1
|
Bertrand D, Joly J, Neerinckx B, Durez P, Lenaerts J, Joos R, Thevissen K, Zwaenepoel T, Vanhoof J, Di Romana S, Taelman V, Van Essche E, Corluy L, Ribbens C, Vanden Berghe M, Devinck M, Ajeganova S, Durnez A, Boutsen Y, Margaux J, Peene I, Van Offel J, Doumen M, Pazmino S, De Meyst E, Kulyk M, Creten N, Westhovens R, Verschueren P. Effectiveness of methotrexate and bridging glucocorticoids with or without early introduction of a 6-month course of etanercept in early RA: results of the 2-year, pragmatic, randomised CareRA2020 trial. RMD Open 2024; 10:e004535. [PMID: 39117445 DOI: 10.1136/rmdopen-2024-004535] [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: 05/15/2024] [Accepted: 07/17/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVES To investigate if patients with early rheumatoid arthritis responding insufficiently to initial methotrexate (MTX) and bridging glucocorticoids (GCs) could benefit from early but temporary etanercept introduction as a second remission-induction attempt. METHODS CareRA2020 (NCT03649061) was a 2-year, open-label, multicentre, pragmatic randomised controlled trial. Treatment-naïve patients started MTX and GC bridging (COBRA-Slim: CS). Within a time window from week (W) 8 until W32, early insufficient responders (28-joint Disease Activity Score - C-reactive Protein (DAS28-CRP) >3.2 between W8 and W32 or ≥2.6 at W32) were randomised to a Standard-CS strategy (adding leflunomide first) or Bio-induction-CS strategy (adding etanercept for 24 weeks). Additional treatment adaptations followed the treat-to-target principle. Longitudinal disease activity (DAS28-CRP) over 104 weeks (primary outcome), achievement of DAS28-CRP <2.6 28 weeks after randomisation, and biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) use at W104 were compared between randomisation groups. RESULTS Following CS treatment, 142 patients were early responders; 55 early insufficient responders received Standard-CS and 55 Bio-induction-CS. Superiority of Bio-induction-CS over Standard-CS could not be demonstrated (ß=-0.204, (95% CI -0.486 to 0.078), p=0.157) for the primary outcome. More patients on Bio-induction-CS achieved DAS28-CRP <2.6 at 28 weeks after randomisation (59% (95% CI 44% to 72%) vs 44% (95% CI 31% to 59%) in Standard-CS) and they were treated less frequently with b/tsDMARDs at W104 (19/55, 35%) compared with Standard-CS (29/55, 53%). CONCLUSION Half of the patients responded well to initial COBRA-Slim induction therapy. In early insufficient responders, adding etanercept for 6 months did not improve disease control over 104 weeks versus adding leflunomide first. However, temporary introduction of etanercept resulted in improved disease control early after randomisation and less patients on b/tsDMARDs at W104. TRIAL REGISTRATION NUMBER NCT03649061. CTR PILOT APPROVAL BELGIUM S59474, EudraCT number: 2017-004054-41.
Collapse
Affiliation(s)
- Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
| | - Johan Joly
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Barbara Neerinckx
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Jan Lenaerts
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
- Reuma Instituut, Hasselt, Belgium
| | - Rik Joos
- Department of Rheumatology, ZNA Jan Palfijn, Merksem, Belgium
| | - Kristof Thevissen
- Reumacentrum, Genk, Belgium
- Department of Rheumatology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Tom Zwaenepoel
- Department of Rheumatology, OLV Ziekenhuis, Aalst, Oost-Vlaanderen, Belgium
| | | | - Silvana Di Romana
- Department of Rheumatology, CHU Saint-Pierre, Bruxelles, Bruxelles, Belgium
| | - Veerle Taelman
- Department of Rheumatology, Regionaal Ziekenhuis Heilig Hart Leuven, Leuven, Vlaams Brabant, Belgium
| | - Els Van Essche
- Department of Rheumatology, Imeldaziekenhuis, Bonheiden, Belgium
| | - Luk Corluy
- Department of Rheumatology, AZ Herentals, Herentals, Belgium
| | - Clio Ribbens
- Department of Rheumatology, CHU de Liège, Liège, Belgium
| | - Marc Vanden Berghe
- Department of Rheumatology, Grand Hôpital de Charleroi Site Saint-Joseph, Gilly, Hainaut, Belgium
| | - Mieke Devinck
- Department of Rheumatology, AZ Sint-Lucas Brugge, Brugge, West-Vlaanderen, Belgium
| | - Sofia Ajeganova
- Department of Rheumatology, UZ Brussel, Brussel, Belgium
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Anne Durnez
- Department of Rheumatology, AZ Jan Portaels, Vilvoorde, Vlaams Brabant, Belgium
| | - Yves Boutsen
- Department of Rheumatology, CHU UCL Namur, Yvoir, Namur, Belgium
| | - Joëlle Margaux
- Department of Rheumatology, Hôpital Erasme, Bruxelles, Belgium
| | - Isabelle Peene
- Department of Rheumatology, AZ Sint-Jan Brugge AV, Brugge, West-Vlaanderen, Belgium
| | - Jan Van Offel
- Department of Rheumatology, UZA, Edegem, Antwerp, Belgium
| | - Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinology, KU Leuven, Leuven, Flanders, Belgium
| | - Elias De Meyst
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Myroslava Kulyk
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Bogomolets National Medical University, Kiiv, Ukraine
| | | | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| |
Collapse
|
2
|
Sugihara T, Tanaka E, Matsui T. Low-Dose Glucocorticoids in Older Patients with Rheumatoid Arthritis: What Does the Evidence Say? Drugs Aging 2024:10.1007/s40266-024-01133-w. [PMID: 39066877 DOI: 10.1007/s40266-024-01133-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 07/30/2024]
Abstract
The short-term use of glucocorticoids (GCs) in combination with methotrexate was recommended for the initial treatment of rheumatoid arthritis by the European League Against Rheumatism. A randomized controlled trial (GLORIA) showed that treatment of older patients with low-dose GCs in combination with disease-modifying anti-rheumatic drugs was more efficacious than disease-modifying anti-rheumatic drugs plus placebo in terms of disease activity control and prevention of joint destruction. Glucocorticoid-related adverse events were likely to increase relative to placebo, with no increase in serious adverse events and fractures over 2 years. Observational studies showed an increased risk of serious infections, cardiovascular events, and fractures associated with long-term continuation of GCs in older patients, but the adverse events may be associated not only with GC toxicity but also with poor disease control of rheumatoid arthritis. In the GLORIA study, low-dose GCs during 2 years could be tapered off safely, but many patients had a flare of disease activity after discontinuation of GCs. In the two representative large Japanese registries (IORRA and NinJa), the proportion of patients using GCs and non-tumor necrosis factor inhibitors increased with increasing age at disease onset, with a decreasing trend in methotrexate use. The proportion of patients in remission with GC treatment also increased with increasing age at onset. These suggested that it is not easy to discontinue GCs in older patients. If GCs cannot be terminated in the short term, it may be acceptable to use GCs to control disease activity for up to 2 years.
Collapse
Affiliation(s)
- Takahiko Sugihara
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Eiichi Tanaka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Toshihiro Matsui
- Department of Rheumatology Research, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| |
Collapse
|
3
|
van Ouwerkerk L, Bergstra SA, Maarseveen TD, Huizinga TWJ, Knevel R, Allaart CF. Is glucocorticoid bridging therapy associated with later use of glucocorticoids and biological DMARDs during the disease course of patients with rheumatoid arthritis in daily practice? A real-world data analysis. Semin Arthritis Rheum 2024; 64:152305. [PMID: 37992515 DOI: 10.1016/j.semarthrit.2023.152305] [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: 07/31/2023] [Revised: 10/19/2023] [Accepted: 10/31/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To evaluate if initially starting glucocorticoid (GC) bridging leads to a higher probability of long-term GC and biological (b)DMARD use in rheumatoid arthritis (RA)-patients. METHODS Electronical health records data from newly diagnosed RA-patients from the Leiden University Medical Center were used. Patients who started GC as part of initial treatment (iGC group) and who did not (niGC group) were compared in terms of GC and bDMARD use later in the disease course. Multivariable adjustment was performed to account for confounding by indication. RESULTS 465/932 newly diagnosed RA-patients (50 %) were treated with GC as initial treatment step. Patients in the iGC group were older, included fewer females, had a higher disease activity at baseline compared to the niGC group plus a more rapid decrease in DAS28 in the first 6 months. During follow-up, 42 % of the iGC group started a second course of GC and 17 % started a bDMARD, compared to 34 % and 13 % In the niGC group. The hazard to start a bDMARD later in the disease course was not significantly different between the two groups in two time periods (0.34 95 %CI(0.09;1.21) resp. 1.48 95 %CI (0.98;2.22)), but the hazard to (re)start GC later on was higher for the iGC group (aHR 1.37 95 %CI(1.09;1.73)). CONCLUSION In this daily practice cohort of newly diagnosed RA patients, patients in the iGC group had a more rapid DAS28 decrease and an increased probability of starting GC later on compared to the niGC group. The probability of bDMARD use was not significantly increased.
Collapse
Affiliation(s)
- L van Ouwerkerk
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands.
| | - S A Bergstra
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - T D Maarseveen
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - T W J Huizinga
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - R Knevel
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - C F Allaart
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
4
|
Venetsanopoulou AI, Voulgari PV, Drosos AA. Advances in non-biological drugs for the treatment of rheumatoid arthritis. Expert Opin Pharmacother 2024; 25:45-53. [PMID: 38126739 DOI: 10.1080/14656566.2023.2297798] [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: 11/01/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a complex autoimmune disease that affects millions of people worldwide, with a systemic impact. This review explores the role of non-biological conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) in its management. AREAS COVERED We discuss the effectiveness and safety of key csDMARDs such as Nonsteroidal anti-inflammatory drugs, corticosteroids, Hydroxychloroquine, Sulfasalazine, Methotrexate, and Leflunomide in relieving symptoms and slowing the progression of the disease. We also highlight the importance of combination therapy using csDMARDs, supported by clinical studies demonstrating the benefits of various csDMARD combinations. Early intervention with these drugs is emphasized to prevent joint damage, improve clinical symptoms, and enhance patient outcomes. EXPERT OPINION Overall, csDMARDs have proven pivotal in managing RA, providing cost-effective and versatile treatment options. We acknowledge the advantages of biologics but highlight the associated challenges, making the choice between non-biological and biological drugs a personalized decision. This comprehensive overview aims to provide a deeper understanding of RA treatment strategies, contributing to improving the quality of life for patients with this chronic condition.
Collapse
Affiliation(s)
- Aliki I Venetsanopoulou
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| |
Collapse
|
5
|
Kaudewitz D, Lorenz HM. [Drug therapy of rheumatoid arthritis: where do biologics and novel synthetic disease-modifying antirheumatic drugs stand today?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1005-1012. [PMID: 37493758 DOI: 10.1007/s00108-023-01554-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/27/2023]
Abstract
Biologics and Janus kinase (JAK) inhibitors play an important role in the treatment of rheumatoid arthritis. As new therapeutic developments have emerged in recent decades, the morbidity and mortality of rheumatoid arthritis have been significantly reduced. The characterization of the structure and function of immune cell receptors has led to the development of biologics that specifically inhibit cytokines and immune cell receptors. An important therapeutic addition was the approval of JAK inhibitors, which act directly on intracellular signaling by tyrosine kinases. This article provides an overview of the current therapeutic options for rheumatoid arthritis with a special focus on indication, mechanism of action and the place in the treatment algorithm of biologics and JAK inhibitors.
