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Hao Y, Oon S, Nikpour M. Efficacy and safety of treat-to-target strategy studies in rheumatic diseases: A systematic review and meta-analysis. Semin Arthritis Rheum 2024; 67:152465. [PMID: 38796922 DOI: 10.1016/j.semarthrit.2024.152465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The concept of treat-to-target (T2T), a treatment strategy in which treatment is directed to reach and maintain a defined goal such as remission or low disease activity (LDA), has been explored for several diseases including rheumatic diseases such as rheumatoid arthritis (RA). However, a comprehensive review of T2T in all rheumatic diseases has not recently been undertaken. OBJECTIVE To perform a systematic review and meta-analysis of the efficacy and safety of a T2T strategy in the management of adult patients with inflammatory rheumatic diseases. METHODS PUBMED, EMBASE and CINAHL were searched from January 1990 to December 2023 using key words related to a T2T strategy and rheumatic diseases; T2T strategy clinical trials or observational studies were included. Clinical, physical function and radiologic outcomes, cost-effectiveness, and adverse events (AEs) of the T2T strategies were investigated and a random-effect meta-analysis was conducted for the most commonly used outcomes in RA studies. RESULTS The search identified 7896 studies, of which 66 fit inclusion criteria, including 50 in RA, 3 in psoriatic arthritis (PsA), 1 in spondyloarthritis (SpA) and 12 in gout. For the studies comparing a T2T strategy with usual care (UC) in RA, 83.3% (20/24) showed a T2T strategy could achieve significantly better clinical outcomes, and the meta-analysis showed that patients treated with a T2T strategy were more likely to be in remission (pooled RR: 1.68 (1.47-1.92), p<0.001] and achieve DAS-28 response (pooled standardised mean difference (SMD): 0.47 (0.26-0.69), P<0.001] at 1 year than patients treated with UC. Sensitivity analyses showed that a T2T strategy with a predefined treatment protocol had better clinical efficacy than that without protocol. In terms of improving physical function and health-related quality of life (HRQoL), 11/19 (57.9%) studies found a T2T strategy was significantly more likely to achieve these than UC, with the meta-analysis for the mean change of HAQ score supporting this conclusion (pooled SMD: 1.48 (0.46-2.51), p=0.004). Five out of 9 studies (55.6%) demonstrated greater benefit regarding radiographic progression from a T2T strategy. In terms of cost-effectiveness and AEs, 2/2 studies found a T2T strategy was more cost-effective than UC and 8/8 studies showed no tendency for AEs to occur more often with a T2T strategy. For the studies in PsA and SpA, a T2T strategy was also demonstrated to be more effective than UC in clinical and functional benefits, but not in radiologic outcomes. All gout studies showed that sUA level could be controlled more effectively with a T2T strategy, and 2 studies revealed that the T2T strategy could inhibit erosion development or crystal deposition. CONCLUSIONS For patients with active RA, a T2T strategy has been shown in mulitple studies to increase the likelihood of achieving clinical response and improving HRQoL without increasing economic costs and AEs. Limited studies have shown clinical and functional benefits from T2T strategies in active PsA and SpA. A T2T strategy has also been found to improve clinical and radiologic outcomes in gout. T2T trials in other rheumatic diseases are lacking.
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Affiliation(s)
- Yanjie Hao
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia
| | - Shereen Oon
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia.
| | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia; Sydney MSK Research Flagship Centre, The University of Sydney School of Public Health, Room 132, Edward Ford Building, Fisher Road, University of Sydney, NSW 2006, Australia; Royal Prince Alfred Hospital Institute of Rheumatology and Orthopedics, 59 Missenden Rd, Camperdown NSW 2050, Australia.
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Hoffmann MH, Kirchner H, Krönke G, Riemekasten G, Bonelli M. Inflammatory tissue priming: novel insights and therapeutic opportunities for inflammatory rheumatic diseases. Ann Rheum Dis 2024:ard-2023-224092. [PMID: 38702177 DOI: 10.1136/ard-2023-224092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
Due to optimised treatment strategies and the availability of new therapies during the last decades, formerly devastating chronic inflammatory diseases such as rheumatoid arthritis or systemic sclerosis (SSc) have become less menacing. However, in many patients, even state-of-the-art treatment cannot induce remission. Moreover, the risk for flares strongly increases once anti-inflammatory therapy is tapered or withdrawn, suggesting that underlying pathological processes remain active even in the absence of overt inflammation. It has become evident that tissues have the ability to remember past encounters with pathogens, wounds and other irritants, and to react more strongly and/or persistently to the next occurrence. This priming of the tissue bears a paramount role in defence from microbes, but on the other hand drives inflammatory pathologies (the Dr Jekyll and Mr Hyde aspect of tissue adaptation). Emerging evidence suggests that long-lived tissue-resident cells, such as fibroblasts, macrophages, long-lived plasma cells and tissue-resident memory T cells, determine inflammatory tissue priming in an interplay with infiltrating immune cells of lymphoid and myeloid origin, and with systemically acting factors such as cytokines, extracellular vesicles and antibodies. Here, we review the current state of science on inflammatory tissue priming, focusing on tissue-resident and tissue-occupying cells in arthritis and SSc, and reflect on the most promising treatment options targeting the maladapted tissue response during these diseases.
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Affiliation(s)
| | - Henriette Kirchner
- Institute for Human Genetics, Epigenetics and Metabolism Lab, University of Lübeck, Lübeck, Germany
| | - Gerhard Krönke
- Department of Rheumatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Michael Bonelli
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
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Kjørholt KE, Sundlisæter NP, Aga AB, Sexton J, Olsen IC, Fremstad H, Spada C, Madland TM, Høili CA, Bakland G, Lexberg Å, Hansen IJW, Hansen IM, Haukeland H, Ljoså MKA, Moholt E, Uhlig T, Kvien TK, Solomon DH, van der Heijde D, Haavardsholm EA, Lillegraven S. Effects of tapering conventional synthetic disease-modifying antirheumatic drugs to drug-free remission versus stable treatment in rheumatoid arthritis (ARCTIC REWIND): 3-year results from an open-label, randomised controlled, non-inferiority trial. THE LANCET. RHEUMATOLOGY 2024; 6:e268-e278. [PMID: 38583450 DOI: 10.1016/s2665-9913(24)00021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Tapering of disease-modifying antirheumatic drugs (DMARDs) to drug-free remission is an attractive treatment goal for patients with rheumatoid arthritis, although long-term effects of tapering and withdrawal remain unclear. We compared 3-year risks of flare between three conventional synthetic DMARD treatment strategies in patients with rheumatoid arthritis in sustained remission. METHODS In this open-label, randomised controlled, non-inferiority trial, we enrolled patients aged 18-80 years with rheumatoid arthritis who had been in sustained remission for at least 1 year on stable conventional synthetic DMARD therapy. Patients from ten hospitals in Norway were randomly assigned (2:1:1) with centre stratification to receive stable conventional synthetic DMARDs, half-dose conventional synthetic DMARDs, or half-dose conventional synthetic DMARDs for 1 year followed by withdrawal of all conventional synthetic DMARDs. The primary endpoint of this part of the study was disease flare over 3 years, analysed as flare-free survival and risk difference in the per-protocol population with a non-inferiority margin of 20%. This trial is registered with ClinicalTrials.gov (NCT01881308) and is completed. FINDINGS Between June 17, 2013, and June 18, 2018, 160 patients were enrolled and randomly assigned to receive stable-dose conventional synthetic DMARDs (n=80), half-dose conventional synthetic DMARDs (n=42), or half-dose conventional synthetic DMARDs tapering to withdrawal (n=38). Four patients did not receive the intervention and 156 patients received the allocated treatment strategy. One patient was excluded due to major protocol violation and 155 patients were included in the per-protocol analysis. 104 (67%) of 156 patients were women and 52 (33%) were men. 139 patients completed 3-years follow-up without major protocol violation; 68 (87%) of 78 patients in the stable-dose group, 36 (88%) of 41 patients in the half-dose group and 35 (95%) of 37 patients in the half-dose tapering to withdrawal group. During the 3-year study period, 80% (95% CI 69-88%) were flare-free in the stable-dose group, compared with 57% (41-71%) in the half-dose group and 38% (22-53%) in the half-dose tapering to withdrawal group. Compared with stable-dose conventional synthetic DMARDs, the risk difference of flare was 23% (95% CI 6-41%, p=0·010) in the half-dose group and 40% (22-58%, p<0·0001) in the half-dose tapering to withdrawal group, non-inferiority was therefore not shown. Adverse events were reported in 65 (83%) of 78 patients in the stable-dose group, 36 (90%) of 40 patients in the half-dose group, and 36 (97%) of 37 patients in the half-dose tapering to withdrawal group. One death occurred in the stable-dose conventional synthetic DMARD group (sudden death considered unlikely related to the study medication). INTERPRETATION Two conventional synthetic DMARD tapering strategies were associated with significantly lower rates of flare-free survival compared with stable conventional synthetic DMARD treatment, and the data do not support non-inferiority. However, drug-free remission was achiveable for a significant subgroup of patients. This trial provides information on risk and benefits of different treatment strategies important for shared decision making. FUNDING Research Council of Norway and South-Eastern Norway Regional Health Authority.
