Salaffi
- Rheumatology Department, Polytechnic University of the Marche, Jesi, Ancona, Italy. .,Clinica Reumatologica, Università Politecnica delle Marche, c/o Ospedale "Carlo Urbani", Via Aldo Moro, 25, 60035, Jesi, AN, Italy.
| | - Marina Carotti
- Radiology Department, Polytechnic University of the Marche, Ancona, Italy
| | - Alessandro Ciapetti
- Rheumatology Department, Polytechnic University of the Marche, Jesi, Ancona, Italy.,Rheumatology Department, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, Wales
| | - Marco Di Carlo
- Rheumatology Department, Polytechnic University of the Marche, Jesi, Ancona, Italy
| | - Stefania Gasparini
- Rheumatology Department, Polytechnic University of the Marche, Jesi, Ancona, Italy
| | - Sonia Farah
- DII, Department of Information Engineering, Politechnic University of Marche, Ancona, Italy
| | - Marwin Gutierrez
- Rheumatology Department, Polytechnic University of the Marche, Jesi, Ancona, Italy.,Musculoskeletal Department, National Rehabilitation Institute, Mexico City, Mexico
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18
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Einarsson JT, Geborek P, Saxne T, Kristensen LE, Kapetanovic MC. Sustained Remission Improves Physical Function in Patients with Established Rheumatoid Arthritis, and Should Be a Treatment Goal: A Prospective Observational Cohort Study from Southern Sweden. J Rheumatol 2016; 43:1017-23. [PMID: 27036384 DOI: 10.3899/jrheum.150995] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE It has been proposed that remission should be maintained throughout the course of rheumatoid arthritis (RA); however, the evidence supporting this is limited. Physical function measured by the Health Assessment Questionnaire (HAQ) is a major outcome in RA, and HAQ is shown to be one of the strongest predictors of longterm outcomes. The purpose of this study was to investigate the physical function over a long time in patients with RA who achieved sustained remission (SR) compared with that of patients occasionally achieving remission [non-sustained remission (NSR)]. METHODS Patients with RA treated with antitumor necrosis factor and included in the South Swedish Arthritis Treatment Group register were eligible for this study. We identified patients with a Disease Activity Score at 28 joints (DAS28) < 2.6 or Simplified Disease Activity Index (SDAI) ≤ 3.3 at some point and those who achieved SR, i.e., remission during consecutive visits for at least 6 months. The course of functional status was assessed using the HAQ at each visit. RESULTS Of the 2416 patients, 1177 (48.7%) reached DAS28 remission at some point. SR was achieved by 382 (15.8%) for the DAS28 and 186 (7.7%) for the SDAI criteria. Comparing the SR and NSR groups, HAQ improved during the first 12 months in the DAS28 remission. HAQ continued to improve relatively as long as SR was maintained. A higher proportion of patients in SR reached full physical function. CONCLUSION In patients with established RA, physical function measured by the HAQ improves in patients reaching SR compared with patients who only occasionally reach remission. The improvement continues while in remission, which supports that maintaining remission should be a treatment goal.
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Affiliation(s)
- Jon Thorkell Einarsson
- From the Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden; The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen, Copenhagen, Denmark.J.T. Einarsson, MD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; P. Geborek, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; T. Saxne, MD, PhD, Professor, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; L.E. Kristensen, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, and The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen; M.C. Kapetanovic, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital.