Collapse
Affiliation(s)
- Dorothee Kaudewitz
- Medizinische Klinik V, Klinik für Hämatologie, Onkologie und Rheumatologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland.
| | - Hanns-Martin Lorenz
- Medizinische Klinik V, Klinik für Hämatologie, Onkologie und Rheumatologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
| |
Collapse
|
6
|
Østergaard M, van Vollenhoven RF, Rudin A, Hetland ML, Heiberg MS, Nordström DC, Nurmohamed MT, Gudbjornsson B, Ørnbjerg LM, Bøyesen P, Lend K, Hørslev-Petersen K, Uhlig T, Sokka T, Grondal G, Krabbe S, Lindqvist J, Gjertsson I, Glinatsi D, Kapetanovic MC, Aga AB, Faustini F, Parmanne P, Lorenzen T, Giovanni C, Back J, Hendricks O, Vedder D, Rannio T, Grenholm E, Ljoså MK, Brodin E, Lindegaard H, Söderbergh A, Rizk M, Kastbom A, Larsson P, Uhrenholt L, Just SA, Stevens DJ, Bay Laurbjerg T, Bakland G, Olsen IC, Haavardsholm EA, Lampa J. Certolizumab pegol, abatacept, tocilizumab or active conventional treatment in early rheumatoid arthritis: 48-week clinical and radiographic results of the investigator-initiated randomised controlled NORD-STAR trial. Ann Rheum Dis 2023; 82:1286-1295. [PMID: 37423647 DOI: 10.1136/ard-2023-224116] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/07/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND The optimal first-line treatment in early rheumatoid arthritis (RA) is debated. We compared clinical and radiographic outcomes of active conventional therapy with each of three biological treatments with different modes of action. METHODS Investigator-initiated, randomised, blinded-assessor study. Patients with treatment-naïve early RA with moderate-severe disease activity were randomised 1:1:1:1 to methotrexate combined with (1) active conventional therapy: oral prednisolone (tapered quickly, discontinued at week 36) or sulfasalazine, hydroxychloroquine and intra-articular glucocorticoid injections in swollen joints; (2) certolizumab pegol; (3) abatacept or (4) tocilizumab. Coprimary endpoints were week 48 Clinical Disease Activity Index (CDAI) remission (CDAI ≤2.8) and change in radiographic van der Heijde-modified Sharp Score, estimated using logistic regression and analysis of covariance, adjusted for sex, anticitrullinated protein antibody status and country. Bonferroni's and Dunnet's procedures adjusted for multiple testing (significance level: 0.025). RESULTS Eight hundred and twelve patients were randomised. Adjusted CDAI remission rates at week 48 were: 59.3% (abatacept), 52.3% (certolizumab), 51.9% (tocilizumab) and 39.2% (active conventional therapy). Compared with active conventional therapy, CDAI remission rates were significantly higher for abatacept (adjusted difference +20.1%, p<0.001) and certolizumab (+13.1%, p=0.021), but not for tocilizumab (+12.7%, p=0.030). Key secondary clinical outcomes were consistently better in biological groups. Radiographic progression was low, without group differences.The proportions of patients with serious adverse events were abatacept, 8.3%; certolizumab, 12.4%; tocilizumab, 9.2%; and active conventional therapy, 10.7%. CONCLUSIONS Compared with active conventional therapy, clinical remission rates were superior for abatacept and certolizumab pegol, but not for tocilizumab. Radiographic progression was low and similar between treatments. TRIAL REGISTRATION NUMBER NCT01491815.
Collapse
Affiliation(s)
- Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam Rheumatology and Immunology Center, Amsterdam, Netherlands
| | - Anna Rudin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Rheumatology Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marte Schrumpf Heiberg
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Dan C Nordström
- Division of Internal Medicine and Rheumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Michael T Nurmohamed
- Location VUmc, Reade and Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Bjorn Gudbjornsson
- Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology, Centre for Rheumatology Research, Reykjavik, Iceland
| | - Lykke Midtbøll Ørnbjerg
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Pernille Bøyesen
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
| | - Kristina Lend
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam Rheumatology Center, Amsterdam, Netherlands
- Department of Medicine, Rheumatology Unit, Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
| | - Kim Hørslev-Petersen
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Till Uhlig
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Tuulikki Sokka
- Jyväskylä Central Hospital, University of Eastern Finland, Jyväskylä, Finland
| | - Gerdur Grondal
- Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Simon Krabbe
- Department of Radiology, Herlev-Gentofte University Hospital, Herlev, Denmark
| | - Joakim Lindqvist
- Department of Medicine, Rheumatology Unit, Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Inger Gjertsson
- Rheumatology Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | - Daniel Glinatsi
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Rigshospitalet, Glostrup, Denmark
- Department of Rheumatology, Skaraborg Hospital, Skövde, Sweden
| | | | | | - Francesca Faustini
- Department of Medicine, Rheumatology Unit, Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
| | - Pinja Parmanne
- Division of Internal Medicine and Rheumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tove Lorenzen
- Department of Rheumatology, Silkeborg University Hospital, Silkeborg, Denmark
| | - Cagnotto Giovanni
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden
| | - Johan Back
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Oliver Hendricks
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Daisy Vedder
- Department of Rheumatology, Reade, Amsterdam, Netherlands
| | - Tuomas Rannio
- Jyväskylä Central Hospital, University of Eastern Finland, Jyväskylä, Finland
| | | | | | - Eli Brodin
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - Hanne Lindegaard
- Rheumatology Research Unit, Odense University Hospital, Odense, Denmark
| | - Annika Söderbergh
- Department of Rheumatology, Örebro University Hospital, Orebro, Sweden
| | - Milad Rizk
- Department of Rheumatology, Västmanlands Hospital Västerås, Västerås, Sweden
| | - Alf Kastbom
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Rheumatology in Östergötland, Linköping, Sweden
| | - Per Larsson
- Academic Specialist Center, Stockholm, Sweden
| | - Line Uhrenholt
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Andreas Just
- Department of Rheumatology, Odense Universitetshospital, Odense, Denmark
- Section of Rheumatology, Department of Medicine, Svendborg Hospital, Svendborg, Denmark
| | - David J Stevens
- Department of Rheumatology, St. Olavs Hospital, University Hospital of Trondheim, Trondheim, Norway
| | | | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of Northern Norway, Tromsø, Norway
- Department Rheumatology, University of Tromsø, Tromsø, Norway
| | - Inge Christoffer Olsen
- Department of Research Support for Clinical Trials, Oslo University Hospital, Oslo, Norway
| | - Espen A Haavardsholm
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Jon Lampa
- Department of Medicine, Rheumatology Unit, Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
7
|
Stouten V, Westhovens R, Pazmino S, De Cock D, Van der Elst K, Joly J, Bertrand D, Verschueren P. Response to: 'Correspondence on 'Five-year treat-to-target outcomes after methotrexate induction therapy with or without other csDMARDs and temporary glucocorticoids for rheumatoid arthritis in the CareRA trial'' by Jain and Dhir et al. Ann Rheum Dis 2023; 82:e163. [PMID: 34193403 DOI: 10.1136/annrheumdis-2021-220857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Veerle Stouten
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - René Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Sofia Pazmino
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Diederik De Cock
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Johan Joly
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Delphine Bertrand
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
8
|
Messelink MA, den Broeder AA, Marinelli FE, Michgels E, Verschueren P, Aletaha D, Tekstra J, Welsing PMJ. What is the best target in a treat-to-target strategy in rheumatoid arthritis? Results from a systematic review and meta-regression analysis. RMD Open 2023; 9:rmdopen-2023-003196. [PMID: 37116986 PMCID: PMC10152050 DOI: 10.1136/rmdopen-2023-003196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/09/2023] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVES A treat-to-target (T2T) strategy has been shown to be superior to usual care in rheumatoid arthritis (RA), but the optimal target remains unknown. Targets are based on a disease activity measure (eg, Disease Activity Score-28 (DAS28), Simplified Disease Activity Indices/Clinical Disease Activity Indices (SDAI/CDAI), and a cut-off such as remission or low disease activity (LDA). Our aim was to compare the effect of different targets on clinical and radiographic outcomes. METHODS Cochrane, Embase and (pre)MEDLINE databases were searched (1 June 2022) for randomised controlled trials and cohort studies after 2003 that applied T2T in RA patients for ≥12 months. Data were extracted from individual T2T study arms; risk of bias was assessed with the Cochrane Collaboration tool. Using meta-regression, we evaluated the effect of the target used on clinical and radiographic outcomes, correcting for heterogeneity between and within studies. RESULTS 115 treatment arms were used in the meta-regression analyses. Aiming for SDAI/CDAI-LDA was statistically superior to targeting DAS-LDA regarding DAS-remission and SDAI/CDAI/Boolean-remission outcomes over 1-3 years. Aiming for SDAI/CDAI-LDA was also significantly superior to DAS-remission regarding both SDAI/CDAI/Boolean-remission (over 1-3 years) and mean SDAI/CDAI (over 1 year). Targeting DAS-remission rather than DAS-LDA only improved the percentage of patients in DAS-remission, and only statistically significantly after 2-3 years of T2T. No differences were observed in Health Assessment Questionnaire and radiographic progression. CONCLUSIONS Targeting SDAI/CDAI-LDA, and to a lesser extent DAS-remission, may be superior to targeting DAS-LDA regarding several clinical outcomes. However, due to the risk of residual confounding and the lack of data on (over)treatment and safety, future studies should aim to directly and comprehensively compare targets. PROSPERO REGISTRATION NUMBER CRD42021249015.
Collapse
Affiliation(s)
| | | | | | - Edwin Michgels
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| | - P Verschueren
- Rheumatology, KU Leuven University Hospitals, Leuven, Belgium
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Janneke Tekstra
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| | - Paco M J Welsing
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| |
Collapse
|
9
|
Rajeshwari B, Kumar S. Rheumatoid Neuropathy: A Brief Overview. Cureus 2023; 15:e34127. [PMID: 36843697 PMCID: PMC9947570 DOI: 10.7759/cureus.34127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/23/2023] [Indexed: 01/25/2023] Open
Abstract
Rheumatoid arthritis is an autoimmune disease commonly found in humans. It is characterized by stiffness and swelling of the joints, along with fatigue and malaise. Rheumatoid neuropathy is a neuropathy that arises as a complication of rheumatoid arthritis. The primary objective of this review article is to provide a detailed account of the various aspects of this neurological complication ranging from its incidence, clinical features, and diagnosis. After searching through various published review articles and textbooks, rheumatoid neuropathy is one of the most common complications of rheumatoid arthritis. Out of all types of neuropathies. the most observed is entrapment neuropathy. Carpel tunnel syndrome is the most common type of entrapment neuropathy. There seems to be a greater predilection of rheumatoid neuropathy in females compared to males. A direct relation exists between rheumatoid factor and the occurrence of neuropathy. Some clinical features of rheumatoid neuropathy include stiffness in hands and feet, burning and tingling, stabbing pain, occasional weakness, and numbness in several cases. The common modalities of diagnosis are history, clinical examination, blood test, magnetic resonance imaging, nerve conduction study, and tissue biopsy. From the above-mentioned modalities, nerve conduction studies must be chosen as they can detect latent cases quickly and effective treatment can be initiated immediately. Finally, we outline the treatment plan for the disease which can be divided into medical and surgical management. Medical management consists of symptomatic treatment such as analgesics, anticonvulsants, and antidepressants, while surgical management is the last resort and consists of nerve compression.
Collapse
Affiliation(s)
- Bhavya Rajeshwari
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| |
Collapse
|
10
|
Mangoni AA, Sotgia S, Zinellu A, Carru C, Pintus G, Damiani G, Erre GL, Tommasi S. Methotrexate and cardiovascular prevention: an appraisal of the current evidence. Ther Adv Cardiovasc Dis 2023; 17:17539447231215213. [PMID: 38115784 PMCID: PMC10732001 DOI: 10.1177/17539447231215213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/02/2023] [Indexed: 12/21/2023] Open
Abstract
New evidence continues to accumulate regarding a significant association between excessive inflammation and dysregulated immunity (local and systemic) and the risk of cardiovascular events in different patient cohorts. Whilst research has sought to identify novel atheroprotective therapies targeting inflammation and immunity, several marketed drugs for rheumatological conditions may serve a similar purpose. One such drug, methotrexate, has been used since 1948 for treating cancer and, more recently, for a wide range of dysimmune conditions. Over the last 30 years, epidemiological and experimental studies have shown that methotrexate is independently associated with a reduced risk of cardiovascular disease, particularly in rheumatological patients, and exerts several beneficial effects on vascular homeostasis and blood pressure control. This review article discusses the current challenges with managing cardiovascular risk and the new frontiers offered by drug discovery and drug repurposing targeting inflammation and immunity with a focus on methotrexate. Specifically, the article critically appraises the results of observational, cross-sectional and intervention studies investigating the effects of methotrexate on overall cardiovascular risk and individual risk factors. It also discusses the putative molecular mechanisms underpinning the atheroprotective effects of methotrexate and the practical advantages of using methotrexate in cardiovascular prevention, and highlights future research directions in this area.
Collapse
Affiliation(s)
- Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Bedford Park, SA 5042, Australia
| | - Salvatore Sotgia
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy; Quality Control Unit, University Hospital (AOUSS), Sassari, Italy
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy; Quality Control Unit, University Hospital (AOUSS), Sassari, Italy
| | - Ciriaco Carru
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
- Quality Control Unit, University Hospital (AOUSS), Sassari, Italy
| | - Gianfranco Pintus
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy; Quality Control Unit, University Hospital (AOUSS), Sassari, Italy
| | - Giovanni Damiani
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- Italian Centre of Precision Medicine and Chronic Inflammation, Milan, Italy
| | - Gian Luca Erre
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University Hospital (AOUSS) and University of Sassari, Sassari, Italy
| | - Sara Tommasi
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| |
Collapse
|
11
|
Bergstra SA, Sepriano A, Kerschbaumer A, van der Heijde D, Caporali R, Edwards CJ, Verschueren P, de Souza S, Pope JE, Takeuchi T, Hyrich KL, Winthrop KL, Aletaha D, Stamm TA, Schoones JW, Smolen JS, Landewé RBM. Efficacy, duration of use and safety of glucocorticoids: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2023; 82:81-94. [PMID: 36410794 DOI: 10.1136/ard-2022-223358] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
Abstract
This systematic literature review (SLR) regarding the efficacy, duration of use and safety of glucocorticoids (GCs), was performed to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA). Studies on GC efficacy were identified from a separate search on the efficacy of disease-modifying antirheumatic drugs (DMARDs). A combined search was performed for the duration of use and safety of GCs in RA patients. Dose-defined and time-defined GC treatment of any dose and duration (excluding intra-articular GCs) prescribed in combination with other DMARDs were considered. Results are presented descriptively. Two included studies confirmed the efficacy of GC bridging as initial therapy, with equal efficacy after 2 years of initial doses of 30 mg/day compared with 60 mg/day prednisone. Based on a recently performed SLR, in clinical trials most patients starting initial GC bridging are able to stop GCs within 12 (22% patients continued on GCs) to 24 months (10% patients continued on GCs). The safety search included 12 RCTs and 21 observational studies. Well-known safety risks of GC use were confirmed, including an increased risk of osteoporotic fractures, serious infections, diabetes and mortality. Data on cardiovascular outcomes were Inconsistent. Overall, safety risks increased with increasing dose and/or duration, but evidence on which dose is safe was conflicting. In conclusion, this SLR has confirmed the efficacy of GCs in the treatment of RA. In clinical trials, most patients have shown to be able to stop GCs within 12-24 months. Well-known safety risks of GC use have been confirmed, but with heterogeneity between studies.