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Affiliation(s)
- Kaja E Kjørholt
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Nina Paulshus Sundlisæter
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Anna-Birgitte Aga
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Joseph Sexton
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Inge C Olsen
- Clinical Trial Unit, Oslo University Hospital, Oslo, Norway
| | - Hallvard Fremstad
- Department of Rheumatology, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Cristina Spada
- Department of Rheumatology, Rheumatism Hospital AS, Lillehammer, Norway
| | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | | | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, Tromsø, Norway; Institute of Clinical Medicine, Faculty of Health Science, UiT The Arctic University, Tromsø, Norway
| | - Åse Lexberg
- Department of Rheumatology, Drammen Hospital, Vestre Viken HF, Drammen, Norway
| | | | - Inger Myrnes Hansen
- Department of Rheumatology, Helgelandssykehuset Mo i Rana, Mo i Rana, Norway
| | - Hilde Haukeland
- Department of Rheumatology, Martina Hansens Hospital, Bærum, Norway
| | | | - Ellen Moholt
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Till Uhlig
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tore K Kvien
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Daniel H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Désirée van der Heijde
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Espen A Haavardsholm
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Siri Lillegraven
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
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Heckert SL, Maassen JM, le Cessie S, Goekoop-Ruiterman YPM, Güler-Yüksel M, Lems W, Huizinga TW, Bergstra SA, Allaart CF. Long-term mortality in treated-to-target RA and UA: results of the BeSt and IMPROVED cohort. Ann Rheum Dis 2024; 83:161-168. [PMID: 37979961 PMCID: PMC10850649 DOI: 10.1136/ard-2023-224814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/19/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES To study long-term (up to 20-year) mortality of two treat-to-target trial cohorts in undifferentiated arthritis (UA) and early rheumatoid arthritis (RA). METHODS The BeSt (BehandelStrategieën) study (n=508, early RA) was performed between 2000 and 2012. For 10 years, patients were treated-to-target disease activity score (DAS)≤2.4.The Induction therapy with Methotrexate and Prednisone in Rheumatoid Or Very Early arthritic Disease (IMPROVED) study (n=610, early RA/UA) was performed between 2007 and 2015. For 5 years, patients were treated-to-target DAS<1.6.Vital status of BeSt/IMPROVED participants was assessed up to and including 31 December 2021. Standardised mortality ratios (SMRs) were calculated. Stratified analyses for anticitrullinated protein antibody (ACPA) and smoking status were performed. Death causes and the potential effect of disease activity during the trial period on late mortality were assessed. RESULTS Excess mortality was found in both BeSt (SMR 1.32, 95% CI 1.14 to 1.53) and IMPROVED (SMR 1.33, 95% CI 1.10 to 1.63) and became manifest after 10 years. Excess mortality was statistically significant in ACPA+ patients who smoked (BeSt: SMR 2.80, 95% CI 2.16 to 3.64; IMPROVED: 2.14, 95% CI 1.33 to 3.45). Mean survival time was 10 (95% CI 5 to 16) months shorter than expected in BeSt and 13 (95% CI 11 to 16) months in IMPROVED. The HR for mortality was 1.34 (95% CI 0.96 to 1.86; BeSt)/1.13 (95% CI 0.67 to 1.91; IMPROVED) per 1 point increase in mean DAS during the trial. The main cause of death was malignancy. CONCLUSIONS After long-term treatment-to-target, excess mortality occurred in patients with RA after>10 years since treatment start, with smoking as an important risk factor.
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Affiliation(s)
- Sascha Louise Heckert
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Johanna Maria Maassen
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - S le Cessie
- Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | | | - Melek Güler-Yüksel
- Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Willem Lems
- Rheumatology, Amsterdam UMC Location VUmc, Amsterdam, Noord-Holland, The Netherlands
| | - Tom Wj Huizinga
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Sytske Anne Bergstra
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Cornelia F Allaart
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Doumen M, Pazmino S, Verschueren P, Westhovens R. Viewpoint: Supporting mental health in the current management of rheumatoid arthritis: time to act! Rheumatology (Oxford) 2023; 62:SI274-SI281. [PMID: 37871921 DOI: 10.1093/rheumatology/kead248] [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: 02/22/2023] [Accepted: 05/23/2023] [Indexed: 10/25/2023] Open
Abstract
Although clinical outcomes of RA have vastly improved in recent years, the disease's mental health impact has seemingly not decreased to the same extent. Even today, learning to live with RA is an active process involving several psychological, cognitive, behavioural and emotional pathways. Consequently, mental health disorders are more common in the context of RA than in the general population, and can be particularly detrimental both to patients' quality of life and to clinical outcomes. However, mental health is a spectrum and represents more than the absence of psychological comorbidity, and supporting patients' psychological wellbeing should thus involve a more holistic perspective than the mere exclusion or specific treatment of mental health disorders. In this viewpoint article, we build on mechanistic and historical insights regarding the relationship between RA and mental health, before proposing a practical stepwise approach to supporting patients' mental health in daily clinical practice.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
- Rheumatology, University Hospitals Leuven, Belgium, Leuven
| | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
- Rheumatology, University Hospitals Leuven, Belgium, Leuven
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
- Rheumatology, University Hospitals Leuven, Belgium, Leuven
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Sakalyte R, Stropuviene S, Jasionyte G, Bagdonaite L, Venalis A. Association between PYTPN22 rs2476601, VEGF rs833070, TNFAIP3 rs6920220 Polymorphisms and Risk for Rheumatoid Arthritis in Early Undifferentiated Arthritis Patients: A Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1824. [PMID: 37893542 PMCID: PMC10607990 DOI: 10.3390/medicina59101824] [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: 08/26/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: About 40% of early undifferentiated arthritis (UA) progresses to rheumatoid (RA) or other chronic arthritis. Novel diagnostic tools predicting the risk for this progression are needed to identify the patients who would benefit from early aggressive treatment. Evidence on the role of single-nucleotide polymorphisms (SNPs) in the development of RA has emerged. The aim of our study was to investigate the association between rs2476601, rs833070, and rs6920220 SNPs and UA progression to RA. Materials and Methods: Ninety-two UA patients were observed for 12 months. At study entry, demographic and clinical characteristics were recorded, musculoskeletal ultrasonography was performed, and blood samples were drawn to investigate levels of inflammatory markers, rheumatoid factor (RF), anti-citrullinated protein antibodies (anti-CCP)detect SNPs. After 12 months, UA outcomes were assessed, and patients were divided into two (RA and non-RA) groups. The association between the risk of progression to chronic inflammatory arthritis and analyzed SNPs was measured by computing odds ratios (OR). Results: After a 12-month follow-up, 27 (29.3%) patients developed RA, and 65 (70.7%) patients were assigned to the non-RA group. The arthritis of 21 patients (22.8%) from the non-RA group resolved completely, while the other 44 (47.2%) patients were diagnosed with another rheumatic inflammatory disease. The patients who developed RA had a significantly greater number of tender and swollen joints (p = 0.010 and p = 0.021 respectively) and were more frequently RF or anti-CCP (p < 0.001), and both RF and anti-CCP positive (p < 0.001) at the baseline as compared with the patients in the non-RA group. No significant association between rs2476601 (OR = 0.99, p = 0.98), rs833070 (OR = 1.0, p = 0.97), and rs6920220 (OR = 0.48, p = 0.13) polymorphisms and the risk of developing RA were found. Conclusions: No association between analyzed SNPs and a greater risk to progress from UA to RA was confirmed, although patients with rs6920220 AA + AG genotypes had fewer tender joints at the disease onset.
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Affiliation(s)
- Regina Sakalyte
- The Clinic of Rheumatology, Traumatology Orthopaedics and Reconstructive Surgery, Institute of Clinical Medicine of the Faculty of Vilnius University, M. K. Čiurlionio Str. 21, 03101 Vilnius, Lithuania
- State Research Institute Centre for Innovative Medicine, Santariškių g. 5, 08406 Vilnius, Lithuania
| | - Sigita Stropuviene
- The Clinic of Rheumatology, Traumatology Orthopaedics and Reconstructive Surgery, Institute of Clinical Medicine of the Faculty of Vilnius University, M. K. Čiurlionio Str. 21, 03101 Vilnius, Lithuania
- State Research Institute Centre for Innovative Medicine, Santariškių g. 5, 08406 Vilnius, Lithuania
| | - Gabija Jasionyte
- The Clinic of Rheumatology, Traumatology Orthopaedics and Reconstructive Surgery, Institute of Clinical Medicine of the Faculty of Vilnius University, M. K. Čiurlionio Str. 21, 03101 Vilnius, Lithuania
| | - Loreta Bagdonaite
- Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio Str. 21, 03101 Vilnius, Lithuania
| | - Algirdas Venalis
- The Clinic of Rheumatology, Traumatology Orthopaedics and Reconstructive Surgery, Institute of Clinical Medicine of the Faculty of Vilnius University, M. K. Čiurlionio Str. 21, 03101 Vilnius, Lithuania
- State Research Institute Centre for Innovative Medicine, Santariškių g. 5, 08406 Vilnius, Lithuania
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Fautrel B. Biologics in rheumatoid arthritis: a lifetime treatment or possibility of drug holidays? Nat Rev Rheumatol 2023; 19:611-612. [PMID: 37525010 DOI: 10.1038/s41584-023-01005-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Bruno Fautrel
- Department of Rheumatology, Sorbonne University AP-HP, Paris, France.
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8
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D'Onofrio B, van der Helm-van Mil A, W J Huizinga T, van Mulligen E. Inducibility or predestination? Queries and concepts around drug-free remission in rheumatoid arthritis. Expert Rev Clin Immunol 2023; 19:217-225. [PMID: 36511619 DOI: 10.1080/1744666x.2023.2157814] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Drug-free remission (DFR) and its maintenance have been defined as the most desirable outcome for rheumatoid arthritis (RA) patients. DFR is linked to resolution of arthritis-related symptoms and restoration of normal functioning. However, there is currently no consensus if an optimal strategy, upon the initiation of treatment to the proper drugs withdrawal, is enough to induce it, or whether it is a predetermined condition related to patients' intrinsic characteristics. AREAS COVERED This review focuses on two key concepts around DFR. First, we analyze patients' intrinsic factors that may increase the chance of DFR, regardless of therapeutic choices. Second, we discuss on the evidence that it can be induced thanks to adequate, extrinsic disease management. Finally, we provide a glimpse into consequences of drugs discontinuation. EXPERT OPINION The early initiation of DMARD and the subsequent strict monitoring and drug adjustments are of primary importance to allow patients to achieve DFR, irrespective of initial treatment strategy. Once remission is obtained and maintained, it is possible to gradually taper and discontinue drugs with no dramatic consequences on the disease course. Among those who stop medication, ACPA-negative patients more often maintain the remission. Thus, DFR might depend on a combination of intrinsic and extrinsic factors.
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Affiliation(s)
- Bernardo D'Onofrio
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Elise van Mulligen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Westhovens R. Filgotinib in rheumatoid arthritis. Expert Rev Clin Immunol 2023; 19:135-144. [PMID: 36396615 DOI: 10.1080/1744666x.2023.2149495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Rheumatoid Arthritis (RA) remains a challenge for rheumatologists and patients despite implementation of intensive treat-to-target strategies in shared decision with patients and an increasing availability of drugs. Janus kinase inhibitors (JAKi) are a new generation of oral targeted drugs. Filgotinib preferentially inhibits JAK1 and is the latest JAKi to be approved for use in RA. AREAS COVERED This narrative review focuses on drug characteristics, efficacy, and safety of filgotinib in patients with RA, summarizing available literature. Trial data are detailed, put into perspective for practice and discussed in regulatory perspective. EXPERT OPINION Preclinical studies demonstrate preferential inhibition of JAK1 and a promising pharmacokinetic profile with few drug-drug interactions. Increase in hemoglobin in line with preferential inhibition of JAK1 over JAK2 is seen in early-phase clinical trials. A phase III program demonstrates efficacy in several disease stages, numerically higher with 200 mg versus 100 mg daily. In the overall RA population such dose-related effect is not observed for safety except for herpes zoster and increases in lipids and creatine phosphokinase. This reassuring safety profile is to be confirmed in future practice. It also needs to be unraveled if JAK1 preferential inhibition plays a key role in this safety profile.