| | - Pierre Geborek
- From the Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden; The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen, Copenhagen, Denmark.J.T. Einarsson, MD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; P. Geborek, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; T. Saxne, MD, PhD, Professor, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; L.E. Kristensen, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, and The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen; M.C. Kapetanovic, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital
| | - Tore Saxne
- From the Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden; The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen, Copenhagen, Denmark.J.T. Einarsson, MD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; P. Geborek, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; T. Saxne, MD, PhD, Professor, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; L.E. Kristensen, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, and The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen; M.C. Kapetanovic, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital
| | - Lars Erik Kristensen
- From the Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden; The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen, Copenhagen, Denmark.J.T. Einarsson, MD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; P. Geborek, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; T. Saxne, MD, PhD, Professor, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; L.E. Kristensen, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, and The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen; M.C. Kapetanovic, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital
| | - Meliha C Kapetanovic
- From the Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden; The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen, Copenhagen, Denmark.J.T. Einarsson, MD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; P. Geborek, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; T. Saxne, MD, PhD, Professor, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital; L.E. Kristensen, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, and The Parker Institute, Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, the Capital Region of Copenhagen; M.C. Kapetanovic, MD, PhD, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital
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Lau CS, Chia F, Harrison A, Hsieh TY, Jain R, Jung SM, Kishimoto M, Kumar A, Leong KP, Li Z, Lichauco JJ, Louthrenoo W, Luo SF, Nash P, Ng CT, Park SH, Suryana BPP, Suwannalai P, Wijaya LK, Yamamoto K, Yang Y, Yeap SS. APLAR rheumatoid arthritis treatment recommendations. Int J Rheum Dis 2015; 18:685-713. [DOI: 10.1111/1756-185x.12754] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Chak Sing Lau
- Division of Rheumatology and Clinical Immunology; Queen Mary Hospital; University of Hong Kong; Hong Kong
| | - Faith Chia
- Department of Rheumatology, Allergy and Immunology; Tan Tock Seng Hospital; Singapore City Singapore
| | - Andrew Harrison
- Department of Medicine; University of Otago Wellington; Wellington South New Zealand
| | - Tsu-Yi Hsieh
- Section of Allergy, Immunology and Rheumatology, and Section of Clinical Skills Training; Taichung Veterans General Hospital; Taichung Taiwan
| | | | - Seung Min Jung
- Division of Rheumatology; Department of Internal Medicine; The Catholic University of Korea; St. Mary's Hospital; Seoul South Korea
| | | | - Ashok Kumar
- Department of Rheumatology; Fortis Flt. Lt Rajan Dhall Hospital; New Delhi India
| | - Khai Pang Leong
- Department of Rheumatology, Allergy and Immunology; Tan Tock Seng Hospital; Singapore City Singapore
| | - Zhanguo Li
- Department of Rheumatology; Peking University People's Hospital; Beijing China
| | | | - Worawit Louthrenoo
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Chiang Mai University; Chiang Mai Thailand
| | - Shue-Fen Luo
- Department of Rheumatology, Allergy and Immunology; Chang Gung Memorial Hospital and Chang Gung University; Tao-Yuan Taiwan
| | - Peter Nash
- Department of Medicine; University of Queensland; Brisbane Queensland Australia
| | - Chin Teck Ng
- Department of Rheumatology and Immunology; Singapore General Hospital; Singapore City Singapore
| | - Sung-Hwan Park
- Division of Rheumatology; Department of Internal Medicine; The Catholic University of Korea; St. Mary's Hospital; Seoul South Korea
| | - Bagus Putu Putra Suryana
- Rheumatology Division; Department of Internal Medicine; Brawijaya University; Saiful Anwar General Hospital; Malang Indonesia
| | - Parawee Suwannalai
- Allergy, Immunology and Rheumatology Division; Internal Medicine Department; Faculty of Medicine; Ramathibodi Hospital; Mahidol University; Bangkok Thailand
| | - Linda Kurniaty Wijaya
- Division of Rheumatology; Department of Internal Medicine; University of Indonesia; Jakarta Indonesia
| | - Kazuhiko Yamamoto
- Department of Allergy and Rheumatology; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Yue Yang
- Department of Rheumatology; Peking University People's Hospital; Beijing China
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Combe B, Rincheval N. Early lessons from the recent-onset rheumatoid arthritis cohort ESPOIR. Joint Bone Spine 2014; 82:13-7. [PMID: 25238951 DOI: 10.1016/j.jbspin.2014.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2014] [Indexed: 12/18/2022]
Abstract
ESPOIR is a French multicenter cohort of patients with undifferentiated arthritis enrolled within six months of symptom onset, naive to disease-modifying antirheumatic drugs and corticosteroid therapy, and either having rheumatoid arthritis (RA) or being at risk for progression to RA. The cohort is sponsored by the French Society for Rheumatology (Société française de rhumatologie [SFR]). Between December 2002 and March 2005, 813 patients were enrolled at 14 regional university hospitals, with the participation of a network of community-based rheumatologists. The objective was to establish a database on recent-onset inflammatory joint disease and, more specifically, on RA to serve for scientific research in the clinical, epidemiological, pathophysiological, and healthcare-cost fields. Ten years after enrolment were started, the cohort still has about 500 patients. The scientific committee has approved 104 clinical research projects, of which many are ongoing, and 54 original articles written by numerous French and international groups have been published. These projects cover a vast spectrum of topics including environmental factors, diagnosis, outcomes, prognosis, disease evaluation, imaging, genetics, biomarkers, costs, and RA management strategies.
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Affiliation(s)
- Bernard Combe
- Département rhumatologie, université Montpellier I, hôpital Lapeyronie, 34295 Montpellier cedex 5, France.
| | - Nathalie Rincheval
- Département rhumatologie, université Montpellier I, hôpital Lapeyronie, 34295 Montpellier cedex 5, France
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