Collapse
Affiliation(s)
- Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria
| | | | - Roberto Caporali
- University of Milan, Milan and Department of Rheumatology, ASST PINI-CTO, Milano, Italy
| | - Christopher John Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick Verschueren
- Department of rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Savia de Souza
- EULAR Patient Research Partner Network, Zurich, Switzerland
| | - Janet E Pope
- University of Western Ontario, Schulich School of Medicine, London, Ontario, Canada
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan.,Saitama Medical University, Iruma-gun, Saitama, Japan
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Trust, UK
| | | | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Wien, Austria.,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria.,2nd Department of Medicine, Hietzing Hospital, Wien, Austria
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| |
Collapse
|
12
|
Samanta J, Amudalapalli A, Shukla A, Harish BV, Gadde S, Sahoo RR, Patro PS. Optimal bridging strategy in active early rheumatoid arthritis: a bridge falling short? Comment on the article by Krause et al. Arthritis Rheumatol 2022; 74:2044. [PMID: 35818723 DOI: 10.1002/art.42302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/24/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Joydeep Samanta
- Department of Rheumatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - Alekhya Amudalapalli
- Department of Rheumatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - Ashlesha Shukla
- Department of Rheumatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - B V Harish
- Department of Rheumatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - Sudhish Gadde
- Department of Rheumatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - Rasmi R Sahoo
- Department of Rheumatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - Pradeepta S Patro
- Department of Rheumatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| |
Collapse
|
13
|
Hauser B, Raterman H, Ralston SH, Lems WF. The Effect of Anti-rheumatic Drugs on the Skeleton. Calcif Tissue Int 2022; 111:445-456. [PMID: 35771255 PMCID: PMC9560949 DOI: 10.1007/s00223-022-01001-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/11/2022] [Indexed: 12/27/2022]
Abstract
The therapeutic armamentarium for rheumatoid arthritis has increased substantially over the last 20 years. Historically antirheumatic treatment was started late in the disease course and frequently included prolonged high-dose glucocorticoid treatment which was associated with accelerated generalised bone loss and increased vertebral and non-vertebral fracture risk. Newer biologic and targeted synthetic treatments and a combination of conventional synthetic DMARDs prevent accelerated systemic bone loss and may even allow repair of cortical bone erosions. Emerging data also gives new insight on the impact of long-term conventional synthetic DMARDs on bone health and fracture risk and highlights the need for ongoing studies for better understanding of "established therapeutics". An interesting new antirheumatic treatment effect is the potential of erosion repair with the use of biologic DMARDs and janus kinase inhibitors. Although several newer anti-rheumatic drugs seem to have favorable effects on bone mineral density in RA patients, these effects are modest and do not seem to influence the fracture risk thus far. We summarize recent developments and findings of the impact of anti-rheumatic treatments on localized and systemic bone integrity and health.
Collapse
Affiliation(s)
- B Hauser
- Rheumatic Disease Unit, Western General Hospital, Edinburgh, UK.
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK.
| | - H Raterman
- Department of Rheumatology, Northwest Clinics, Alkmaar, The Netherlands
| | - S H Ralston
- Rheumatic Disease Unit, Western General Hospital, Edinburgh, UK
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - W F Lems
- Amsterdam Rheumatology and Immunology Centre, Amsterdam, The Netherlands
| |
Collapse
|
14
|
Grümme L, Singh D, Schulze-Koops H. [Early rheumatoid arthritis]. MMW Fortschr Med 2022; 164:24-31. [PMID: 36413292 DOI: 10.1007/s15006-022-2095-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Lea Grümme
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum, München, Deutschland
| | - Delila Singh
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, München, Deutschland
| | - Hendrik Schulze-Koops
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, München, Deutschland.
| |
Collapse
|
15
|
Boers M, Hartman L, Opris-Belinski D, Bos R, Kok MR, Da Silva JA, Griep EN, Klaasen R, Allaart CF, Baudoin P, Raterman HG, Szekanecz Z, Buttgereit F, Masaryk P, Klausch LT, Paolino S, Schilder AM, Lems WF, Cutolo M. Low dose, add-on prednisolone in patients with rheumatoid arthritis aged 65+: the pragmatic randomised, double-blind placebo-controlled GLORIA trial. Ann Rheum Dis 2022; 81:925-936. [PMID: 35641125 PMCID: PMC9209692 DOI: 10.1136/annrheumdis-2021-221957] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/02/2022] [Indexed: 12/12/2022]
Abstract
Background Low-dose glucocorticoid (GC) therapy is widely used in rheumatoid arthritis (RA) but the balance of benefit and harm is still unclear. Methods The GLORIA (Glucocorticoid LOw-dose in RheumatoId Arthritis) pragmatic double-blind randomised trial compared 2 years of prednisolone, 5 mg/day, to placebo in patients aged 65+ with active RA. We allowed all cotreatments except long-term open label GC and minimised exclusion criteria, tailored to seniors. Benefit outcomes included disease activity (disease activity score; DAS28, coprimary) and joint damage (Sharp/van der Heijde, secondary). The other coprimary outcome was harm, expressed as the proportion of patients with ≥1 adverse event (AE) of special interest. Such events comprised serious events, GC-specific events and those causing study discontinuation. Longitudinal models analysed the data, with one-sided testing and 95% confidence limits (95% CL). Results We randomised 451 patients with established RA and mean 2.1 comorbidities, age 72, disease duration 11 years and DAS28 4.5. 79% were on disease-modifying treatment, including 14% on biologics. 63% prednisolone versus 61% placebo patients completed the trial. Discontinuations were for AE (both, 14%), active disease (3 vs 4%) and for other (including covid pandemic-related disease) reasons (19 vs 21%); mean time in study was 19 months. Disease activity was 0.37 points lower on prednisolone (95% CL 0.23, p<0.0001); joint damage progression was 1.7 points lower (95% CL 0.7, p=0.003). 60% versus 49% of patients experienced the harm outcome, adjusted relative risk 1.24 (95% CL 1.04, p=0.02), with the largest contrast in (mostly non-severe) infections. Other GC-specific events were rare. Conclusion Add-on low-dose prednisolone has beneficial long-term effects in senior patients with established RA, with a trade-off of 24% increase in patients with mostly non-severe AE; this suggests a favourable balance of benefit and harm. Trial registration number NCT02585258.
Collapse
Affiliation(s)
- Maarten Boers
- Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands .,Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Linda Hartman
- Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.,Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Daniela Opris-Belinski
- Rheumatology, Carol Davila University of Medicine and Pharmacy, Romania, Bucharest, Romania
| | - Reinhard Bos
- Rheumatology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Marc R Kok
- Rheumatology and Clinical Immunology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Jose Ap Da Silva
- Reumatologia, Faculdade de Medicina e Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | | | - Ruth Klaasen
- Rheumatology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | | | - Paul Baudoin
- Rheumatology, Reumazorg Flevoland, Emmeloord, The Netherlands
| | | | - Zoltan Szekanecz
- Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Frank Buttgereit
- Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Berlin, Germany
| | - Pavol Masaryk
- National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - L Thomas Klausch
- Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | | | - Willem F Lems
- Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | | |
Collapse
|
16
|
Boers M. Three Months of Glucocorticoids in Rheumatoid Arthritis: A Bridge Too Short? Arthritis Rheumatol 2022; 74:1609-1611. [PMID: 35643954 DOI: 10.1002/art.42249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Maarten Boers
- Department of Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| |
Collapse
|
17
|
Krause D, Mai A, Klaassen-Mielke R, Timmesfeld N, Trampisch U, Rudolf H, Baraliakos X, Schmitz E, Fendler C, Klink C, Boeddeker S, Saracbasi-Zender E, Christoph HJ, Igelmann M, Menne HJ, Schmid A, Rau R, Wassenberg S, Sonuc N, Ose C, Schade-Brittinger C, Trampisch HJ, Braun J. The efficacy of short-term bridging strategies with high- and low-dose prednisolone on radiographic and clinical outcomes in active early rheumatoid arthritis: a double-blind, randomized, placebo-controlled trial. Arthritis Rheumatol 2022; 74:1628-1637. [PMID: 35643951 DOI: 10.1002/art.42245] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/30/2022] [Accepted: 05/24/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE In active early rheumatoid arthritis (RA), glucocorticoids are often used for bridging, due to the delayed action of methotrexate. We compare the effect of three bridging strategies including high-dose and low-dose prednisolone on radiographic and clinical outcomes. METHODS Adult RA patients from one rheumatology hospital and 23 rheumatology practices presenting with moderate/high disease activity were randomised (1:1:1) to 60 mg (high-dose, HDP), 10 mg prednisolone (low-dose, LDP) daily (tapered to 0 mg within 12 weeks), or placebo. The 12-week-intervention period was followed by 40 weeks of therapy at physicians' discretion. The primary outcome was radiographic change at 1 year measured by the modified Sharp/van der Heijde (mSvdH) score. Disease activity was assessed by DAS28 (ESR). RESULTS Of 395 randomized patients (n=132 HDP, n=131 LDP, n=132 placebo), 375 (95%) remained in the modified intention-to-treat analysis. Mean changes (standard deviation) in mSvdH scores of the 3 groups after one year were comparable: HDP 1.0 (2.0), LDP 1.1 (2.2), placebo 1.1 (1.5) units. The primary analysis showed no superiority of HDP vs. placebo (estimated difference of the mean change -0.04 (95% confidence interval (CI) -0.5; 0.4)). At week 12, mean DAS28 (ESR) differed: HDP vs. placebo: -0.6 (95%CI -1.0; -0.2); LDP vs. placebo: -0.8 (95% CI -1.2; -0.5). At week 52, there was no significant difference in DAS28 (ESR) between the 3 groups (range 2.6-2.8). Serious adverse events occurred similarly often. CONCLUSION Short-term glucocorticoid bridging therapy at high dose showed no benefit with regard to progression of radiographic damage at one year.
Collapse
Affiliation(s)
- Dietmar Krause
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum.,Rheumatology practice Gladbeck
| | - Anna Mai
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | | | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Ulrike Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | | | | | | | | | | | | | | | | | | | | | - Rolf Rau
- Department of Rheumatology, Evangelisches Fachkrankenhaus und Altenhilfe Ratingen gGmbH
| | | | - Nilüfer Sonuc
- Centre for Clinical Studies, Institute of Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen
| | | | | | - Hans J Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | | |
Collapse
|
18
|
van Ouwerkerk L, Palmowski A, Nevins IS, Buttgereit F, Verschueren P, Smolen JS, Landewé RB, Bijlsma JJ, Kerschbaumer A, Westhovens R, Huizinga TW, Allaart CF, Bergstra SA. Systematic literature review of observational cohorts and clinical trials into the success rate of glucocorticoid discontinuation after their use as bridging therapy in patients with rheumatoid arthritis. Ann Rheum Dis 2022; 81:937-943. [PMID: 35470162 DOI: 10.1136/annrheumdis-2022-222338] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/14/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the success rate of glucocorticoid (GC) discontinuation during follow-up in observational cohorts and clinical trials using temporary GC as part of initial therapy ('bridging') in newly diagnosed patients with rheumatoid arthritis (RA). METHODS Systematic literature searches were conducted to identify observational cohorts and clinical trials including patients with RA treated with initial GC bridging therapy, defined as discontinuation of GC within 1 year. Patient percentages still using GC were considered the reverse of successful discontinuation. Random effects meta-analyses were performed stratified by time point. RESULTS The scoping literature search for observational cohort studies could not identify studies answering the research question. The literature search for clinical trials identified 7160 abstracts, resulting in 10 included studies, with varying type and dose of GC and varying tapering schedules, of which 4 reported sufficient data on GC discontinuation or use after the bridging phase. The pooled proportion of patients who were still or again using GC was 22% (95% CI 8% to 37%, based on four trials) at 12 months and 10% at 24 months (95% CI -1 to 22, based on two trials). Heterogeneity was substantial (I²≥65%). CONCLUSION The success rate of GC discontinuation after bridging as part of initial treatment of RA has been described in a limited number of studies. Reports on observational cohorts did not answer the research question. In clinical trials, protocolised discontinuation was mostly successful, although 22% of the patients who started GC bridging therapy still or again used GC at 12 months, and 10% at 24 months.