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Affiliation(s)
- Rene Westhovens
- Emeritus Professor KU Leuven, Skeletal Biology and Engineering Research Center Department of Development and Regeneration, Leuven, Belgium
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10
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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.
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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
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11
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Doumen M, Pazmino S, Bertrand D, Westhovens R, Verschueren P. Glucocorticoids in rheumatoid arthritis: Balancing benefits and harm by leveraging the therapeutic window of opportunity. Joint Bone Spine 2022; 90:105491. [PMID: 36410680 DOI: 10.1016/j.jbspin.2022.105491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/21/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022]
Abstract
Glucocorticoids have been available since the early 1950s and have since become an integral part of the management of rheumatoid arthritis (RA). Due to their rapid effect, glucocorticoids have an appealing profile for treating flares or as "bridging" agents in early RA. The efficacy of glucocorticoids to treat RA has been well established, both to control disease activity and to delay the progression of joint damage. However, despite their benefits, glucocorticoids have equally well-known adverse effects. It is generally accepted that long-term use of glucocorticoids, particularly at higher doses, is not advisable, and recent guidelines for the management of RA therefore either recommend against the use of glucocorticoids or suggest using them only as bridging therapy. Perceptions on the harmful effects of glucocorticoids remain, although mainly based on observational studies. Prolonged glucocorticoid therapy at low doses is still highly prevalent in clinical practice, but recent data suggest a rather favourable risk-benefit balance for this strategy, even in senior patients. Balancing the benefits and risks of treating RA with glucocorticoids thus remains a somewhat controversial topic. This narrative review outlines the historical and current position of glucocorticoids in the management of RA, while summarising recent evidence on their beneficial and detrimental effects. Furthermore, practical strategies for the current use and tapering of glucocorticoids in RA are formulated.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium.
| | - Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Rene Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
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12
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Verstappen M, van der Helm-van Mil AHM. Sustained DMARD-free remission in rheumatoid arthritis - about concepts and moving towards practice. Joint Bone Spine 2022; 89:105418. [PMID: 35636705 PMCID: PMC7615888 DOI: 10.1016/j.jbspin.2022.105418] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
Abstract
Sustained DMARD-free remission (SDFR) is the best possible outcome in RA. It is characterized by sustained absence of clinical arthritis, which is accompanied by resolution of symptoms and restoration of normal physical functioning. Therefore it's the best proxy for cure in RA. The mechanisms underlying SDFR-development are yet unidentified. Hypothetically, there are two possible scenarios. The first hypothesis is based on the concept of regaining immune-tolerance, which implies that RA-patients are similar at diagnosis and that disease-processes during the disease-course shift into a favorable direction, resulting in regaining a state in which arthritis is persistently absent. This could imply that SDFR is theoretically achievable for all RA-patients. The alternative hypothesis is that RA-patients who achieve SDFR are intrinsically different from those who cannot. This would imply that DMARD-cessation could be restricted to a subgroup of RA-patients. Since the 1990s, DMARD-discontinuation and SDFR have been increasingly studied as long-term-outcome in RA. In this review, we describe hitherto results of clinical, genetic, serological, histological and imaging studies and looked for arguments for the first or second hypothesis in both auto-antibody-positive and auto-antibody-negative RA. In auto-antibody-negative RA, SDFR is presumably restricted to a subgroup of patients with high serological-markers of inflammation at diagnosis and a rapid and sustained decrease in inflammation after treatment-start. Identifying these RA-patients could be helpful in realizing personalized-medicine. In auto-antibody-positive RA, only few patients achieve SDFR and no definite conclusions can be drawn, but data could suggest that SDFR-patients might be a subgroup with relatively low inflammation from disease-presentation onwards.
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Affiliation(s)
- Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands; Department of Rheumatology, Erasmus Medical Centre, Rotterdam, The Netherlands
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13
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Wang X, Tang Z, Huang T, Hu H, Zhao Y, Liu Y. Withdrawal of MTX in rheumatoid arthritis patients on bDMARD/tsDMARD plus methotrexate at target: a systematic review and meta-analysis. Rheumatology (Oxford) 2022; 62:1410-1416. [PMID: 36125185 DOI: 10.1093/rheumatology/keac515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/05/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To evaluate the effect of methotrexate (MTX) withdrawal on disease activity and remission rate in patients at target after treatment with bDMARDs/tsDMARDs plus MTX. METHODS We searched the PubMed, EMBASE, and CENTRAL databases for all RCTs on MTX withdrawal in patients with rheumatoid arthritis at target after combination therapy from inception to 2022-3-7 in order to extract data, including the change from withdrawal in DAS28 at the end point; proportion of low disease activity (LDA) assessed by DAS28, SDAI or CDAI; proportion of remission assessed by DAS28, SDAI, CDAI or ACR/EULAR Boolean remission. The Cochrane Q test and I2 test were used to assess heterogeneity, and random-effects models were used for data synthesis. This study is registered with PROSPERO (CRD42022303891). RESULTS Six articles were included for qualitative and quantitative analysis, all of which were noninferior RCTs involving 1430 patients (734 in the withdrawal group and 696 in the continuation group). Compared with continuing combination therapy, tapering off or discontinuing MTX increased DAS28 by 0.20 (95% CI 0.09-0.32, I2 = 0%) and decreased the percentage of patients with LDA assessed by DAS28 to < 3.2 (RR 0.88 [0.80, 0.97] I2 = 0%). However, MTX withdrawal did not decrease remission rates assessed by DAS28, SDAI, CDAI or ACR/EULAR Boolean remission (RR 0.90 [0.81, 1.01], 0.93 [0.77, 1.11], 0.90 [0.74, 1.11], 0.95 [0.70, 1.29], respectively). CONCLUSION Withdrawing MTX slightly increases the RA disease activity in patients treated at target with bDMARDs/tsDMARDs plus MTX and has limited effects for patients with deep remission.
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Affiliation(s)
- Xiangpeng Wang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Ziyi Tang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Tianwen Huang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Huifang Hu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yaxi Zhao
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
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14
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Wu G, Liu C, Cao B, Cao Z, Zhai H, Liu B, Jin S, Yang X, Lv C, Wang J. Connective tissue growth factor-targeting DNA aptamer suppresses pannus formation as diagnostics and therapeutics for rheumatoid arthritis. Front Immunol 2022; 13:934061. [PMID: 35990694 PMCID: PMC9389230 DOI: 10.3389/fimmu.2022.934061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
Connective tissue growth factor (CTGF) has been recently acknowledged as an ideal biomarker in the early disease course, participating in the pathogenesis of pannus formation in rheumatoid arthritis (RA). However, existing approaches for the detection of or antagonist targeting CTGF are either lacking or unsatisfactory in the diagnosis and treatment of RA. To address this, we synthesized and screened high-affinity single-stranded DNA aptamers targeting CTGF through a protein-based SELEX procedure. The structurally optimized variant AptW2-1-39-PEG was characterized thoroughly for its high-affinity (KD 7.86 nM), sensitivity (minimum protein binding concentration, 2 ng), specificity (negative binding to other biomarkers of RA), and stability (viability-maintaining duration in human serum, 48 h) properties using various biochemical and biophysical assays. Importantly, we showed the antiproliferative and antiangiogenic activities of the aptamers obtained using functional experiments and further verified the therapeutic effect of the aptamers on joint injury and inflammatory response in collagen-induced arthritis (CIA) mice, thus advancing this study into actual therapeutic application. Furthermore, we revealed that the binding within AptW2-1-39-PEG/CTGF was mediated by the thrombospondin 1 (TSP1) domain of CTGF using robust bioinformatics tools together with immunofluorescence. In conclusion, our results revealed a novel aptamer that holds promise as an additive or alternative approach for CTGF-targeting diagnostics and therapeutics for RA.
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Affiliation(s)
- Gan Wu
- Department of Anesthesia and Critical Care, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Biochemistry, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Can Liu
- Department of Biochemistry, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Ben Cao
- Department of Biochemistry, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Zelin Cao
- Department of Biochemistry, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Haige Zhai
- Department of Biochemistry, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Bin Liu
- Department of Biochemistry, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Shengwei Jin
- Department of Anesthesia and Critical Care, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinyu Yang
- Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, China
- *Correspondence: Jianguang Wang, ; Chen Lv, ; Xinyu Yang,
| | - Chen Lv
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Jianguang Wang, ; Chen Lv, ; Xinyu Yang,
| | - Jianguang Wang
- Department of Anesthesia and Critical Care, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Biochemistry, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
- *Correspondence: Jianguang Wang, ; Chen Lv, ; Xinyu Yang,
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15
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Duong SQ, Crowson CS, Athreya A, Atkinson EJ, Davis JM, Warrington KJ, Matteson EL, Weinshilboum R, Wang L, Myasoedova E. Clinical predictors of response to methotrexate in patients with rheumatoid arthritis: a machine learning approach using clinical trial data. Arthritis Res Ther 2022; 24:162. [PMID: 35778714 PMCID: PMC9248180 DOI: 10.1186/s13075-022-02851-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methotrexate is the preferred initial disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA). However, clinically useful tools for individualized prediction of response to methotrexate treatment in patients with RA are lacking. We aimed to identify clinical predictors of response to methotrexate in patients with rheumatoid arthritis (RA) using machine learning methods. METHODS Randomized clinical trials (RCT) of patients with RA who were DMARD-naïve and randomized to placebo plus methotrexate were identified and accessed through the Clinical Study Data Request Consortium and Vivli Center for Global Clinical Research Data. Studies with available Disease Activity Score with 28-joint count and erythrocyte sedimentation rate (DAS28-ESR) at baseline and 12 and 24 weeks were included. Latent class modeling of methotrexate response was performed. The least absolute shrinkage and selection operator (LASSO) and random forests methods were used to identify predictors of response. RESULTS A total of 775 patients from 4 RCTs were included (mean age 50 years, 80% female). Two distinct classes of patients were identified based on DAS28-ESR change over 24 weeks: "good responders" and "poor responders." Baseline DAS28-ESR, anti-citrullinated protein antibody (ACPA), and Health Assessment Questionnaire (HAQ) score were the top predictors of good response using LASSO (area under the curve [AUC] 0.79) and random forests (AUC 0.68) in the external validation set. DAS28-ESR ≤ 7.4, ACPA positive, and HAQ ≤ 2 provided the highest likelihood of response. Among patients with 12-week DAS28-ESR > 3.2, ≥ 1 point improvement in DAS28-ESR baseline-to-12-week was predictive of achieving DAS28-ESR ≤ 3.2 at 24 weeks. CONCLUSIONS We have developed and externally validated a prediction model for response to methotrexate within 24 weeks in DMARD-naïve patients with RA, providing variably weighted clinical features and defined cutoffs for clinical decision-making.
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Affiliation(s)
- Stephanie Q Duong
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Cynthia S Crowson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.,Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arjun Athreya
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | | | - John M Davis
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Richard Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Elena Myasoedova
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA. .,Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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16
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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: 0] [Impact Index Per Article: 0] [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.
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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
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17
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Pazmino S, Westhovens R, Doumen M, Bertrand D, Verschueren P. Undifferentiated arthritis, not just another early manifestation of rheumatoid arthritis. Rheumatology (Oxford) 2022; 61:3101-3103. [PMID: 35262681 DOI: 10.1093/rheumatology/keac127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/26/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Rene Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium.,Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium.,Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium.,Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium
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18
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Westhovens R. CT-P13 SC for the treatment of rheumatoid arthritis. Expert Rev Clin Immunol 2021; 18:5-13. [PMID: 34842032 DOI: 10.1080/1744666x.2022.2012451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Management of Rheumatoid Arthritis (RA) has improved following the implementation of early intensive treat to target recommendations and the availability of different biologicals. Most experience is with TNF blockers, but challenges remain in the efficacy/safety balance, immunogenicity, and long-term drug survival as well as availability and affordability despite the introduction of biosimilars. AREA COVERED We provide an overview of the development of CT-P13 SC based on infliximab biosimilar CT-P13 IV. The one-year pivotal phase I/III trial in RA showed CT-P13 120 mg SC fixed dose to have favorable pharmacokinetics compared to CT-P13 IV classical weight adapted dosing, similar to lower anti-drug antibodies, similar safety and non-inferiority for efficacy at 6 months. EXPERT OPINION CT-P13 SC is an additional option in RA treatment and by extension for other inflammatory diseases as Inflammatory Bowel Disease. This new way of administration has the potential to improve long-term drug survival of infliximab, improve patient outcomes, and patient comfort.
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Affiliation(s)
- Rene Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration KU Leuven, Rheumatologist UZ, Leuven, Belgium
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19
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Liu F, Li W, Zhu J, Liu F, Fan W, Chen Z. Predictive role of ultrasound remission for progressive ultrasonography-detected structural damage in patients with rheumatoid arthritis. J Investig Med 2021; 70:391-395. [PMID: 34518320 DOI: 10.1136/jim-2021-001885] [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: 07/27/2021] [Indexed: 11/03/2022]
Abstract
Regarding the persistence of subclinical synovitis, the concept of ultrasound remission has been proposed in addition to clinical remission. However, there have been no studies that explored the different time points of ultrasound remission to predict non-progressive structural damage. Given this, the aim of our study is to explore whether early ultrasound remission in patients with rheumatoid arthritis (RA) has predictive value for non-progressive structural damage in the subsequent 12 months. Sixty-one patients with RA were prospectively studied. Synovial hypertrophy, power Doppler (PD) signal, and bone erosions of bilateral wrists, metacarpophalangeal joints I-V, and proximal interphalangeal joints II-III were assessed by ultrasonography at baseline and at 3, 6, and 12 months. Ultrasound remission was defined as no PD signal. Clinical remission was defined as Disease Activity Score in 28 Joints <2.6. Ultrasonography-detected joint damage progression was defined as increase in bone erosion score of ≥1 in the subsequent 12 months. Baseline ultrasonographic factors were not significantly correlated with progressive ultrasonography-detected joint damage in patients with RA at 12 months (all p>0.05). Ultrasound remission at 3 and 6 months was significantly correlated with non-progressive ultrasonography-detected structural damage at 12 months (p=0.006 and p=0.004), with relatively low sensitivity and high specificity. Clinical remission at 3 months was significantly correlated with non-progression of ultrasonography-detected structural damage at 12 months (p=0.029), with relatively low sensitivity and moderate specificity. Ultrasound remission at 3 and 6 months has high specificity in predicting non-progressive structural damage in patients with RA at 12 months; however, the sensitivity is limited.
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Affiliation(s)
- Feifei Liu
- Department of Ultrasound, Peking University People's Hospital, Beijing, China
| | - Wenxue Li
- Department of Ultrasound, Peking University People's Hospital, Beijing, China
| | - Jiaan Zhu
- Department of Ultrasound, Peking University People's Hospital, Beijing, China
| | - Fang Liu
- Department of Ultrasound, Peking University People's Hospital, Beijing, China
| | - Wenting Fan
- Department of Ultrasound, Peking University People's Hospital, Beijing, China
| | - Zheng Chen
- Department of Ultrasound, Peking University People's Hospital, Beijing, China
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20
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Maassen JM, van Ouwerkerk L, Allaart CF. Tapering of disease-modifying antirheumatic drugs: an overview for daily practice. THE LANCET. RHEUMATOLOGY 2021; 3:e659-e670. [PMID: 38287612 DOI: 10.1016/s2665-9913(21)00224-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/25/2021] [Accepted: 07/08/2021] [Indexed: 01/31/2024]
Abstract
In this Review, we discuss the possibility of drug tapering in patients with rheumatoid arthritis in remission or low disease activity, for glucocorticoids and disease-modifying antirheumatic drugs. We review international guidelines and recommendations, as well as remaining uncertainties, and provide an overview of the current literature. Three strategies of tapering are discussed: (1) tapering by discontinuation of one of the drugs in combination therapy regimens, (2) tapering by reducing the dose of one of the drugs in combination therapy regimens, and (3) tapering by dose reduction of monotherapy with disease-modifying antirheumatic drugs. We discuss the outcomes and robustness of evidence of trials and observational cohorts, and we give a trajectory for further research and drug tapering in daily practice.
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Affiliation(s)
| | - Lotte van Ouwerkerk
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
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21
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Luurssen-Masurel N, van Mulligen E, Weel-Koenders AEAM, Hazes JMW, de Jong PHP. The susceptibility of attaining and maintaining DMARD-free remission in different (rheumatoid) arthritis phenotypes. Rheumatology (Oxford) 2021; 61:keab631. [PMID: 34352094 DOI: 10.1093/rheumatology/keab631] [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: 04/01/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To compare (sustained) DMARD-free remission rates((S)DFR), defined as respectively ≥6 months and >1 year, after 2 and 5 years between three clinical arthritis phenotypes; undifferentiated arthritis(UA), autoantibody-negative(RA-) and positive rheumatoid arthritis(RA+). METHODS All UA(n = 130), RA-(n = 176) and RA + (n = 331) patients from the tREACH trial, a stratified single-blinded trial with a treat-to-target approach, were used. (S)DFR comparisons between phenotypes after 2 and 5 years were performed with Logistic regression. Medication use and early and late flares(DAS ≥ 2.4), respectively defined as < 12 and >12 months after reaching DFR, were also compared. Cox proportional hazard models were used to evaluate potential predictors for (S)DFR. RESULTS Within 2 and 5 years less DFR was seen in RA + (17.2-25.7%), followed by RA-(28.4-42.1%) and UA patients(43.1-58.5%). This also applied for SDFR within 2 and 5 years (respectively 7.6% and 21.4%; 20.5% and 38.1%; and 35.4% and 55.4%). A flare during tapering was seen in 22.7% of patients. Of the patients in DFR 7.5% had an early flare and 3.4% a late flare. Also more treatment intensifications occurred in RA+ compared with RA- and UA. We found that higher baseline DAS, ACPA positivity, BMI and smoking were negatively associated with (S)DFR, while clinical phenotype(reference RA+), short symptom duration(<6 months) and remission within 6 months were positively associated. CONCLUSIONS (Long-term) clinical outcomes differ between undifferentiated arthritis, autoantibody-negative and positive rheumatoid arthritis(RA). These data reconfirm that RA can be subdivided into aforementioned clinical phenotypes and that treatment might be stratified upon these phenotypes, although validation is needed. TRIAL REGISTRATION ISRCTN, https://www.isrctn.com/, ISRCTN26791028.
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22
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Luurssen-Masurel N, Weel AEAM, Koc GH, Hazes JMW, de Jong PHP. The number of risk factors for persistent disease determines the clinical course of early arthritis. Rheumatology (Oxford) 2021; 60:3617-3627. [PMID: 33484138 PMCID: PMC8328505 DOI: 10.1093/rheumatology/keaa820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/17/2020] [Indexed: 11/22/2022] Open
Abstract
Objectives Management of early arthritis is based upon early recognition of individuals at high risk of developing persistent arthritis. Therefore, this study investigates whether the number of risk factors for persistent disease or treatment determines the clinical course of early arthritis by comparing the chance at (sustained) DMARD-free remission ((S)DFR) after 2 years follow-up. Methods Data from the tREACH trial, a stratified single-blinded multicentre strategy trial with a treat-to-target approach were used. We selected all patients with ≥1 swollen joint who did not fulfil 1987 and/or 2010 criteria for RA. The number of risk factors present; autoantibody-positivity, polyarthritis (>4), erosive disease and elevated acute phase reactants, determined risk group stratification. Multivariate logistic regression analyses were performed with (S)DFR as dependent variables and baseline disease activity score (DAS), treatment, symptom duration and number of risk factors present as independent variables. Results In total, 130 early arthritis patients were included and respectively 31, 66 and 33 had 0, 1 and ≥2 risk factors present. DFR rates were respectively 74%, 48% and 45% for early arthritis patients with 0, 1 and ≥2 risk factors present. In accordance SDFR rates were 61%, 32% and 30%. In our logistic model (S)DFR was not influenced by the initial treatment strategies when stratified for risk groups. Conclusion The chance at (S)DFR in early arthritis diminishes when more risk factors are present, which is irrespective of the given initial treatment. Our data point out to a stratified management approach in early arthritis based on their risk profile, but validation is needed. Trial registration ISRCTN registry: ISRCTN26791028 (http://www.isrctn.com/ISRCTN26791028).
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Affiliation(s)
| | - A E A M Weel
- Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands.,Erasmus School of Health Policy & Management, Rotterdam, The Netherlands
| | - G H Koc
- Department of Internal Medicine, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - J M W Hazes
- Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands
| | - P H P de Jong
- Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands
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23
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Ocon AJ, Reed G, Pappas DA, Curtis JR, Kremer JM. Short-term dose and duration-dependent glucocorticoid risk for cardiovascular events in glucocorticoid-naive patients with rheumatoid arthritis. Ann Rheum Dis 2021; 80:1522-1529. [PMID: 34215644 DOI: 10.1136/annrheumdis-2021-220577] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/22/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Rheumatoid arthritis (RA), along with glucocorticoid use, is associated with cardiovascular disease. Cardiovascular safety of glucocorticoids in RA is controversial and may be related to dose and duration of use. We determined if initiating glucocorticoids in steroid-naive RA patients would increase cardiovascular event (CVE) risk in a dose and duration-dependent manner over short-term intervals. METHODS Patients enrolled in CorEvitas (formerly Corrona) RA registry. Cox proportional-hazards models estimated adjusted HRs (aHR) for incident CVE in patients who initiated glucocorticoid treatment, adjusting for RA duration, traditional cardiovascular risk factors and time-varying covariates: Clinical Disease activity Index, disease-modifying antirheumatic drugs use and prednisone-equivalent use. Glucocorticoid use assessed current daily dose, cumulative dose and duration of use over rolling intervals of preceding 6 months and 1 year. RESULTS 19 902 patients met criteria. 1106 CVE occurred (1.66/100 person-years). Increased aHR occurred at current doses of ≥5-9 mg 1.56 (1.18-2.06) and ≥10 mg 1.91 (1.31-2.79), without increased risk at 0-4 mg 1.04 (0.55-1.59). Cumulative dose over preceding 6 months showed increased aHR at 751-1100 mg 1.43 (1.04-1.98) and >1100 mg 2.05 (1.42-2.94), without increased risk at lower doses; duration of use over preceding 6 months exhibited increased aHR for >81 days of use 1.54 (1.08-2.32), without increased risk at shorter durations. One-year analyses were consistent. CONCLUSIONS Over preceding 6-month and 1-year intervals, initiating glucocorticoids in steroid-naïve RA patients is associated with increased risk of CVE at daily doses ≥5 mg and increased cumulative dose and duration of use. No association with risk for CVE was found with daily prednisone of ≤4 mg or shorter cumulative doses and durations.