Collapse
Affiliation(s)
| | - Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Isabell S Nevins
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | | | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Wien, Austria
| | - Robert Bm Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Johannes Jw Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - René Westhovens
- Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Tom Wj Huizinga
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Cornelia F Allaart
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | | |
Collapse
|
19
|
Khatri S, Hansen J, Pedersen NB, Brandt-Clausen IP, Gram-Nielsen S, Mendes AC, Chronakis IS, Keiding UB, Catrina AI, Rethi B, Clausen MH, Kragstrup T, Astakhova K. Cyclic Citrullinated Peptide Aptamer Treatment Attenuates Collagen-Induced Arthritis. Biomacromolecules 2022; 23:2126-2137. [PMID: 35438963 DOI: 10.1021/acs.biomac.2c00144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe the study of a novel aptamer-based candidate for treatment of seropositive rheumatoid arthritis. The candidate is a nanoparticle-formulated cyclic citrullinated peptide aptamer, which targets autoantibodies and/or the immune reactions leading to antibody production. Due to its specificity, the peptide aptamer nanoparticles might not interfere with normal immune functions as seen with other disease-modifying antirheumatic drugs. Over a 3-week course of treatment, joint swelling and arthritis score in collagen-induced rats were significantly decreased compared with animals treated with phosphate-buffered saline, unloaded nanoparticles, or nanoparticles with a noncitrullinated control peptide. The reduction in joint swelling was associated with decreased anticitrullinated peptide autoantibody levels in the blood. Treatment with aptamer nanoparticles also increased interleukin-10 levels. The effect seen with the proposed treatment candidate could be mediated by upregulation of anti-inflammatory mediators and decreased levels of anticitrullinated peptide antibodies.
Collapse
Affiliation(s)
- Sangita Khatri
- Department of Chemistry, Technical University of Denmark, Kgs Lyngby 2800, Denmark
| | - Jonas Hansen
- Department of Chemistry, Technical University of Denmark, Kgs Lyngby 2800, Denmark
| | - Nadia Bom Pedersen
- Department of Chemistry, Technical University of Denmark, Kgs Lyngby 2800, Denmark
| | | | - Sanne Gram-Nielsen
- DTU Biofacility, Technical University of Denmark, Kgs Lyngby 2800, Denmark
| | - Ana C Mendes
- DTU FOOD, Technical University of Denmark, Kgs Lyngby 2800, Denmark
| | | | - Ulrik Bering Keiding
- Center for Nanomedicine and Theranostics, Department of Chemistry, Technical University of Denmark, Kgs Lyngby 2800, Denmark
| | - Anca I Catrina
- Department of Medicine/Solna, Division of Rheumatology, Karolinska Institute and Karolinska University Hospital, Stockholm 164 90, Sweden
| | - Bence Rethi
- Department of Medicine/Solna, Division of Rheumatology, Karolinska Institute and Karolinska University Hospital, Stockholm 164 90, Sweden
| | - Mads Hartvig Clausen
- IBIO TECH ApS, Copenhagen 2450, Denmark.,Center for Nanomedicine and Theranostics, Department of Chemistry, Technical University of Denmark, Kgs Lyngby 2800, Denmark
| | - Tue Kragstrup
- IBIO TECH ApS, Copenhagen 2450, Denmark.,Department of Biomedicine, University of Aarhus, Aarhus C 8000, Denmark
| | - Kira Astakhova
- Department of Chemistry, Technical University of Denmark, Kgs Lyngby 2800, Denmark.,IBIO TECH ApS, Copenhagen 2450, Denmark
| |
Collapse
|
20
|
Rosales Rosado Z, Font Urgelles J, Hernández Rodríguez I, León Mateos L, Abásolo Alcázar L, Jover Jover JÁ. Clinical management and discontinuation of treatment in patients with recent onset rheumatoid arthritis in a rheumatology consultation. REUMATOLOGIA CLINICA 2022; 18:77-83. [PMID: 35153040 DOI: 10.1016/j.reumae.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 08/17/2020] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The treatment of Rheumatoid Arthritis (RA) has changed dramatically in recent years, especially with the use of disease modifying drugs (DMARDs). Data on the management of this disease in clinical trials are abundant, but not so in real life. The aim of our study is to describe the management of an early RA cohort in daily clinical practice, especially DMARD discontinuations and reasons. METHODS A retrospective observational study of patients with RA diagnosed between 01/07 and 12/14 followed up to 01/17, using >1 DMARD ≥ 3 months. VARIABLES sociodemographic, clinical, treatment, DMARD discontinuation and reason. Descriptive analysis of sociodemographic, clinical and treatment characteristics. Discontinuation incidence rate (DIR) due to survival techniques, expressed in 100 patients*year with 95% confidence interval. RESULTS 814 patients were included with 2388 courses of treatment, 77% women, mean age 57.5 years. First course: monotherapy (92.75%), especially Methotrexate (56.06%). In later courses there was increased combined therapy and use of biologicals (mainly Etanercept). There were 1094 discontinuations (29.5 [27.8-31.3]). The DIR was higher for adverse events (15.9 [14.7-17.3]), biologicals (49.6 [43.1-57.2]) and combined therapy. The DMAR with the lowest DIR was MTX (25.8 [23.8-28.1]). CONCLUSION Methotrexate was the most used drug, biologicals increased throughout the follow-up, the most frequent being Etanercept. The DMARD DIR was 29*100 patients per year, mainly due to adverse events. It seems to be higher in the therapies that include biologicals and combined therapies. MTX is the drug with the lowest DIR.
Collapse
|
21
|
[Innovative strategies for treatment of rheumatoid arthritis]. Z Rheumatol 2022; 81:118-124. [PMID: 34997270 DOI: 10.1007/s00393-021-01144-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
Besides excellent guidelines and newly developed highly effective drugs, evidence-based strategic use of these new drugs has especially contributed to enormous advances in rheumatoid arthritis treatment, apparent especially since 2000. Currently, the treat-to-target (T2T) strategy has proven to be the most successful in several studies and systematic reviews. The target is to achieve remission, which should be reached and sustained for an optimal outcome (i.e. stable over a long time period). If the initial disease-modifying antirheumatic drug (DMARD) treatment fails, the best strategy for continuing treatment is controversial, with swap or switch being open to debate (change within a class of drugs or change in the mechanism of action). Recent studies seem to indicate that switching to another mechanism of action is the most successful approach. A hotly discussed topic is the question whether DMARD treatment can or should be tapered when sustained remission has been achieved? Many patients wish for a reduction of drugs in cases of stable remission; however, the stable disease control might become destabilized by tapering. The main priority is the reduction or tapering of glucocorticoid treatment. When the decision for reduction of DMARD treatment is made together with the patient, a complete cessation bears a high risk of a flare, therefore, a careful step by step reduction of DMARD treatment should be preferred. In the case of a running combination, the question whether the conventional DMARD (mostly methotrexate), the biological (b)DMARD or targeted synthetic (ts)DMARD should be reduced first, must be decided on an individual basis. Most patients prefer to first reduce methotrexate and transfer to a monotherapy.
Collapse
|
22
|
Vitamin Status as Predictors in Rheumatoid Arthritis. CURRENT HEALTH SCIENCES JOURNAL 2021; 47:190-195. [PMID: 34765237 PMCID: PMC8551887 DOI: 10.12865/chsj.47.02.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/22/2021] [Indexed: 11/18/2022]
Abstract
Musculoskeletal disorders are the leading cause of long term disability in EU with a significant impact on health care system and with increased social and economic costs. Despite of recent advances in Rheumatoid arthritis (RA) research field, here is still lacking of specific biomarkers that can be used in order to distinguish between different RA patterns and the clinical criteria are still the main tool used only for classification of diseases. Our hypothesis is that the vitamin deficiency associated with chronic inflammation can lead to a mild increase in Hcy level in blood that can act as predictor of increased risk of complication in RA patients. The aim of our study was to identify a correlation between level of Hcy in peripheral blood samples collected from RA patients and to establish if the Hcy level can be validate as potential predictive biomarker in RA patients treated with different DMARDs. Our findings suggest that Hcy level in plasma and CRP are independent predictors of chronic inflammatory status and are useful biomarkers in order to estimate the risk of complication in RA patients. To our knowledge to date, studies before had a controversial findings regarding the efficiency of folate and B12 vitamins supplements on decreasing the cardiovascular events risk. We showed that the folic acid and B12 supplements are important.
Collapse
|
23
|
Once-monthly hemin suppresses inflammatory and autoreactive CD4 + T cell responses to robustly ameliorate experimental rheumatoid arthritis. iScience 2021; 24:103101. [PMID: 34622156 PMCID: PMC8479697 DOI: 10.1016/j.isci.2021.103101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 12/15/2022] Open
Abstract
Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that would permanently damage the affected joints. Unfortunately, a large proportion of RA patients fail to respond adequately to current treatments. Here, repurposing hemin and its ultra-long-acting formulation were explored for the effective treatment of RA in animal models. We provided evidence that hemin prevented the onset and ameliorated the clinical course of RA. Notably, hemin treatment rescued the dysregulated gene expression in animal models of RA, resulting in attenuation of Th1/Th17 cell-mediated responses and proinflammatory cytokines. Moreover, we further formulated hemin into the in-situ forming implant, and a single injection of the ultra-long-acting hemin exerted potent disease-modifying effects for at least six weeks with a remarkable dose reduction. Taken together, given the potent anti-inflammatory and immunosuppressive effects, the once-monthly hemin injection holds promise for rapid clinical translation, and represents a potential strategy to treat RA and possibly other autoimmune diseases. Repurposing hemin prevents the onset and ameliorates the clinical course of RA Once-monthly hemin achieve sustained remission of RA for at least six weeks Hemin rescue dysregulated gene expression and attenuate autoreactive immune responses
Collapse
|
24
|
Mahmoudian A, Lohmander LS, Mobasheri A, Englund M, Luyten FP. Early-stage symptomatic osteoarthritis of the knee - time for action. Nat Rev Rheumatol 2021; 17:621-632. [PMID: 34465902 DOI: 10.1038/s41584-021-00673-4] [Citation(s) in RCA: 127] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 02/07/2023]
Abstract
Osteoarthritis (OA) remains the most challenging arthritic disorder, with a high burden of disease and no available disease-modifying treatments. Symptomatic early-stage OA of the knee (the focus of this Review) urgently needs to be identified and defined, as efficient early-stage case finding and diagnosis in primary care would enable health-care providers to proactively and substantially reduce the burden of disease through proper management including structured education, exercise and weight management (when needed) and addressing lifestyle-related risk factors for disease progression. Efforts to define patient populations with symptomatic early-stage knee OA on the basis of validated classification criteria are ongoing. Such criteria, as well as the identification of molecular and imaging biomarkers of disease risk and/or progression, would enable well-designed clinical studies, facilitate interventional trials, and aid the discovery and validation of cellular and molecular targets for novel therapies. Treatment strategies, relevant outcomes and ethical issues also need to be considered in the context of the cost-effective management of symptomatic early-stage knee OA. To move forwards, a multidisciplinary and sustained international effort involving all major stakeholders is required.
Collapse
Affiliation(s)
- Armaghan Mahmoudian
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium.,Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Ali Mobasheri
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Martin Englund
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Frank P Luyten
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium.
| |
Collapse
|
25
|
Sundin U, Sundlisater NP, Aga AB, Sexton J, Nordberg LB, Hammer HB, van der Heijde D, Kvien TK, Haavardsholm EA, Lillegraven S. Value of MRI and ultrasound for prediction of therapeutic response and erosive progression in patients with early rheumatoid arthritis managed by an aggressive treat-to-target strategy. RMD Open 2021; 7:rmdopen-2020-001525. [PMID: 33547228 PMCID: PMC7871342 DOI: 10.1136/rmdopen-2020-001525] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/18/2021] [Accepted: 01/27/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To investigate if inflammation detected by MRI or ultrasound at rheumatoid arthritis (RA) onset is predictive of erosive progression or poor response to methotrexate monotherapy, and to investigate if subclinical inflammation in remission is predictive of future treatment escalation or erosive progression. METHODS In a 2-year study, 218 patients with disease-modifying antirheumatic drug-naïve early RA were treated by a tight-control treat-to-target strategy corresponding to current recommendations. MRI and ultrasound were performed at regular intervals. Baseline imaging-based inflammation measures were analysed as predictors for early methotrexate failure and erosive progression using univariate and multivariate regression adjusted for clinical, laboratory and radiographic measures. In patients in remission after 1 year, imaging measures were analysed as predictors of treatment escalation and erosive progression during the second year. The added value of imaging in prediction models was assessed using receiver operating characteristic analyses. RESULTS Baseline MRI inflammation was associated with MRI erosive progression and ultrasound with radiographic erosive progression. No imaging inflammation measure was associated with early methotrexate failure. Imaging inflammation was present in a majority of patients in clinical remission. Tenosynovitis was associated with treatment escalation, and synovitis and tenosynovitis with MRI/radiographic erosive progression during the second year. Imaging information did not improve prediction models for any of the outcomes. CONCLUSIONS Imaging-detected inflammation, both at diagnosis and in remission, is associated with elements of future disease development. However, the lack of a significant effect on prediction models indicates limited value of systematic MRI and ultrasound in management of early RA.