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Affiliation(s)
- Anthony James Ocon
- Medicine and Allergy, Immunology, Rheumatology, University of Rochester Medical Center, Rochester, New York, USA
| | - George Reed
- Medicine, Preventative and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Corrona Research Foundation, LLC, Waltham, MA, USA
| | - Dimitrios A Pappas
- Corrona Research Foundation, LLC, Waltham, MA, USA.,Medicine and Rheumatology, Columbia University, New York, New York, USA.,CorEvitas (formerly CORRONA), LCC, Waltham, Massachusetts, USA
| | - Jeffrey R Curtis
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joel M Kremer
- Corrona Research Foundation, LLC, Waltham, MA, USA.,CorEvitas (formerly CORRONA), LCC, Waltham, Massachusetts, USA.,Medicine and Rheumatology, Albany Medical College, The Center for Rheumatology, LLC, Albany, New York, USA
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24
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Bugatti S, De Stefano L, Manzo A, Sakellariou G, Xoxi B, Montecucco C. Limiting factors to Boolean remission differ between autoantibody-positive and -negative patients in early rheumatoid arthritis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211011826. [PMID: 34093745 PMCID: PMC8141996 DOI: 10.1177/1759720x211011826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/31/2021] [Indexed: 12/14/2022] Open
Abstract
Background: The patient global assessment of disease activity (PGA) is the major limiting factor to Boolean remission in patients with established rheumatoid arthritis (RA). Here, we investigated the limiting variables to disease remission in patients with early RA treated with conventional synthetic disease modifying anti-rheumatic drugs, also in relation to autoantibody status. Methods: Data were retrieved from 535 early RA patients (<12 months of symptoms) with an observation period of 6–12 months upon initiation of therapy with methotrexate aimed at the achievement of low disease activity based on the 28-joints disease activity score. Near-remission was defined as any of the four core items of Boolean remission >1 with the remaining three all ⩽1. Reasons for missing Boolean remission and predictors of near-remission subcategories were analyzed in relation to baseline disease variables. Results: After 6 and 12 months, near-remission was two-times more frequent than Boolean remission (25.6% and 26.9% at the two time-points). A 28-swollen joint count (SJC28) >1 was responsible for the majority of near-remission (56.2% and 57.6% at 6 and 12 months, respectively), and PGA > 1 accounted for approximatively 35% of the cases. Autoantibody-positivity independently predicted the risk of missing remission because of SJC28 > 1 [adjusted odds ratio (OR) 95% confidence interval (CI) 2.81 (1.59–4.9) at 6 months and 1.73 (1.01–3.01) at 12 months], whilst autoantibody-negativity was an independent predictor of PGA near-remission [adjusted OR (95% CI) 2.45 (1.25–4.80) at 6 months and 5.71 (2.47–13.2) at 12 months]. Conclusion: In early RA, Boolean remission is more frequently missed because of persistent swollen joints. However, barriers to full-remission vary in relation to the autoantibody status. Autoantibody-positive patients more commonly experience residual swollen joints, whilst PGA more frequently impairs remission in autoantibody-negative patients. Efforts to target full-remission in early RA may thus require different strategies according to autoantibody profile.
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Affiliation(s)
- Serena Bugatti
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation University Hospital, Viale Golgi 19, Pavia, 27100, Italy
| | - Ludovico De Stefano
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Antonio Manzo
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Blerina Xoxi
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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25
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Källmark H, Einarsson JT, Nilsson J, Olofsson T, Saxne T, Geborek P, C. Kapetanovic M. Sustained Remission in Patients With Rheumatoid Arthritis Receiving Triple Therapy Compared to Biologic Therapy: A Swedish Nationwide Register Study. Arthritis Rheumatol 2021; 73:1135-1144. [DOI: 10.1002/art.41720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 03/02/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Hanna Källmark
- Lund University and Skåne University Hospital Lund Sweden
| | | | | | - Tor Olofsson
- Lund University and Skåne University Hospital Lund Sweden
| | - Tore Saxne
- Lund University and Skåne University Hospital Lund Sweden
| | - Pierre Geborek
- Lund University and Skåne University Hospital Lund Sweden
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26
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Bergstra SA, Van Der Pol JA, Riyazi N, Goekoop-Ruiterman YPM, Kerstens PJSM, Lems W, Huizinga TWJ, Allaart CF. Earlier is better when treating rheumatoid arthritis: but can we detect a window of opportunity? RMD Open 2021; 6:rmdopen-2020-001242. [PMID: 32471854 PMCID: PMC7299505 DOI: 10.1136/rmdopen-2020-001242] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives The window of opportunity (WOO) hypothesis suggests a limited time frame to stop rheumatoid arthritis (RA). We hypothesised that a WOO could either be represented by a hyperbolic (‘curved’) decline in the chance to achieve the outcome sustained drug-free remission (sDFR) over time, after which achieving sDFR is not possible anymore, or by a more gradual linear decline approaching zero chance to achieve sDFR. Methods Patients with RA (symptom duration <2 years) were included from two randomised trials: BehandelStrategieën (BeSt), n=508 and Induction therapy with Methotrexate and Prednisone in Rheumatoid Or Very Early arthritic Disease (IMPROVED), n=479. Cox-regression was performed to assess the shape of the association between symptom duration and sDFR (Disease Activity Score<1.6, no disease-modifying anti-rheumatic drugs for ≥1 year) for patients starting slow-acting monotherapy (IMPROVED, BeSt) or fast-acting combination therapy (BeSt). Likelihood ratio tests were used to compare the fit of linear and non-linear models in both databases separately. Predictions from the best fitting models were used to assess whether the absolute risk to achieve sDFR approaches zero with increasing symptom duration. Results In BeSt and IMPROVED, 54/226 and 110/421 patients achieved sDFR with fast-acting treatment, and 53/243 (BeSt) with slow-acting treatment. Non-linear models did not fit better than linear models (fast-acting treatment BeSt p=0.743, IMPROVED p=0.337; slow-acting treatment BeSt p=0.609). After slow-acting monotherapy, linear models declined steeper. None of the models approached zero chance to achieve sDFR over time. Conclusions The chance to achieve sDFR decreased gradually over time, and decreased fastest in patients starting slow-acting monotherapy. In both treatment groups, we found no evidence for a WOO within 2 years symptom duration.
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Affiliation(s)
- Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Joy A Van Der Pol
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Naghmeh Riyazi
- Department of Rheumatology, HAGA Hospital, The Hague, Netherlands
| | | | - Pit J S M Kerstens
- Rheumatology, Amsterdam Rheumatology & Immunology Center
- Reade, Amsterdam, Netherlands
| | - Willem Lems
- Department of Rheumatology, VU Medical Center, Amsterdam, Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
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27
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Verstappen M, van Mulligen E, de Jong PHP, van der Helm-Van Mil AHM. DMARD-free remission as novel treatment target in rheumatoid arthritis: A systematic literature review of achievability and sustainability. RMD Open 2021; 6:rmdopen-2020-001220. [PMID: 32393523 PMCID: PMC7299506 DOI: 10.1136/rmdopen-2020-001220] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 01/08/2023] Open
Abstract
Objectives Although current treatment guidelines for rheumatoid arthritis (RA) suggest tapering disease-modifying anti-rheumatic drugs (DMARDs), it is unclear whether DMARD-free remission (DFR) is an achievable and sustainable outcome. Therefore, we systematically reviewed the literature to determine the prevalence and sustainability of DFR and evaluated potential predictors for DFR. Methods A systematic literature search was performed in March 2019 in multiple databases. All clinical trials and observational studies reporting on discontinuation of DMARDs in RA patients in remission were included. Our quality assessment included a general assessment and assessment of the description of DFR. Prevalence of DFR and its sustainability and flares during tapering and after DMARD stop were summarised. Also, potential predictors for achieving DFR were reviewed. Results From 631 articles, 51 were included, comprising 14 clinical trials and 5 observational studies. DFR definition differed, especially for the duration of DMARD-free state. Considering only high- and moderate-quality studies, DFR was achieved in 5.0%–24.3% and sustained DFR (duration>12 months) in 11.6%–19.4% (both relative to the number of patients eligible for tapering). Flares occurred frequently during DMARD tapering (41.8%–75.0%) and in the first year after achieving DFR (10.4%–11.8%), while late flares, >1 year after DMARD-stop, were infrequent (0.3%–3.5%). Many patient characteristics lacked association with DFR. Absence of autoantibodies and shared epitope alleles increased the chance of achieving DFR. Conclusions DFR is achievable in RA and is sustainable in ~10%–20% of patients. DFR can become an important outcome measure for clinical trials and requires consistency in the definition. Considering the high rate of flares in the first year after DMARD stop, a DMARD-free follow-up of >12 months is advisable to evaluate sustainability.
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Affiliation(s)
- M Verstappen
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - E van Mulligen
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - P H P de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - A H M van der Helm-Van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
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28
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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.