Collapse
Affiliation(s)
- Ulf Sundin
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway .,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Nina Paulshus Sundlisater
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Joseph Sexton
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Lena Bugge Nordberg
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hilde Berner Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Desirée van der Heijde
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Rheumatology, Leiden University Medical Center, Leiden, South Holland, The Netherlands
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Siri Lillegraven
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | | |
Collapse
|
26
|
Pazmino S, Boonen A, De Cock D, Stouten V, Joly J, Bertrand D, Westhovens R, Verschueren P. Short-term glucocorticoids reduce risk of chronic NSAID and analgesic use in early methotrexate-treated rheumatoid arthritis patients with favourable prognosis: subanalysis of the CareRA randomised controlled trial. RMD Open 2021; 7:rmdopen-2021-001615. [PMID: 34031262 PMCID: PMC8149441 DOI: 10.1136/rmdopen-2021-001615] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/12/2021] [Indexed: 01/18/2023] Open
Abstract
Objective To explore non-steroidal anti-inflammatory drug (NSAID) and analgesic use in early rheumatoid arthritis (eRA) patients with a favourable risk profile initiating methotrexate (MTX) with or without glucocorticoid (GC) bridging. Methods Patients with eRA (≤1 year) and favourable risk profile (no erosions, negative rheumatoid factor and anticitrullinated protein antibodiesor low disease activity) in the 2-year CareRA trial were randomised to MTX 15 mg with a step-down GC scheme (COBRA Slim), or MTX without oral GCs, Tight-Step-Up (TSU). Used analgesics were recorded, including frequency, start/end date and indication. Chronic intake (≥90 consecutive days in trial) of NSAIDs, acetaminophen, opioids including tramadol and antidepressants for the indication of musculoskeletal (MSK) pain was considered. Treatments were compared using χ2 and analysis of variance with Holm’s correction for multiple testing. Results In total, 43 patients were randomised to COBRA Slim and 47 to TSU. At study inclusion, 33/43 (77%) of patients in the COBRA Slim and 32/47 (68%) in the TSU arm had been using analgesics (p=0.5). During the trial, 67 NSAID and analgesics were used for MSK pain in 26/43 (60%) COBRA Slim patients of which 9/43 (21%) daily chronically (DC), while 107 NSAID and analgesics were used in 43/47 (92%) TSU patients, of which 25/47 (53%) DC. The total number of patients on NSAID and analgesics at any time during the study (p<0.01) and chronically (p=0.01) was significantly different between treatment arms. Number of patients on DC NSAIDs was also significantly different (p<0.01) between COBRA Slim 6/43 (14%) and TSU 19/47 (40%). Conclusion In eRA patients considered to have a favourable prognosis, initial oral GC bridging resulted in lower chronic NSAID and analgesic use. Trial registration number NCT01172639.
Collapse
Affiliation(s)
- Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Flanders, Belgium
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Flanders, Belgium
| | - Veerle Stouten
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Flanders, Belgium
| | - Johan Joly
- Department of Rheumatology, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Flanders, Belgium
| | - Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Flanders, Belgium
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Flanders, Belgium.,Department of Rheumatology, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Flanders, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Flanders, Belgium.,Department of Rheumatology, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Flanders, Belgium
| |
Collapse
|
27
|
Roubille C, Coffy A, Rincheval N, Dougados M, Flipo RM, Daurès JP, Combe B. Ten-year analysis of the risk of severe outcomes related to low-dose glucocorticoids in early rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:3738-3746. [PMID: 33320245 DOI: 10.1093/rheumatology/keaa850] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/14/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To explore the 10-year tolerability profile of glucocorticoids (GC) use in patients with early RA. METHODS Analysis of 10-year outcome from the early arthritis ESPOIR cohort. Patients were stratified in two groups, without or with GC treatment at least once during their follow-up. The primary outcome was a composite of deaths, cardiovascular diseases (CVD), severe infections and fractures. The weighted Cox time-dependent analysis model was used with inverse probability of treatment weighting (IPTW) propensity score method. RESULTS Among the 608 patients [480 women, mean age of 47.5 (12.1) years], 397 (65%) received low-dose GC [median 1.9 mg/day (IQR 0.6-4.2), mean cumulative prednisone dose 8468 mg (8376), mean duration 44.6 months (40.1)]. In univariate analysis, over 95 total events (10 deaths, 18 CVDs, 32 fractures and 35 severe infections), patients taking GC experienced more events (n = 71) than those without GC (n = 24) (P =0.035). Highest cumulative exposure of GC (≥8.4 g) was associated with highest risk of occurrence of the primary outcome (24.3%, P =0.007), CVDs (7.9%, P =0.001) and severe infections (9.9%, P =0.024). The risk of events over time was significantly associated with GC, age, hypertension and ESR. The risk associated with GC treatment increased between the first follow-up visit [hazard ratio (HR) at 1 year = 0.46, 95% CI: 0.23, 0.90] and 10 years (HR = 6.83, 95% CI: 2.29, 20.35). CONCLUSION The 10-year analysis of this prospective early RA cohort supports a dose and time-dependent impact of low-dose GC treatment, with a long-term high risk of severe outcomes. TRIAL REGISTRATION (ClinicalTrials.gov Identifier: NCT03666091).
Collapse
Affiliation(s)
- Camille Roubille
- Department of Internal Medicine, CHU Montpellier, Montpellier University, Montpellier, France.,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Amandine Coffy
- Statistiques, University Institute of Clinical Research EA2415 and Clinique Beausoleil, Montpellier cedex, France
| | - Nathalie Rincheval
- Statistiques, University Institute of Clinical Research EA2415 and Clinique Beausoleil, Montpellier cedex, France.,Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France
| | - Maxime Dougados
- Medicine Faculty and Rheumatology B Department, Paris-Descartes University, UPRES-EA 4058; APHP, Cochin Hospital, Paris, France
| | - René-Marc Flipo
- Department of Rheumatology, Roger Salengro Hospital, Lille, France
| | - Jean-Pierre Daurès
- Statistiques, University Institute of Clinical Research EA2415 and Clinique Beausoleil, Montpellier cedex, France
| | - Bernard Combe
- Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France
| |
Collapse
|
28
|
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
|
29
|
McWilliams DF, Thankaraj D, Jones-Diette J, Morgan R, Ifesemen OS, Shenker NG, Walsh DA. The efficacy of systemic glucocorticosteroids for pain in rheumatoid arthritis: a systematic literature review and meta-analysis. Rheumatology (Oxford) 2021; 61:76-89. [PMID: 34213524 PMCID: PMC8742830 DOI: 10.1093/rheumatology/keab503] [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] [Indexed: 11/14/2022] Open
Abstract
Objectives Glucocorticosteroids (GCs) are recommended to suppress inflammation in people with active RA. This systematic review and meta-analysis aimed to quantify the effects of systemic GCs on RA pain. Methods A systematic literature review of randomized controlled trials (RCTs) in RA comparing systemic GCs to inactive treatment. Three databases were and spontaneous pain and evoked pain outcomes were extracted. Standardized mean differences (SMDs) and mean differences were meta-analysed. Heterogeneity (I2, tau statistics) and bias (funnel plot, Egger’s test) were assessed. Subgroup analyses investigated sources of variation. This study was pre-registered (PROSPERO CRD42019111562). Results A total of 18 903 titles, 880 abstracts and 226 full texts were assessed. Thirty-three RCTs suitable for the meta-analysis included 3123 participants. Pain scores (spontaneous pain) decreased in participants treated with oral GCs; SMD = −0.65 (15 studies, 95% CI −0.82, −0.49, P <0.001) with significant heterogeneity (I2 = 56%, P =0.0002). Efficacy displayed time-related decreases after GC initiation. Mean difference visual analogue scale pain was −15 mm (95% CI −20, −9) greater improvement in GC than control at ≤3 months, −8 mm (95% CI −12, −3) at >3–6 months and −7 mm (95% CI −13, 0) at >6 months. Similar findings were obtained when evoked pain outcomes were examined. Data from five RCTs suggested improvement also in fatigue during GC treatment. Conclusion Oral GCs are analgesic in RA. The benefit is greatest shortly after initiation and GCs might not achieve clinically important pain relief beyond 3 months. Treatments other than anti-inflammatory GCs should be considered to reduce the long-term burden of pain in RA.
Collapse
Affiliation(s)
- Daniel F McWilliams
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Divya Thankaraj
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Julie Jones-Diette
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | | | - Onosi S Ifesemen
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | | | - David A Walsh
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| |
Collapse
|
30
|
Westhovens R, Rigby WFC, van der Heijde D, Ching DWT, Stohl W, Kay J, Chopra A, Bartok B, Matzkies F, Yin Z, Guo Y, Tasset C, Sundy JS, Jahreis A, Mozaffarian N, Messina OD, Landewé RB, Atsumi T, Burmester GR. Filgotinib in combination with methotrexate or as monotherapy versus methotrexate monotherapy in patients with active rheumatoid arthritis and limited or no prior exposure to methotrexate: the phase 3, randomised controlled FINCH 3 trial. Ann Rheum Dis 2021; 80:727-738. [PMID: 33452004 PMCID: PMC8142453 DOI: 10.1136/annrheumdis-2020-219213] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To investigate efficacy and safety of the Janus kinase-1 inhibitor filgotinib in patients with active rheumatoid arthritis (RA) with limited or no prior methotrexate (MTX) exposure. METHODS This 52-week, phase 3, multicentre, double-blind clinical trial (NCT02886728) evaluated once-daily oral filgotinib in 1252 patients with RA randomised 2:1:1:2 to filgotinib 200 mg with MTX (FIL200 +MTX), filgotinib 100 mg with MTX (FIL100 +MTX), filgotinib 200 mg monotherapy (FIL200), or MTX. The primary endpoint was proportion achieving 20% improvement in American College of Rheumatology criteria (ACR20) at week 24. RESULTS The primary endpoint was achieved by 81% of patients receiving FIL200+ MTX versus 71% receiving MTX (p<0.001). A significantly greater proportion treated with FIL100+ MTX compared with MTX achieved an ACR20 response (80%, p=0.017) at week 24. Significant improvement in Health Assessment Questionnaire-Disability Index was seen at week 24; least-squares mean change from baseline was -1.0 and -0.94 with FIL200+MTX and FIL100+MTX, respectively, versus -0.81 with MTX (p<0.001, p=0.008, respectively). Significantly higher proportions receiving FIL200+MTX (54%) and FIL100+MTX (43%) achieved DAS28(CRP) <2.6 versus MTX (29%) (p<0.001 for both) at week 24. Hierarchical testing stopped for comparison of ACR20 for FIL200 monotherapy (78%) versus MTX (71%) at week 24 (p=0.058). Adverse event rates through week 52 were comparable between all treatments. CONCLUSIONS FIL200+MTX and FIL100+MTX both significantly improved signs and symptoms and physical function in patients with active RA and limited or no prior MTX exposure; FIL200 monotherapy did not have a superior ACR20 response rate versus MTX. Filgotinib was well tolerated, with acceptable safety compared with MTX.
Collapse
Affiliation(s)
- René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Division of Rheumatology, University Hospitals KU Leuven, Leuven, Flanders, Belgium
| | - William F C Rigby
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | | | - William Stohl
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jonathan Kay
- Division of Rheumatology, Department of Medicine, UMass Memorial Medical Center, Worcester, Massachusetts, USA
- Division of Rheumatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | | | | | - Zhaoyu Yin
- Gilead Sciences, Foster City, California, USA
| | - Ying Guo
- Gilead Sciences, Foster City, California, USA
| | | | - John S Sundy
- Gilead Sciences, Foster City, California, USA
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Osvaldo Daniel Messina
- Cosme Argerich Hospital, Buenos Aires, Argentina
- Investigaciones Reumatologicas y Osteologicas SRL IRO, Buenos Aires, Argentina
| | - Robert Bm Landewé
- Department of Rheumatology & Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Rheumatology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
- Free University and Humboldt University, Berlin, Germany
| |
Collapse
|
31
|
Maassen JM, Dos Santos Sobrín R, Bergstra SA, Goekoop R, Huizinga TWJ, Allaart CF. Glucocorticoid discontinuation in patients with early rheumatoid and undifferentiated arthritis: a post-hoc analysis of the BeSt and IMPROVED studies. Ann Rheum Dis 2021; 80:1124-1129. [PMID: 34049858 DOI: 10.1136/annrheumdis-2021-220403] [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: 03/19/2021] [Accepted: 05/18/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate the success rate of glucocorticoid discontinuation and to study which factors are associated with successful discontinuation. METHODS Data from two treat-to-target studies, BeSt (target Disease Activity Score (DAS) ≤2.4) and IMPROVED (target DAS <1.6), were evaluated for all patients initially treated with a tapered high dose of prednisone with conventional synthetic disease-modifying antirheumatic drugs. Prednisone was discontinued when DAS ≤2.4 was maintained for 28 weeks in BeSt and as soon as DAS was <1.6 in IMPROVED. Discontinuation was considered successful if the target was maintained at the next visit. Logistic regression analyses were performed to identify predictors of successful discontinuation. A mixed effects logistic regression model was used to assess whether primary versus secondary discontinuation was as successful. RESULTS In the BeSt study, 40% (47 of 93) of patients flared after primary prednisone discontinuation, and of the other 60% (56 of 93), 38% had to restart later. Of those who restarted (secondary discontinuation), 47% (17 of 35) again flared. In IMPROVED, after primary discontinuation 39% (158 of 400) flared, and of the other 61% (242 of 400), 40% had to restart later. After secondary discontinuation 49% (68 of 139) flared. Only in IMPROVED a secondary attempt was less successful (BeSt OR 0.71, p=0.45; IMPROVED OR 0.60, p=0.01). A lower DAS both at baseline and stop visit and male gender (in IMPROVED) were associated with successful primary discontinuation. CONCLUSION Primary glucocorticoid discontinuation resulted in direct loss of disease control in approximately 40% and secondary in 50% of patients. 'Standard' baseline characteristics seem insufficient to personalise the duration of temporary glucocorticoid bridging, but the DAS at the time of discontinuation might provide guidance.
Collapse
Affiliation(s)
| | - Raquel Dos Santos Sobrín
- Rheumatology, Clinical University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Tom W J Huizinga
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|
32
|
Verschueren P, Stouten V, Westhovens R, De Cock D, Pazmino S. Comment on: what is the best treatment for early rheumatoid arthritis? Rheumatology (Oxford) 2021; 60:e177-e178. [PMID: 32176299 DOI: 10.1093/rheumatology/keaa106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/07/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Patrick Verschueren
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Veerle Stouten
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven
| | - René Westhovens
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Diederik De Cock
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven
| | - Sofia Pazmino
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven
| |
Collapse
|
33
|
Destiani DP, Naja S, Dewi S, Rahmadi AR, Sulaiman SAS, Abdulah R. Efficacy of methotrexate in reducing the risk of bone erosion in patients with rheumatoid arthritis: a systematic review of randomized controlled trials. Osteoporos Int 2021; 32:805-816. [PMID: 33210179 DOI: 10.1007/s00198-020-05743-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
Even though new drugs for the treatment of rheumatoid arthritis (RA) have been developed, methotrexate (MTX) remains a commonly used drug for RA management. In addition to monitoring disease activity during RA treatment, bone erosion should be closely assessed throughout long-term RA management. In this review article, we present a systematic review of MTX effectiveness in reducing the risk of bone erosion. We reviewed randomized controlled trial studies that involved MTX monotherapy or MTX in combination with placebo. Evaluation of the progression of bone erosion was examined by radiographic assessment such as total Sharp score (TSS) or van der Heijde score (SvdH or vdH TSS), joint space narrowing (JSN), erosion score (ERO), and proportion of radiographic nonprogressors. Several key factors were found to influence the response to MTX treatment, such as gene polymorphism. The exact mechanism of the prevention of bone erosion by MTX remains unclear, which warrants future investigations. The variability of RA disease activity in study subjects resulted in variations in the results reported by individual studies. Collective analysis suggests that MTX could slow down the progression of bone erosion based on a radiographic score of less than 0.5-1/year.
Collapse
Affiliation(s)
- D P Destiani
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jl. Raya Bandung Sumedang KM. 21, Jatinangor, Bandung, 45363, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - S Naja
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jl. Raya Bandung Sumedang KM. 21, Jatinangor, Bandung, 45363, Indonesia
| | - S Dewi
- Immunology Study Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Division of Rheumatology, Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - A R Rahmadi
- Division of Rheumatology, Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - S A S Sulaiman
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Advance Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
| | - R Abdulah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jl. Raya Bandung Sumedang KM. 21, Jatinangor, Bandung, 45363, Indonesia.
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia.
| |
Collapse
|
34
|
Hua C, Buttgereit F, Combe B. Glucocorticoids in rheumatoid arthritis: current status and future studies. RMD Open 2021; 6:rmdopen-2017-000536. [PMID: 31958273 PMCID: PMC7046968 DOI: 10.1136/rmdopen-2017-000536] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 11/05/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022] Open
Abstract
Since their first use for treating rheumatoid arthritis (RA) in the late 1940s, glucocorticoids (GCs) have been representing a substantial part of the therapeutic arsenal for RA. However, even if GCs are still widely prescribed drugs, their toxicity is discussed controversially, so obtaining consensus on their use in RA is difficult. Hence, the most recent European League Against Rheumatism and American College of Rheumatology recommendations on early arthritis and RA management advocate the use of GCs as adjunct treatment to conventional synthetic disease-modifying antirheumatic drugs, at the lowest dose possible and for the shortest time possible. However, the recommendations remain relatively vague on dose regimens and routes of administration. Here, we describe literature data on which the current recommendations are based as well as data from recent trials published since the drafting of the guidelines. Moreover, we make proposals for daily practice and provide suggestions for studies that could help clarifying the place of GCs in RA management. Indeed, numerous items, including the benefit/risk ratio of low-dose and very low-dose GCs and optimal duration of GCs as bridging therapy, remain on the research agenda, and future studies are needed to guide the next recommendations for RA.
Collapse
Affiliation(s)
- Charlotte Hua
- Rheumatology Department, Nîmes Hospital, EA2415, Montpellier University, Nîmes, France
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin (CCM), Berlin, Germany
| | - Bernard Combe
- Rheumatology Department, Montpellier hospital, UMR 5535, Montpellier University, Montpellier, France
| |
Collapse
|
35
|
Stouten V, Westhovens R, Pazmino S, De Cock D, Van der Elst K, Joly J, Bertrand D, Verschueren P. Five-year treat-to-target outcomes after methotrexate induction therapy with or without other csDMARDs and temporary glucocorticoids for rheumatoid arthritis in the CareRA trial. Ann Rheum Dis 2021; 80:965-973. [PMID: 33811036 DOI: 10.1136/annrheumdis-2020-219825] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/02/2021] [Accepted: 03/23/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To compare outcomes of different treatment schedules from the care in early rheumatoid arthritis (CareRA) trial over 5 years. METHODS Patients with RA completing the 2-year CareRA randomised controlled trial were eligible for the 3-year observational CareRA-plus study. 5-year outcomes after randomisation to initial methotrexate (MTX) monotherapy with glucocorticoid bridging (COBRA-Slim) were compared with MTX step-up without glucocorticoids or conventional synthetic disease-modifying antirheumatic drug (DMARD) combinations with glucocorticoid bridging, per prognostic patient group. Disease activity (Disease Activity Score based on 28 joints calculated with C reactive protein (DAS28-CRP)) and functionality (Health Assessment Questionnaire (HAQ)) were compared between treatment arms using longitudinal models; safety and drug use were detailed. RESULTS Of 322 eligible patients, 252 (78%) entered CareRA-plus, of which 203 (81%) completed the study. Treatments for high-risk patients resulted in comparable DAS28-CRP (p=0.539) and HAQ scores over 5 years (p=0.374). Low-risk patients starting COBRA-Slim had lower DAS28-CRP (p<0.001) and HAQ scores (p=0.041) than those starting only on MTX. At study completion, 114/203 (56%) patients never had their original DMARD therapy intensified, with comparable rates between all treatments. Safety was comparable between treatments in high-risk patients. In low-risk patients, there were 18 adverse events in 10 COBRA-Slim and 36 in 17 patients treated with initial MTX monotherapy (p=0.048). Over 5 years, 22% of patients initiated biologics, 25% took glucocorticoids for >3 months and 17% for >6 months outside the bridging period. CONCLUSIONS All intensive treatments with glucocorticoids bridging demonstrated excellent 5 year outcomes. Initiating COBRA-Slim was comparably effective as more complex treatments for high-risk patients with early RA and more effective than initial MTX monotherapy for low-risk patients with limited need for biologics and chronic glucocorticoid use.
Collapse
Affiliation(s)
- Veerle Stouten
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - René Westhovens
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Sofia Pazmino
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Diederik De Cock
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Johan Joly
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Delphine Bertrand
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, KU Leuven, Leuven, Belgium .,Rheumatology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
36
|
van Boheemen L, Ter Wee MM, Seppen B, van Schaardenburg D. How to enhance recruitment of individuals at risk of rheumatoid arthritis into trials aimed at prevention: understanding the barriers and facilitators. RMD Open 2021; 7:e001592. [PMID: 33685929 PMCID: PMC7942248 DOI: 10.1136/rmdopen-2021-001592] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Several trials to test the efficacy of a pharmacological intervention aimed at primary prevention of rheumatoid arthritis (RA) are ongoing or have recently been completed. A common issue in these trials is the severe difficulty with patient recruitment. In order to enhance recruitment, this qualitative study identified barriers and facilitators of individuals at risk of RA to participate in a prevention trial. METHODS Individuals at risk of developing RA (ie, arthralgia with anticitrullinated protein antibodies and/or rheumatoid factor without arthritis), who had previously been asked to participate in a prevention trial, participated in focus group discussions (n=18) exploring their facilitators and barriers for trial participation. Thematic analysis identified factors that were important in at-risk individuals' decision about trial participation. RESULTS The prospect of personal benefit, the acknowledgement of one's symptoms and the desire to contribute to society facilitated trial participation. In contrast, misconception about what it means to be at risk, or about the aim of the prevention trial, negative views on trial medication, and a low perceived urgency to act on the possibility of developing RA versus a high perceived burden of participating in a trial discouraged participation. CONCLUSIONS To enhance inclusion in trials aimed to prevent RA, the results suggest to use strategies such as optimising education about RA, personal risk, trial aim and trial medication, explicitly addressing misconceptions and concerns, using tools to improve information provision, limiting study burden in trial design and encouraging physicians to mention trial participation.
Collapse
Affiliation(s)
- Laurette van Boheemen
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, North Holland, The Netherlands
| | - Marieke M Ter Wee
- Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Rheumatology and immunology, AI&I, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Bart Seppen
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, North Holland, The Netherlands
| | - Dirkjan van Schaardenburg
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, North Holland, The Netherlands
- Rheumatology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| |
Collapse
|
37
|
Sapart E, Sokolova T, de Montjoye S, Dierckx S, Nzeusseu A, Avramovska A, Durez P. Should we use glucocorticoid in Early Rheumatoid Arthritis?: Results at 5 years from the ERA UCLouvain Brussels cohort. Rheumatology (Oxford) 2021; 60:5576-5582. [PMID: 33605405 DOI: 10.1093/rheumatology/keab151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/01/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To evaluate the proportion of patients with ERA who have initiated or not GC, to analyse the baseline characteristics, and to assess the clinical benefit and side effects of GC during 5 years of follow-up. METHODS We included patients with ERA from the UCLouvain Brussels cohort who met the ACR/EULAR 2010 classification criteria and were naïve to cDMARDs. We retrospectively collected patient characteristics prior to the introduction of cDMARDs with or without GC. Efficiency and serious adverse events were analysed at 6, 12, 36 and 60 months. RESULTS Data from 474 eligible ERA patients were collected. 180 patients initiated GC compared with 294 who did not.At baseline, the increased CRP is the main factor that favors the initiation of GC followed by smoking, absence of ACPA, prescription of methotrexate as a monotherapy and age.5 years follow-up of DAS28-CRP, HAQ or VAS pain values did not differ between the two groups.We also analysed a subgroup of 139 patients who received >1 g of prednisolone during the 5 years period. We confirmed the same baseline differences and observed in addition more males and higher DAS-28CRP values. During the 5 years follow up, DAS-28CRP, VAS pain and HAQ remained significantly higher in this subgroup. More severe infections were also reported. CONCLUSION In our ERA cohort, the initiation of GC treatment does not bring additional benefit for the short and long-term control of the disease. GC was more prescribed in seronegative RA patients with a higher level of inflammation. DISCLOSURE STATEMENT the authors declare no conflicts of interest. ETHICS STATEMENT authors declare that the study complies with the Declaration of Helsinki.
Collapse
Affiliation(s)
- Emilie Sapart
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Tatiana Sokolova
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Stéphanie de Montjoye
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | | | - Adrien Nzeusseu
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Aleksandra Avramovska
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| |
Collapse
|
38
|
Sugihara T, Ishizaki T, Onoguchi W, Baba H, Matsumoto T, Iga S, Kubo K, Kamiya M, Hirano F, Hosoya T, Miyasaka N, Harigai M. Effectiveness and safety of treat-to-target strategy in elderly-onset rheumatoid arthritis: a 3-year prospective observational study. Rheumatology (Oxford) 2021; 60:4252-4261. [DOI: 10.1093/rheumatology/keaa922] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/06/2020] [Indexed: 01/18/2023] Open
Abstract
Abstract
Objectives
To evaluate 3-year outcomes of following a treat-to-target (T2T) strategy targeting low disease activity for patients with elderly-onset RA (EORA) and to confirm safety profile of T2T.
Methods
Treatment was adjusted to target low disease activity with conventional synthetic DMARDs, followed by biologic DMARDs (bDMARDs) in 197 MTX-naïve EORA patients (mean age 74.9 years) with moderate-to-high disease activity. Non-implementation of T2T was evaluated at week 12, 24, 36, 52, 76, 104 and 128. To evaluate risks of using MTX, bDMARDs and glucocorticoids, 2122 periods of 3 months each were analysed using Bayesian hierarchical logistic regression models.
Results
Of the patients, 84.7% received methotrexate, 34.0% glucocorticoids with DMARDs and 41.6% bDMARDs during the observation period. Sixty-nine of the 197 patients failed to adhere to T2T because of comorbidities or the patient’s own decision: 33 failed once, 19 twice, 10 three times and 6 four times or more. Simplified disease activity index (SDAI) remission and HAQ Disability Index (HAQ-DI) ≤0.5 at 3 years were achieved in 57.8% and 70.3% of the 128 patients adhering to T2T, and 34.8% and 43.5% of the 69 patients who did not adhere to T2T, respectively, and these were significantly different. Eighty-nine serious adverse events (SAEs) of any type were reported in 61 patients. MTX, bDMARDs and glucocorticoid were not associated with SAEs when adjusted for mean SDAI during the observation period and comorbidities at baseline.