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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
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29
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Xie W, Huang H, Li G, Hao Y, Gui Y, Wang Y, Deng X, Zhao J, Geng Y, Ji L, Zhang X, Song Z, Zhang Z. Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020. Ann Rheum Dis 2021; 80:997-1003. [PMID: 33811037 DOI: 10.1136/annrheumdis-2021-220112] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To unravel the dynamical trajectory and features of glucocorticoids (GC) tapering and discontinuation in patients with rheumatoid arthritis (RA) commencing GC with concomitant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). METHODS We used data from longitudinal real-world Treat-to-TARget in RA cohort. Patients with RA who started GC and contaminant csDMARDs therapy were included. The changes in GC dose and disease activity were evaluated. GC discontinuation rate was analysed using Kaplan-Meier analysis. The relapse profile within 6 months after GC discontinuation was also analysed. RESULTS A total of 207 patients with RA were included. During a median follow-up of 38.6 months, 124 patients discontinued GC. The median prednisolone dose of 10 (5-10) mg/day at initiation was reduced by 50% in the first 6 months and then more slowly, to zero by 48 months eventually. The cumulative probabilities of GC discontinuation were 9.7%, 26.6%, 48.0% and 58.6% at month 6, years 1, 2 and 3, with calculated median time to GC cessation of 27 months. In 110 DMARD-naïve patients, the corresponding cumulative probabilities of GC discontinuation were, respectively, 12.7%, 30.0%, 50.9% and 60.6%, with calculated median time to GC cessation of 24 months. Of the 124 patients who discontinued GC, adding other csDMARDs or concomitant csDMARDs increment was documented in 28.2% of them. Approximately half of 124 patients were in clinical remission at GC discontinuation. Within 6 months after GC withdrawal, 79.1% (91/115) of patients maintained relapse free. CONCLUSIONS In patients with RA commencing GC besides csDMARDs, GC is feasibly discontinued with favourable control of disease activity in real-life setting, mostly without short-term flare. But the withdrawal time is far from reaching the recommended time frame, indicating the gap between real-world practice and current guidelines.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanni Gui
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Xuerong Deng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Juan Zhao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yan Geng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - LanLan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Xiaohui Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhibo Song
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
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30
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Shifa I, Hazlewood GS, Durand C, Barr SG, Mydlarski PR, Beck PL, Burton JM, Khan FM, Jamani K, Osman M, Storek J. Efficacy of Allogeneic Hematopoietic Cell Transplantation for Autoimmune Diseases. Transplant Cell Ther 2021; 27:489.e1-489.e9. [PMID: 33775907 DOI: 10.1016/j.jtct.2021.03.023] [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: 02/04/2021] [Revised: 03/06/2021] [Accepted: 03/21/2021] [Indexed: 12/29/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) may be efficacious for autoimmune diseases (AIDs), but its efficacy for individual AIDs is unknown. Factors influencing the likelihood of relapse for each AID are also unknown. This study aimed to determine the likelihood of relapse for each common AID and to generate hypotheses about factors influencing the likelihood of relapse. We reviewed charts of adult patients with nonhematologic AIDs who had undergone HCT in Alberta (n = 21) and patients described in the literature (n = 67). We used stringent inclusion criteria to minimize the inclusion of patients whose AID may have been cured before transplantation. We also used stringent definitions of AID relapse and remission. AID relapsed in 2 of 9 patients (22%) with lupus, in 4 of 12 (33%) with rheumatoid arthritis (RA), in 0 of 4 (0%) with systemic sclerosis (SSc), in 3 of 16 (19%) with psoriasis, in 1 of 12 (8%) with Behçet's disease (BD), in 1 of 15 (7%) with Crohn's disease (CD), in 0 of 5 (0%) with ulcerative colitis (UC), in 4 of 8 (50%) with multiple sclerosis (MS), and in 3 of 3 (100%) with type 1 diabetes mellitus (T1DM). Among highly informative patients (followed for >1 year after discontinuation of immunosuppressive therapy if no relapse, or donor AID status known if relapse), relapse occurred in 0 of 3 patients with lupus, in 2 of 7 with RA, in 0 of 2 with SSc, in 3 of 6 with psoriasis, in 0 of 3 with BD, in 0 of 10 with CD, in 0 of 3 with UC, in 2 of 3 with MS, and in 2 of 2 with T1DM. There appeared to be no associations between AID relapse and low intensity of pretransplantation chemoradiotherapy, multiple lines of AID therapy (surrogate for AID refractoriness) except perhaps for lupus, absence of serotherapy for graft-versus-host disease (GVHD) prophylaxis, lack of GVHD except perhaps for lupus, or incomplete donor chimerism. Even though remission commonly occurs after HCT in lupus, RA, SSc, psoriasis, BD, CD, and UC, HCT is efficacious for only a subset of patients. The efficacy appears to be unrelated to pretransplantation therapy, GVHD, or chimerism. Large studies are needed to determine the characteristics of patients likely to benefit from HCT for each AID.
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Affiliation(s)
- Iman Shifa
- Division of Hematology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Glen S Hazlewood
- Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Caylib Durand
- Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan G Barr
- Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P Régine Mydlarski
- Division of Dermatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul L Beck
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jodie M Burton
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Faisal M Khan
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Division of Hematology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Osman
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jan Storek
- Division of Hematology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Schett G, Tanaka Y, Isaacs JD. Why remission is not enough: underlying disease mechanisms in RA that prevent cure. Nat Rev Rheumatol 2021; 17:135-144. [PMID: 33303993 DOI: 10.1038/s41584-020-00543-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 01/04/2023]
Abstract
Cure is the aspirational aim for the treatment of all diseases, including chronic inflammatory conditions such as rheumatoid arthritis (RA); however, it has only been during the twenty-first century that remission, let alone cure, has been a regularly achievable target in RA. Little research has been carried out on how to cure RA, and the term 'cure' still requires definition for this disease. Even now, achieving a cure seems to be a rare occurrence among individuals with RA. Therefore, this Review is aimed at addressing the obstacles to the achievement of cure in RA. The differences between remission and cure in RA are first defined, followed by a discussion of the underlying factors (referred to as drivers) that prevent the achievement of cure in RA by triggering sustained immune activation and effector cytokine production. Such drivers include adaptive immune system activation, mesenchymal tissue priming and so-called 'remote' (non-immune and non-articular) factors. Strategies to target these drivers are also presented, with an emphasis on the development of strategies that could complement currently used cytokine inhibition and thereby improve the likelihood of curing RA.
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Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany.
- Deutsches Zentrum fur Immuntherapie, FAU Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany.
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Verstappen M, Niemantsverdriet E, Matthijssen XME, le Cessie S, van der Helm-van Mil AHM. Early DAS response after DMARD-start increases probability of achieving sustained DMARD-free remission in rheumatoid arthritis. Arthritis Res Ther 2020; 22:276. [PMID: 33228814 PMCID: PMC7684730 DOI: 10.1186/s13075-020-02368-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background Sustained DMARD-free remission (SDFR) is increasingly achievable. The pathogenesis underlying SDFR development is unknown and patient characteristics at diagnosis poorly explain whether SDFR will be achieved. To increase the understanding, we studied the course of disease activity scores (DAS) over time in relation to SDFR development. Subsequently, we explored whether DAS course could be helpful identifying RA patients likely to achieve SDFR. Methods 772 consecutive RA patients, promptly treated with csDMARDs (mostly methotrexate and treat-to-target treatment adjustments), were studied for SDFR development (absence of synovitis, persisting minimally 12 months after DMARD stop). The course of disease activity scores (DAS) was compared between RA patients with and without SDFR development within 7 years, using linear mixed models, stratified for ACPA. The relation between 4-month DAS and the probability of SDFR development was studied with logistic regression. Cumulative incidence of SDFR within DAS categories (< 1.6, 1.6–2.4, 2.4–3.6, ≥ 3.6) at 4 months was visualized using Kaplan-Meier curves. Results In ACPA-negative RA patients, those achieving SDFR showed a remarkably stronger DAS decline within the first 4 months, compared to RA patients without SDFR; − 1.73 units (95%CI, 1.28–2.18) versus − 1.07 units (95%CI, 0.90–1.23) (p < 0.001). In APCA-positive RA patients, such an effect was not observed, yet SDFR prevalence in this group was low. In ACPA-negative RA, DAS decline in the first 4 months and absolute DAS levels at 4 months (DAS4 months) were equally predictive for SDFR development. Incidence of SDFR in ACPA-negative RA patients was high (70.2%) when DAS4 months was < 1.6, whilst SDFR was rare (7.1%) when DAS4 months was ≥ 3.6. Conclusions In ACPA-negative RA, an early response to treatment, i.e., a strong DAS decline within the first 4 months, is associated with a higher probability of SDFR development. DAS values at 4 months could be useful for later decisions to stop DMARDs.
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Affiliation(s)
- M Verstappen
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - E Niemantsverdriet
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - X M E Matthijssen
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - A H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
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Wang D, Cui Y, Lei H, Cao D, Tang G, Huang H, Yuan T, Rao L, Mo B. Diagnostic accuracy of 14-3-3 η protein in rheumatoid arthritis: A meta-analysis. Int J Rheum Dis 2020; 23:1443-1451. [PMID: 32909672 PMCID: PMC7756802 DOI: 10.1111/1756-185x.13921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/18/2020] [Accepted: 07/05/2020] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the overall diagnostic performance of 14-3-3 η protein in patients with rheumatoid arthritis (RA). METHODS PubMed, EMBASE, and Web of Science were searched to acquire eligible studies. Articles published in English before 20 February 2020 were included. Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate the risk of bias and application concern of the included articles. Pooled analysis of diagnostic indicators of 14-3-3 η protein for RA was conducted by using a random effects model. Subgroup analysis was used to explore the sources of heterogeneity. Deeks' funnel plot asymmetry test was used to evaluate for the presence of publication bias. RESULTS A total of 13 studies (1554 positive and 1934 negative participants) were included. The pooled sensitivity and specificity were 0.73 (95% CI 0.71-0.75) and 0.88 (95% CI 0.87-0.90), respectively. The pooled positive/negative likelihood were 5.98 (95% CI 4.39-8.14) and 0.28 (95% CI 0.21-0.37), respectively. In addition, the pooled diagnostic odds ratio was 23.48 (95% CI 13.76-40.08) and the area under curve was 0.9245. The results of subgroup analysis indicated that ethnicity and control group might be the source of heterogeneity. The results of sensitivity analysis were stable. No significant publication bias was found. CONCLUSIONS The current evidence indicated that 14-3-3 η protein has moderate accuracy for the diagnosis of RA.
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Affiliation(s)
- Decai Wang
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Yalan Cui
- Department of Anatomy, Guilin Medical University, Guilin, China
| | - Huiren Lei
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Ding Cao
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Guoting Tang
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Haiming Huang
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Ting Yuan
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Lizong Rao
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Biwen Mo
- Department of Respiratory and Critical Care Medicine, Guangxi Zhuang Autonomous Region Education Department Key Laboratory of Respiratory Diseases, Affiliated Hospital of Guilin Medical University, Guilin, China
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van Mulligen E, Weel AE, Hazes JM, van der Helm-van Mil A, de Jong PHP. Tapering towards DMARD-free remission in established rheumatoid arthritis: 2-year results of the TARA trial. Ann Rheum Dis 2020; 79:1174-1181. [PMID: 32482645 PMCID: PMC7456559 DOI: 10.1136/annrheumdis-2020-217485] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To evaluate the 2-year clinical effectiveness of two gradual tapering strategies. The first strategy consisted of tapering the conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) first (i.e., methotrexate in ~90%), followed by the tumour necrosis factor inhibitor (TNF-inhibitor), the second strategy consisted of tapering the TNF-inhibitor first, followed by the csDMARD. METHODS This multicentre single-blinded randomised controlled trial included patients with rheumatoid arthritis (RA) with well-controlled disease for ≥3 consecutive months, defined as a Disease Activity Score (DAS) measured in 44 joints ≤2.4 and a swollen joint count ≤1, which was achieved with a csDMARD and a TNF-inhibitor. Eligible patients were randomised into gradual tapering the csDMARD followed by the TNF-inhibitor, or vice versa. The primary outcome was the number of disease flares. Secondary outcomes were DMARD-free remission (DFR), DAS, functional ability (Health Assessment Questionnaire Disability Index (HAQ-DI)) and radiographic progression. RESULTS 189 patients were randomly assigned to tapering their csDMARD (n=94) or TNF-inhibitor (n=95) first. The cumulative flare rate after 24 months was, respectively, 61% (95% CI 50% to 71%) and 62% (95% CI 52% to 72%). The patients who tapered their csDMARD first were more often able to go through the entire tapering protocol and reached DFR more often than the group that tapered the TNF-inhibitor first (32% vs 20% (p=0.12) and 21% vs 10% (p=0.07), respectively). Mean DAS and HAQ-DI over time, and radiographic progression did not differ between groups (p=0.45, p=0.17, p=0.8, respectively). CONCLUSION The order of tapering did not affect flare rates, DAS or HAQ-DI. DFR was achievable in 15% of patients with established RA, slightly more frequent in patients that first tapered csDMARDs. Because of similar effects from a clinical viewpoint, financial arguments may influence the decision to taper TNF-inhibitors first.
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Affiliation(s)
| | - Angelique E Weel
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Rheumatology, Maasstad Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus Universiteit Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - J M Hazes
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Annette van der Helm-van Mil
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
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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: 147] [Impact Index Per Article: 36.8] [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.
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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
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Clinical characteristics associated with drug-free sustained remission in patients with rheumatoid arthritis: Data from Korean Intensive Management of Early Rheumatoid Arthritis (KIMERA). Semin Arthritis Rheum 2020; 50:1414-1420. [PMID: 32241617 DOI: 10.1016/j.semarthrit.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There is limited information on treatment withdrawal in patients with rheumatoid arthritis (RA). This study investigated the clinical course after stopping disease-modifying anti-rheumatic drugs (DMARDs) in patients with well-controlled RA and the clinical features associated with disease flare. METHODS Among patients in the Korean Intensive Management of Early Rheumatoid Arthritis (KIMERA) cohort, discontinuation of DMARDs was determined by a shared decision between patient and rheumatologist. Drug-free remission was defined as (1) non-use of DMARDs and corticosteroids, (2) Disease Activity Score in 28 joints (DAS28) <2.6, and (3) no evidence of synovitis. The maintenance rate of drug-free remission and the predictors for flare were evaluated using Cox proportional hazard models. RESULTS Of 234 patients, 50 patients discontinued DMARDs. All but one using etanercept were treated with conventional synthetic DMARDs. The median follow-up duration was 30 months, and 31 patients (62%) experienced disease flare after stopping DMARDs. The maintenance rate of drug-free remission was 94.0%, 86.7%, and 46.1% at 12, 24, and 48 months, respectively. Disease flare was correlated with longer time to remission, failure of initial DMARDs, and longer duration of disease and higher disease activity at DMARD withdrawal (P = 0.001, 0.022, 0.010 and 0.037, respectively). In multivariate analyses, longer duration of disease (>24 months) and higher disease activity (DAS28 >2.26) at DMARD withdrawal was independently associated with disease flare. CONCLUSION Drug-free remission was feasible in selected patients with well-controlled RA. Patients with early RA and lower disease activity at DMARD withdrawal are more likely to maintain the drug-free remission.
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Bortezomib Treatment Modulates Autophagy in Multiple Myeloma. J Clin Med 2020; 9:jcm9020552. [PMID: 32085480 PMCID: PMC7073518 DOI: 10.3390/jcm9020552] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 12/11/2022] Open
Abstract
Although the introduction of bortezomib as a therapeutic strategy has improved the overall survival of multiple myeloma (MM) patients, 15–20% of high-risk patients do not respond to bortezomib over time or become resistant to treatment. Therefore, the development of new therapeutic strategies, such as combination therapies, is urgently needed. Methods: Given that bortezomib resistance may be mediated by activation of the autophagy pathway as an alternative mechanism of protein degradation, and that an enormous amounts of misfolded protein is generated in myeloma plasma cells (PCs), we investigated the effect of the simultaneous inhibition of proteasome by bortezomib and autophagy by hydroxychloroquine (HCQ) treatment on PCs and endothelial cells (ECs) isolated from patients with monoclonal gammopathy of undetermined significance (MGUS) and MM. Results: We found that bortezomib combined with HCQ induces synergistic cytotoxicity in myeloma PCs whereas this effect is lost on ECs. Levels of microtubule-associated protein light chain beta (LC3B) and p62 are differentially modulated in PCs and ECs, with effects on cell viability and proliferation. Conclusions: Our results suggest that treatment with bortezomib and HCQ should be associated with an anti-angiogenic drug to prevent the pro-angiogenic effect of bortezomib, the proliferation of a small residual tumor PC clone, and thus the relapse.
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Yamaguchi A, Hirata S, Kubo S, Fukuyo S, Hanami K, Nakano K, Nakayamada S, Saito K, Tanaka Y. 5-year remission rate after the discontinuation of adalimumab in patients with rheumatoid arthritis: Long-term follow-up results of the HONOR study. Mod Rheumatol 2019; 30:799-806. [PMID: 31814496 DOI: 10.1080/14397595.2019.1702141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objectives: To determine the rate and factors associated with remission (disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) of <2.6) during a 5-year follow-up after the discontinuation of adalimumab (ADA) in patients with rheumatoid arthritis (RA).Methods: 75 patients who had been treated with ADA + methotrexate (MTX) and maintained DAS28-ESR <2.6 for at least 6 months were enrolled. Among them, 52 patients discontinued ADA, and 46 patients completed a 5-year follow-up.Results: During the 5 years, 11 patients had DAS28-ESR <2.6. In 15 patients with DAS28-ESR <3.2, no significant changes were found in the health assessment questionnaire disability index (HAQ-DI) and modified total Sharp score (mTSS). When comparing patients with DAS28-ESR ≤1.61 versus 1.61 <DAS28-ESR <2.6, 50% and 15% of the two groups demonstrated sustained remission, respectively. Remission was more common in patients with shorter disease duration (≤2 years) than those with longer duration (>2 years). Among 31 patients who experienced flare, ADA was restarted in 24 patients, and 17 patients of these achieved DAS28-ESR <3.2 within 1-year.Conclusion: During the 5-year ADA-free period, remission rate was persistent in 21% of the patients. ADA-free remission was possible especially in patients with deeper remission (DAS28-ESR ≤1.61) and shorter disease duration (≤2 years).
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Affiliation(s)
- Ayako Yamaguchi
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shintaro Hirata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.,Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Satoshi Kubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shunsuke Fukuyo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kentaro Hanami
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuyoshi Saito
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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The impact of different criteria sets on early remission and identifying its predictors in rheumatoid arthritis: results from an observational cohort (2009–2018). Clin Rheumatol 2019; 39:381-389. [DOI: 10.1007/s10067-019-04807-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/16/2019] [Accepted: 10/02/2019] [Indexed: 12/21/2022]
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Bergstra SA, Couto MC, Govind N, Chopra A, Salomon Escoto K, Murphy E, Huizinga TW, Allaart CF. Impact of the combined presence of erosions and ACPA on rheumatoid arthritis disease activity over time: results from the METEOR registry. RMD Open 2019; 5:e000969. [PMID: 31413867 PMCID: PMC6667972 DOI: 10.1136/rmdopen-2019-000969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/17/2019] [Accepted: 07/17/2019] [Indexed: 11/26/2022] Open
Abstract
Objective To investigate associations between baseline presence of erosions and/or anti-citrullinated protein antibodies (ACPA) on functional ability, disease activity and treatment survival over time. Methods Real life data from newly diagnosed rheumatoid arthritis patients were identified in the international METEOR registry. Patients were grouped according to presence/absence of ACPA and/or erosions at baseline. Associations between the presence of ACPA and/or erosions (four groups) with the change of Disease Activity Score (DAS) and Health Assessment Questionnaire (HAQ) over time were assessed using linear mixed models during maximum 6 or maximum 12 months from baseline. Treatment survival was assessed using multiple failure-times Cox regression. Results Data were included from 701 ACPA‒/erosions‒, 334 ACPA‒/erosions+, 1585 ACPA+/erosions‒ and 1993 ACPA+/erosions+ patients. We found statistically significant differences in DAS and HAQ change over time between the four groups, both after maximum follow-up durations of 6 and of 12 months, but after stratification differences proved small and not clinically meaningful. Patients in the ACPA‒/erosions‒ group were less likely to switch treatment compared with the ACPA+/erosions‒ reference group (p<0.001). The other two ACPA/erosions groups did not differ from the reference group. Conclusions In this analysis of worldwide real life data, we found statistically significant, but clinically irrelevant differences in treatment response to initial disease modifying anti-rheumatic drug therapies as measured by DAS and HAQ in ACPA‒/erosions‒, ACPA‒/erosions+, ACPA+/erosions‒ and ACPA+/erosions+ rheumatoid arthritis patients. However, after maximum follow-up durations of 6 and 12 months all groups had a similar response to initial treatment, but with a lower likelihood to switch treatment for ACPA‒/erosions‒ patients during the first year of follow-up.