Conclusion
T2T strategy for EORA by using MTX and bDMARDs was effective with an acceptable safety profile. Adhering to T2T led to better outcomes.
Collapse
Affiliation(s)
- Takahiko Sugihara
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology
| | | | - Hiroyuki Baba
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Takumi Matsumoto
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Shoko Iga
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
| | - Kanae Kubo
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
| | - Mari Kamiya
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Fumio Hirano
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tadashi Hosoya
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Nobuyuki Miyasaka
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| |
Collapse
|
39
|
Hsu CY, Chen JF, Su YJ, Chen YC, Lai HM, Yu SF, He HR, Cheng TT. Time-averaged disease activity of rheumatoid arthritis associated with long-term bone mineral density changes. Ther Adv Chronic Dis 2020; 11:2040622320981517. [PMID: 33489063 PMCID: PMC7768880 DOI: 10.1177/2040622320981517] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 11/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Rheumatoid arthritis (RA) is associated with poor bone mineral density (BMD). We designed the current study owing to the lack of long-term prospective studies regarding whether a high disease activity leads to increased bone loss. Methods: We have continually enrolled patients with RA. According to the average disease activity score in 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR) during follow-up, the patients were classified into remission, low disease activity, and moderate or high disease activity groups. Patients were examined with dual-energy X-ray absorptiometry at baseline and after 3 years of follow-up. BMD changes were compared among the groups. Results: We have studied 477 patients. Overall BMD was significantly reduced from baseline to the 3-year follow-up (p < 0.05). After stratifying according to the time-averaged DAS28-ESR levels and use of anti-osteoporosis treatment (AOT), the BMD values of the femur and spine significantly increased in patients in the remission group with AOT. The BMD changes of different DAS28-ESR patients were further compared using the generalized estimation equation model. For the patients on AOT, the negative change in femoral BMD values of the moderate or high activity group was significant when compared with the remission group with positive BMD changes (regression coefficient, –0.038; 95% confidence interval, –0.055 to –0.021). Conclusion: For RA patients, if remission is achieved, AOT can better improve BMD, especially in the femur. In addition, moderate or high disease activity will lead to significant bone loss; therefore, disease activity must be actively controlled.
Collapse
Affiliation(s)
- Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Yu-Jih Su
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Han-Ming Lai
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Hsiao-Ru He
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Kaohsiung 833
| |
Collapse
|
40
|
Zhang L, Chen F, Geng S, Wang X, Gu L, Lang Y, Li T, Ye S. Methotrexate (MTX) Plus Hydroxychloroquine versus MTX Plus Leflunomide in Patients with MTX-Resistant Active Rheumatoid Arthritis: A 2-Year Cohort Study in Real World. J Inflamm Res 2020; 13:1141-1150. [PMID: 33376379 PMCID: PMC7755368 DOI: 10.2147/jir.s282249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/18/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To compare the efficacy, safety, and cost-effectiveness of methotrexate (MTX) plus hydroxychloroquine (HCQ) vs MTX plus leflunomide (LEF) in established rheumatoid arthritis (RA) with inadequate response to MTX monotherapy in a real-world Chinese cohort. Patients and Methods A prospective RA cohort (n=549) was screened with eligible patients who had inadequate response (disease activity score in 28 joints using erythrocyte sedimentation rate, DAS28-ESR>3.2) to initial MTX monotherapy and subsequently received either MTX+HCQ or MTX+LEF. Propensity score matching (PSM) was applied to adjust the possible baseline confounders between two groups. The primary outcome was the proportion of patients achieving first remission (DAS28-ESR<2.6) during follow-up by log rank test. Secondary outcomes were changes of DAS28, glucocorticoids (GCs) exposure, safety, cost-effectiveness, sustained remission, and low disease activity (LDA) rate after 24-month follow-up. Results Overall, 222 eligible patients were subjected to the aforementioned two treatment protocols (MTX+HCQ, n=102; MTX+LEF, n=120). After PSM adjustment, 97 patients in each group were analyzed. A higher remission rate was observed in the MTX+HCQ group than in the MTX+LEF group (70.1% vs 56.7%, P=0.048). The median time to remission was 11 and 16 months in the two groups, respectively. At the endpoint, more patients achieved remission (46.8% vs 32.5%, P=0.063) and maintained sustained LDA in the HCQ group (53.2% vs 38.6%, P=0.062) and also more patients withdrew GCs in this group (32% vs 16.7%, P=0.053) than those in the LEF group. Safety profiles were non-alarming, with no significant difference between the two groups. The incremental cost-effectiveness ratio yielded by MTX+HCQ over MTX+LEF was $1,111.8 per quality-adjusted life-year (QALY), within the cost-effective threshold set as the per capita gross domestic product (GDP) of China. Conclusion The MTX+HCQ combination was seemingly superior to MTX+LEF in a real-world cohort of Chinese RA patients with inadequate response to methotrexate monotherapy in respect of the efficacy and cost-effectiveness.
Collapse
Affiliation(s)
- Le Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.,Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Fangfang Chen
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Shikai Geng
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaodong Wang
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Liyang Gu
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Yitian Lang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Ting Li
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Shuang Ye
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| |
Collapse
|
41
|
The Story Behind the Use of Glucocorticoids in the Treatment of Rheumatoid Arthritis. Semin Arthritis Rheum 2020; 51:15-19. [PMID: 33360225 DOI: 10.1016/j.semarthrit.2020.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022]
Abstract
Cortisone was introduced in the treatment of rheumatoid arthritis (RA) in 1948 by Hench and colleagues at the Mayo Clinic which resulted in dramatic improvement of inflammation, function and sense of well-being. It became obvious early on that side effects could develop depending on the dose and duration of use. When cortisone became available in 1950 the practicing physician developed practice patterns without guidance from government agencies, professional organizations or the pharmaceutic industry. The physician did not have guidance about what dose to use or the duration of use, as is available today. In the last 25 years, controlled studies have shown the benefits and safety of low dose prednisone in early RA. The diurnal effect of endogeneous glucocorticoids provides a clue to the timing of a glucocorticoid dose and the duration of the dose is established. The guidelines by the American College of Rheumatology (ACR) particularly but also the European League Against Rheumatism (EULAR) have emphasized side effects and stressed limited use of glucocorticoids in RA. Biologics have been developed and promoted that are used to replace and taper off low dose prednisone. Yet, glucocorticoids used appropriately can be the cornerstone of effective, safe, and inexpensive treatment of early active rheumatoid arthritis.
Collapse
|
42
|
Rosales Rosado Z, Font Urgelles J, Hernández Rodríguez I, León Mateos L, Abásolo Alcázar L, Jover Jover JÁ. Clinical Management and Discontinuation of Treatment in Patients with Recent Onset Rheumatoid Arthritis in a Rheumatology Consultation. REUMATOLOGIA CLINICA 2020; 18:S1699-258X(20)30228-X. [PMID: 33234499 DOI: 10.1016/j.reuma.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION The treatment of rheumatoid arthritis has changed dramatically in recent years, especially with the use of disease modifying drugs (DMARDs). Data on the management of this disease in clinical trials are abundant, but not so in real life. The aim of our study is to describe the management of an early rheumatoid arthritis cohort in daily clinical practice, especially DMARD discontinuations and reasons. METHODS A retrospective observational study of patients with rheumatoid arthritis diagnosed between 01/07 and 12/14 followed up to 01/17, using>1 DMARD≥3 months. VARIABLES sociodemographic, clinical, treatment, DMARD discontinuation and reason. Descriptive analysis of sociodemographic, clinical and treatment characteristics. Discontinuation incidence rate (DIR) due to survival techniques, expressed in 100 patients/year with 95% confidence interval. RESULTS 814 patients were included with 2,388 courses of treatment, 77% women, mean age 57.5 years. First course: monotherapy (92.75%), especially methotrexate (56.06%). In later courses there was increased combined therapy and use of biologicals (mainly etanercept). There were 1,094 discontinuations (29.5 [27.8-31.3]). The DIR was higher for adverse events (15.9 [14.7-17.3]), biologicals (49.6 [43.1-57.2]) and combined therapy. The DMAR with the lowest DIR was methotrexate (25.8 [23.8-28.1]). CONCLUSION Methotrexate was the most used drug, biologicals increased throughout the follow-up, the most frequent being Etanercept. The DMARD DIR was 29/100 patients per year, mainly due to adverse events. It seems to be higher in the therapies that include biologicals and combined therapies. Methotrexate is the drug with the lowest DIR.
Collapse
|
43
|
|
44
|
Fleischmann R, Furst DE. Safety of repository corticotropin injection as an adjunctive therapy for the treatment of rheumatoid arthritis. Expert Opin Drug Saf 2020; 19:935-944. [PMID: 32497440 DOI: 10.1080/14740338.2020.1779219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Disease-modifying antirheumatic drugs (DMARDs) have significantly improved clinical symptoms and quality of life with reduced disease progression in many patients with rheumatoid arthritis (RA). Short-term glucocorticoid therapy is often used initially in combination with DMARDs, but some patients still have difficulty reaching treatment goals. Repository corticotropin injection (RCI, Acthar® Gel) is approved as adjunctive therapy for short-term administration in patients with continued RA disease activity. AREAS COVERED To determine the safety of RCI in the treatment of RA, adverse events (AEs) from a recent clinical trial of RCI as an adjunctive therapy along with DMARDs and glucocorticoids (ClinicalTrials.gov identifier NCT02919761) were compared with AEs reported in randomized clinical trials of DMARDs and glucocorticoids alone. A systematic review of the literature yielded 4 articles describing the detailed safety results of DMARD/glucocorticoid combination therapy used in the treatment of RA for comparison. EXPERT OPINION There were no clinically significant differences between the AE profiles of RCI/DMARD/glucocorticoid treatment in the RCI clinical trial and those in the DMARD/glucocorticoid safety profile compiled from the reviewed clinical trials; this was supported by pharmacovigilance data. These results support the short-term safety of RCI as an adjunctive therapy for patients with persistently active RA.
Collapse
Affiliation(s)
- Roy Fleischmann
- Metroplex Clinical Research Center, University of Texas Southwestern Medical Center , Dallas, TX, USA
| | - Daniel E Furst
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles , Los Angeles, CA, USA
| |
Collapse
|
45
|
Kerschbaumer A, Sepriano A, Smolen JS, van der Heijde D, Dougados M, van Vollenhoven R, McInnes IB, Bijlsma JWJ, Burmester GR, de Wit M, Falzon L, Landewé R. Efficacy of pharmacological treatment in rheumatoid arthritis: a systematic literature research informing the 2019 update of the EULAR recommendations for management of rheumatoid arthritis. Ann Rheum Dis 2020; 79:744-759. [PMID: 32033937 PMCID: PMC7286044 DOI: 10.1136/annrheumdis-2019-216656] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To inform the 2019 update of the European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA). METHODS A systematic literature research (SLR) to investigate the efficacy of any disease-modifying antirheumatic drug (DMARD) (conventional synthetic (cs)DMARD, biological (b) and biosimilar DMARD, targeted synthetic (ts)DMARD) or glucocorticoid (GC) therapy in patients with RA was done by searching MEDLINE, Embase and the Cochrane Library for articles published between 2016 and 8 March 2019. RESULTS 234 abstracts were selected for detailed assessment, with 136 finally included. They comprised the efficacy of bDMARDs versus placebo or other bDMARDs, efficacy of Janus kinase (JAK) inhibitors (JAKi) across different patient populations and head-to-head of different bDMARDs versus JAKi or other bDMARDs. Switching of bDMARDs to other bDMARDs or tsDMARDs, strategic trials and tapering studies of bDMARDs, csDMARDs and JAKi were assessed. The drugs evaluated included abatacept, adalimumab, ABT-122, baricitinib, certolizumab pegol, SBI-087, CNTO6785, decernotinib, etanercept, filgotinib, golimumab, GCs, GS-9876, guselkumab, hydroxychloroquine, infliximab, leflunomide, mavrilimumab, methotrexate, olokizumab, otilimab, peficitinib, rituximab, sarilumab, salazopyrine, secukinumab, sirukumab, tacrolimus, tocilizumab, tofacitinib, tregalizumab, upadacitinib, ustekinumab and vobarilizumab. The efficacy of many bDMARDs and tsDMARDs was shown. Switching to another tumour necrosis factor inhibitor (TNFi) or non-TNFi bDMARDs after TNFi treatment failure is efficacious. Tapering of DMARDs is possible in patients achieving long-standing stringent clinical remission; in patients with residual disease activity (including patients in LDA) the risk of flares is increased during the tapering. Biosimilars are non-inferior to their reference products. CONCLUSION This SLR informed the task force regarding the evidence base of various therapeutic regimen for the development of the update of EULAR's RA management recommendation.
Collapse
Affiliation(s)
| | - Alexandre Sepriano
- Leiden University Medical Center, Leiden, The Netherlands
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | | | | | | | | | | | | | | | | | - Robert Landewé
- Amsterdam Rheumatology Center, Amsterdam, The Netherlands
| |
Collapse
|
46
|
Stouten V, Westhovens R, Pazmino S, De Cock D, Van der Elst K, Joly J, Verschueren P. Effectiveness of different combinations of DMARDs and glucocorticoid bridging in early rheumatoid arthritis: two-year results of CareRA. Rheumatology (Oxford) 2020; 58:2284-2294. [PMID: 31236568 DOI: 10.1093/rheumatology/kez213] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 03/03/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To investigate whether MTX should be combined with an additional DMARD and bridging glucocorticoids as initial treatment for patients with early RA to induce an effective long-term response. METHODS The Care in early RA study is a two-year investigator-initiated pragmatic multicentre randomized trial. Early RA patients, naïve to DMARDs and glucocorticoids, were stratified based on prognostic factors. High-risk patients were randomized to COBRA-Classic (n = 98): MTX, sulfasalazine, prednisone step-down from 60 mg; COBRA-Slim (n = 98): MTX, prednisone step-down from 30 mg; or COBRA-Avant-Garde (n = 93): MTX, leflunomide, prednisone step-down from 30 mg. Low-risk patients were randomized to COBRA-Slim (n = 43); or Tight Step Up (TSU) (n = 47): MTX without prednisone. Clinical/radiological outcomes at year 2, sustainability of response, safety and treatment adaptations were assessed. RESULTS In the high-risk group 71/98 (72%) patients achieved a DAS28-CRP < 2.6 with COBRA-Slim compared with 64/98 (65%) with COBRA-Classic and 69/93 (74%) with COBRA-Avant-Garde (P = 1.00). Other clinical/radiological outcomes and sustainability of response were similar. COBRA-Slim treatment resulted in less therapy-related adverse events compared with COBRA-Classic (P = 0.02) or COBRA-Avant-Garde (P = 0.005). In the low-risk group, 29/43 (67%) patients on COBRA-Slim and 34/47 (72%) on TSU achieved a DAS28-CRP < 2.6 (P = 1.00). On COBRA-Slim, low-risk patients had lower longitudinal DAS28-CRP scores over 2 years, a lower need for glucocorticoid injections and a comparable safety profile compared with TSU. CONCLUSION All regimens combining DMARDs with glucocorticoids were effective for patients with early RA up to 2 years. The COBRA-Slim regimen, MTX monotherapy with glucocorticoid bridging, provided the best balance between efficacy and safety, irrespective of patients' prognosis. TRIAL REGISTRATION ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT01172639.
Collapse
Affiliation(s)
- Veerle Stouten
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Belgium
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Belgium
| | - Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Belgium
| | - Kristien Van der Elst
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Joly
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | | |
Collapse
|
47
|
Pazmino S, Boonen A, Stouten V, De Cock D, Joly J, Van der Elst K, Westhovens R, Verschueren P. Two-year cost-effectiveness of different COBRA-like intensive remission induction schemes in early rheumatoid arthritis: a piggyback study on the pragmatic randomised controlled CareRA trial. Ann Rheum Dis 2020; 79:556-565. [DOI: 10.1136/annrheumdis-2019-216874] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/17/2020] [Accepted: 03/01/2020] [Indexed: 01/01/2023]
Abstract
ObjectivesTo evaluate the cost-effectiveness of treat-to-target strategies among recently diagnosed patients with rheumatoid arthritis (RA) using methotrexate (MTX) and a step-down glucocorticoid (GC) scheme (COBRA Slim) compared with (1) this combination with either sulphasalazine (COBRA Classic) or leflunomide (COBRA Avant-Garde) in high-risk patients and (2) MTX without GCs (Tight-Step-Up, TSU) in low-risk patients.MethodsThe incremental cost-utility was calculated from a healthcare perspective in the intention-to-treat population (n=379) of the 2-year open-label pragmatic randomised controlled Care in early RA trial. Healthcare costs were collected prospectively through electronic trial records. Quality-adjusted life years (QALYs) were estimated using mapping algorithms for EuroQoL-5 Dimension. Multiple imputation was used to handle missing data and bootstrapping to calculate CIs. Robustness was tested with biological disease-modifying antirheumatic drugs at biosimilar prices.ResultsIn the high-risk group, Classic (∆k€1.464, 95% CI −0.198 to 3.127) and Avant-Garde (∆k€0.636, 95% CI −0.987 to 2.258) were more expensive compared with Slim and QALYs were slightly worse for Classic (∆−0.002, 95% CI −0.086 to 0.082) and Avant-Garde (∆−0.009, 95% CI −0.102 to 0.084). This resulted in the domination of Classic and Avant-Garde by Slim. In the low-risk group, Slim was cheaper (∆k€−0.617, 95% CI −2.799 to 1.566) and QALYs were higher (∆0.141, 95% CI 0.008 to 0.274) compared with TSU, indicating Slim dominated. Results were robust against the price of biosimilars.ConclusionsThe combination of MTX with a GC bridging scheme is less expensive with comparable health utility than more intensive step-down combination strategies or a conventional step-up approach 2 years after initial treatment.Trial registration numberNCT01172639.
Collapse
|
48
|
Morgan C, Costello RE, Ray DW, Dixon WG. How Do Glucocorticoids Used in Rheumatic Disease Affect Body Weight? A Narrative Review of the Evidence. Arthritis Care Res (Hoboken) 2020; 72:489-497. [PMID: 30875454 PMCID: PMC7155058 DOI: 10.1002/acr.23879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 03/05/2019] [Indexed: 12/17/2022]
Abstract
Glucocorticoids (GCs) are widely used to effectively treat inflammatory disease, but GCs have a number of recognized side effects. Patients and clinicians view these side effects differently, with clinicians most concerned with serious side effects such as osteoporosis and diabetes mellitus. Consequently, these side effects are well researched with clinical guidelines and recommendations. A side effect of particular concern to patients is weight gain, but this topic has not been well researched, and consequently clinicians find it difficult to provide patients with accurate information about the potential of weight gain. The aim of this review is to provide an overview of GC use specifically in rheumatic disease, patient views on GC therapy, and GC-induced weight gain. We will discuss the evidence, including the extent and the impact of weight gain on the patient, and highlight areas that warrant further investigation.
Collapse
Affiliation(s)
| | - Ruth E. Costello
- Manchester Academic Health Science Centre and The University of ManchesterManchesterUK
| | - David W. Ray
- University of Manchester, Manchester, and University of OxfordOxfordUK
| | - William G. Dixon
- Manchester Academic Health Science Centre and The University of ManchesterManchesterUK
| |
Collapse
|
49
|
Effectiveness of maintenance therapy with methotrexate compared with leflunomide for patients with RA having achieved disease control with both these drugs: results of a predefined sub-analysis of CareRA, a pragmatic RCT. Clin Rheumatol 2020; 39:2593-2601. [PMID: 32166429 DOI: 10.1007/s10067-020-05008-4] [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: 11/28/2019] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION/OBJECTIVES Evidence regarding the effectiveness of step-down strategies for patients with well-controlled early rheumatoid arthritis (RA) on a combination of methotrexate (MTX) and leflunomide (LEF) is currently lacking. METHOD The Care in early RA (CareRA) trial is a 2-year randomized pragmatic trial comparing different remission induction strategies in treatment-naïve patients with early RA. For this study, we included participants who achieved low disease activity (LDA) (DAS28-CRP ≤ 3.2) between 40 to 52 weeks after starting a combination of MTX, LEF, and a prednisone bridging scheme followed by a treat-to-target approach. Patients were re-randomized to a maintenance monotherapy of either MTX 15 mg weekly or LEF 20 mg daily. Remission rates (DAS28-CRP < 2.6) at week 65 counted from re-randomization, as well as drug retention rates and safety during the 65 weeks of follow-up, were compared. RESULTS Remission rates at week 65 after re-randomization were numerically higher in patients assigned to MTX (29/32; 90.6%) compared with patients on LEF (20/27; 74.1%) (p = 0.091). Of patients assigned to MTX, 60% (19/32) maintained LDA while continuing their assigned monotherapy until week 65 after re-randomization versus 44% (12/27) in the LEF group (p = 0.25). Patients re-randomized to MTX were more frequently in LDA measured by Clinical Disease Activity Index (32/32; 100%) compared with patients on LEF (23/27; 85.2%) (p = 0.024) 65 weeks after re-randomization. According to survival analyses, the probability of maintaining MTX monotherapy was higher (81%) than maintaining LEF monotherapy (55%) for 65 weeks (p = 0.025) after re-randomization. Safety analysis after re-randomization showed a good safety profile in both groups. CONCLUSION MTX monotherapy seems not significantly more efficacious as maintenance treatment compared with LEF monotherapy but has a better retention rate and is well tolerated in early RA patients in LDA after combination therapy with both. TRIAL REGISTRATION Clinical trials NCT01172639 Key points • Methotrexate should be preferred over leflunomide as maintenance therapy after an initial intensive combination of these two drugs. • Methotrexate shows a better retention rate to leflunomide as maintenance therapy in this context.
Collapse
|
50
|
Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, Dougados M, Kerschbaumer A, McInnes IB, Sepriano A, van Vollenhoven RF, de Wit M, Aletaha D, Aringer M, Askling J, Balsa A, Boers M, den Broeder AA, Buch MH, Buttgereit F, Caporali R, Cardiel MH, De Cock D, Codreanu C, Cutolo M, Edwards CJ, van Eijk-Hustings Y, Emery P, Finckh A, Gossec L, Gottenberg JE, Hetland ML, Huizinga TWJ, Koloumas M, Li Z, Mariette X, Müller-Ladner U, Mysler EF, da Silva JAP, Poór G, Pope JE, Rubbert-Roth A, Ruyssen-Witrand A, Saag KG, Strangfeld A, Takeuchi T, Voshaar M, Westhovens R, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020; 79:685-699. [PMID: 31969328 DOI: 10.1136/annrheumdis-2019-216655] [Citation(s) in RCA: 1591] [Impact Index Per Article: 397.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations to account for the most recent developments in the field. METHODS An international task force considered new evidence supporting or contradicting previous recommendations and novel therapies and strategic insights based on two systematic literature searches on efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) since the last update (2016) until 2019. A predefined voting process was applied, current levels of evidence and strengths of recommendation were assigned and participants ultimately voted independently on their level of agreement with each of the items. RESULTS The task force agreed on 5 overarching principles and 12 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, sarilumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (the Janus kinase (JAK) inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering on sustained clinical remission is provided. Cost and sequencing of b/tsDMARDs are addressed. Initially, MTX plus GCs and upon insufficient response to this therapy within 3 to 6 months, stratification according to risk factors is recommended. With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAK inhibitor should be added to the csDMARD. If this fails, any other bDMARD (from another or the same class) or tsDMARD is recommended. On sustained remission, DMARDs may be tapered, but not be stopped. Levels of evidence and levels of agreement were mostly high. CONCLUSIONS These updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost.
Collapse
Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Robert B M Landewé
- Amsterdam University Medical Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Maxime Dougados
- Rhumatologie B, Hopital Cochin, 27 rue du Fbg Saint-Jacques, Paris, France
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alexandre Sepriano
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal, and Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Maarten de Wit
- EULAR Patient Research Partner; Department Medical Humanities, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - John Askling
- Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Alejandro Balsa
- Servicio de Reumatologia Hospital Universitario La Paz, Instituto de Investigacion IdiPAZ, Madrid, Spain
| | - Maarten Boers
- Department of Epidemiology and Biostatistics and Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Maya H Buch
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, and IRCCS S Matteo Foundation, Pavia, Italy
| | | | - Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Maurizio Cutolo
- Research Laboratory and Division of Clinical Rheumatology, Department of Internal Medicine - University of Genoa, Genoa, Italy
| | - Christopher John Edwards
- Musculoskeletal Research Unit, NIHR Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Yvonne van Eijk-Hustings
- Department of Patient & Care and Department of Rheumatology, University of Maastricht, Maastricht, The Netherlands
| | - Paul Emery
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Axel Finckh
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Laure Gossec
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris and Pitié Salpêtrière hospital, AP-HP, Rheumatology Department, Paris, France
| | - Jacques-Eric Gottenberg
- Strasbourg University Hospital and University of Strasbourg, CNRS, Institut de Biologie Moléculaire et Cellulaire, Immunopathologie, et Chimie Thérapeutique, Strasbourg, France
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marios Koloumas
- European League Against Rheumatism, Zurich, Switzerland.,Cyprus League against Rheumatism, Nikosia, Cyprus
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Xavier Mariette
- Université Paris-Sud, AP-HP, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus-Liebig University Giessen, Bad Nauheim, Germany
| | | | - Jose A P da Silva
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra Praceta Mota Pinto, and Coimbra Institute for Clinical and Biomedical Research (i-CRB), Faculty of Medicine of Coimbra, Coimbra, Portugal
| | - Gyula Poór
- National Institute of Rheumatology & Physiology, Semmelweis University, Budapest, Hungary
| | - Janet E Pope
- University of Western Ontario, Schulich School of Medicine & Dentistry, Department of Medicine, London, Ontario, Canada
| | | | | | - Kenneth G Saag
- Department of Medicine, Division of Rheumatology, University of Alabama at Birmingham, Brmingham, Alabama, USA
| | - Anja Strangfeld
- Programme Area Epidemiology, Deutsches Rheumaforschungszentrum Berlin, Berlin, Germany
| | - Tsutomu Takeuchi
- Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | | |
Collapse
|