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Affiliation(s)
- Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Karen Salomon Escoto
- Univeristy of Massaschusetts Medical School, Rheumatology Center, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | | | - Tom Wj Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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41
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Xie W, Li J, Zhang X, Sun X, Zhang Z. Sustained clinical remission of rheumatoid arthritis and its predictive factors in an unselected adult Chinese population from 2009 to 2018. Int J Rheum Dis 2019; 22:1670-1678. [PMID: 31297977 DOI: 10.1111/1756-185x.13651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 05/21/2019] [Accepted: 06/13/2019] [Indexed: 01/07/2023]
Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology Peking University First Hospital Beijing China
| | - Ji Li
- Department of Rheumatology and Clinical Immunology Peking University First Hospital Beijing China
| | - Xiaohui Zhang
- Department of Rheumatology and Clinical Immunology Peking University First Hospital Beijing China
| | - Xiaoying Sun
- Department of Rheumatology and Clinical Immunology Peking University First Hospital Beijing China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology Peking University First Hospital Beijing China
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42
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Baganz L, Richter A, Albrecht K, Schneider M, Burmester GR, Zink A, Strangfeld A. Are prognostic factors adequately selected to guide treatment decisions in patients with rheumatoid arthritis? A collaborative analysis from three observational cohorts. Semin Arthritis Rheum 2019; 48:976-982. [DOI: 10.1016/j.semarthrit.2018.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/24/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Burgers LE, van der Pol JA, Huizinga TWJ, Allaart CF, van der Helm-van Mil AHM. Does treatment strategy influence the ability to achieve and sustain DMARD-free remission in patients with RA? Results of an observational study comparing an intensified DAS-steered treatment strategy with treat to target in routine care. Arthritis Res Ther 2019; 21:115. [PMID: 31064384 PMCID: PMC6505077 DOI: 10.1186/s13075-019-1893-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/04/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To study the impact of treatment strategy on achieving and sustaining disease-modifying antirheumatic drug (DMARD)-free remission in patients with rheumatoid arthritis (RA). METHODS Two hundred seventy-nine RA patients (median follow-up 7.8 years) were studied. Of these, 155 patients participated in a disease activity score (DAS) < 1.6 steered trial aimed at DMARD-free remission. Initial treatment comprised methotrexate with high-dose prednisone (60 mg/day) and a possibility to start biologicals after 4 months. In the same period and hospital, 124 patients were treated according to routine care, comprising DAS < 2.4 steered treatment. Percentages of DMARD-free remission (absence of synovitis for ≥ 1 year after DMARD cessation), late flares (recurrence of clinical synovitis ≥ 1 year after DMARD cessation), and DMARD-free sustained remission (DMARD-free remission sustained during complete follow-up) were compared between both treatment strategies. RESULTS Patients receiving intensive treatment were younger and more often ACPA-positive. On a group level, there was no significant association between intensive treatment and DMARD-free remission (35% vs 29%, corrected hazard ratio (HR) 1.4, 95%CI 0.9-2.2), nor in ACPA-negative RA (49% versus 44%). In ACPA-positive RA intensive treatment resulted in more DMARD-free remission (25% vs 6%, corrected HR 4.9, 95%CI 1.4-17). Intensive treatment was associated with more late flares (20% versus 8%, HR 2.3, 95%CI 0.6-8.3). Subsequently, there was no difference in DMARD-free sustained remission on a group level (28% versus 27%), nor in the ACPA-negative (43% versus 42%) or ACPA-positive stratum (17% versus 6%, corrected HR 3.1, 95%CI 0.9-11). CONCLUSIONS Intensive treatment did not result in more DMARD-free sustained remission, compared to routine up-to-date care. The data showed a tendency towards an effect of intensive treatment in ACPA-positive RA; this needs further investigation.
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Affiliation(s)
- L E Burgers
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands.
| | - J A van der Pol
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - T W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - C F Allaart
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - A H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
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Wang XP, Cheng QY, Gu MM, Leng RX, Fan YG, Li BZ, Ye DQ. Diagnostic accuracy of anti-keratin antibody for rheumatoid arthritis: a meta-analysis. Clin Rheumatol 2019; 38:1841-1849. [PMID: 30810911 DOI: 10.1007/s10067-019-04464-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 12/11/2018] [Accepted: 02/03/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Anti-keratin antibody (AKA) is a serum antibody for patients with rheumatoid arthritis (RA), and it has a high specificity. Diagnostic role of AKA in RA was evaluated in this study. METHODS PubMed, EMBASE, and Web of Science were searched to acquire eligible studies. Articles published before 15 March 2018 were considered to be included. Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate the risk of bias and application concern of the included articles. Pooled analysis of diagnostic indicators of AKA for RA was conducted by using a random effects model. Subgroup analysis was employed to explore the potential influencing factors. RevMan 5.3, Stata 11.0, and Meta-DiSc 1.4 software were used in this study. RESULTS A total of 15 studies (2350 positive and 2067 negative participants) were included. The pooled sensitivity was 0.46 (95% CI 0.44-0.48), pooled specificity was 0.94 (95% CI 0.93-0.95), and pooled diagnostic odds ratio was 15.86 (95% CI 9.48-26.52). In addition, the area under the curve was 0.7194. CONCLUSIONS The current evidence indicated that AKA has high diagnostic specificity in RA and may be useful for RA diagnostic application in clinic.
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Affiliation(s)
- Xue-Ping Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Qian-Yao Cheng
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Ming-Ming Gu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Rui-Xue Leng
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Yin-Guang Fan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Bao-Zhu Li
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China.
- Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, 230032, Anhui, China.
| | - Dong-Qing Ye
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China.
- Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, 230032, Anhui, China.
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Frenken M, Schleich C, Brinks R, Abrar DB, Goertz C, Schneider M, Ostendorf B, Sewerin P. The value of the simplified RAMRIS-5 in early RA patients under methotrexate therapy using high-field MRI. Arthritis Res Ther 2019; 21:21. [PMID: 30642376 PMCID: PMC6332674 DOI: 10.1186/s13075-018-1789-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 12/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of the study was to evaluate a simplified version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) for five joints of the hand (RAMRIS-5) in patients with early rheumatoid arthritis (RA) before and after the initiation of methotrexate (MTX) therapy using high-resolution, 3-T magnetic resonance imaging (MRI). METHODS Twenty-eight patients with a seropositive, early RA (disease duration of less than 6 months (range 2-23 weeks)) according to 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria (mean age 56.8 years, range 39-74) were prospectively assessed with a baseline investigation including clinical assessment (disease activity score of 28 joints (DAS-28) and C-reactive protein (CRP)) and 3-T MRI of the clinically dominant hand. Follow-up visits were performed 3 and 6 months after initiation of a MTX therapy at baseline. MRI scans were analyzed in accordance with RAMRIS and the simplified RAMRIS-5. RESULTS DAS-28 and CRP decreased significantly after initiation of MTX therapy. Even though erosion scores increased over time, RAMRIS and RAMRIS-5 also decreased significantly after the start of therapy. There was a strong correlation between the total RAMRIS-5 and RAMRIS at baseline (r = 0.838; P <0.001) and follow-up (3 months: r = 0.876; P <0.001; 6 months: r = 0.897; P <0.001). In the short term (3-month follow-up), RAMRIS and RAMRIS-5 demonstrated similar ability to detect changes for all subgroups (bone edema, erosion, and synovitis). In the long-term comparison (6-month follow-up), RAMRIS-5 also showed similar effectiveness when detecting changes in bone edema and erosion compared with RAMRIS. Deviations occurred regarding only synovitis, where change was slightly higher in RAMRIS-5: SRM (RAMRIS) = 0.07 ± 0.14; SRM (RAMRIS-5) = 0.34 ± 0.06. CONCLUSIONS Three-Tesla MRI-based RAMRIS-5 is a simplified and resource-saving RAMRIS score which compares favorably with the RAMRIS when detecting changes in early RA. Even though there is a slight abbreviation between RAMRIS-5 and the original score regarding the change of synovitis, it may be used for diagnosis and therapy monitoring in follow-up evaluations.
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Affiliation(s)
- Miriam Frenken
- Department for Diagnostic and Interventional Radiology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Christoph Schleich
- Department for Diagnostic and Interventional Radiology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Ralph Brinks
- Department and Hiller Research Unit for Rheumatology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Daniel Benjamin Abrar
- Department for Diagnostic and Interventional Radiology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Christine Goertz
- Department and Hiller Research Unit for Rheumatology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Matthias Schneider
- Department and Hiller Research Unit for Rheumatology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Benedikt Ostendorf
- Department and Hiller Research Unit for Rheumatology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Philipp Sewerin
- Department and Hiller Research Unit for Rheumatology, UKD, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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Nasonov EL, Olyunin YA, Lila AM. RHEUMATOID ARTHRITIS: THE PROBLEMS OF REMISSION AND THERAPY RESISTANCE. ACTA ACUST UNITED AC 2018. [DOI: 10.14412/1995-4484-2018-263-271] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Rheumatoid arthritis (RA) is an immunoinflammatory (autoimmune) rheumatic disease of unknown etiology, which is characterized by chronic erosive arthritis and systemic visceral organ damage that results in early disability and shorter patient survival. Despite RA treatment advances associated with the design of novel drugs and the improvement of treatment strategies to achieve remission in many patients, there are still many theoretical and clinical problems concerning both the definition of the concept of remission, its characteristics and types and approaches to the optimum policy of symptomatic and pathogenetic drug therapy at different stages of the disease, the use of which will be able to rapidly induce and maintain remission in the long-term. Further investigations are needed to study the nature of heterogeneity of pathogenetic mechanisms of RA and approaches to early diagnosis, to improve methods for monitoring disease activity and biomarkers for the efficiency of and resistance to therapy and, finally, to develop differentiation therapy, including those related to a search for new therapeutic targets.
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Bugatti S, Sakellariou G, Luvaro T, Greco MI, Manzo A. Clinical, Imaging, and Pathological Suppression of Synovitis in Rheumatoid Arthritis: Is the Disease Curable? Front Med (Lausanne) 2018; 5:140. [PMID: 29868592 PMCID: PMC5962817 DOI: 10.3389/fmed.2018.00140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/24/2018] [Indexed: 12/18/2022] Open
Abstract
The management of patients with rheumatoid arthritis (RA) has witnessed a dramatic revolution in recent years, and disease remission has become an increasingly achievable outcome. Rheumatologists are now facing the urgent question of whether, once remission has been achieved and stably maintained, drugs can be tapered, and even discontinued. The concept of disease remission however encompasses progressive layers of complexity, all of which need to be disentangled before considering RA as a “curable” condition. As the synovial membrane represents the ultimate target of the pathological process of RA, a critical issue remains whether disease remission coincides with true suppression of inflammation and definitive tissue “healing.” In this short review, we will provide a critical summary of recent studies investigating the possibility of controlling RA synovitis at the clinical, imaging or pathological level. Potential advantages and limitations of these perspectives in the definition of remission are also discussed.
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Affiliation(s)
- Serena Bugatti
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Garifallia Sakellariou
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Terenzj Luvaro
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Maria Immacolata Greco
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Antonio Manzo
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
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48
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What is the optimal target for treat-to-target strategies in rheumatoid arthritis? Curr Opin Rheumatol 2018; 30:282-287. [DOI: 10.1097/bor.0000000000000484] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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49
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van der Woude D, van der Helm-van Mil AH. Update on the epidemiology, risk factors, and disease outcomes of rheumatoid arthritis. Best Pract Res Clin Rheumatol 2018; 32:174-187. [DOI: 10.1016/j.berh.2018.10.005] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/22/2018] [Accepted: 09/09/2018] [Indexed: 12/12/2022]
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50
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Bykerk VP. Rheumatoid arthritis: Moving towards IMPROVED drug-free remission. Nat Rev Rheumatol 2018; 14:191-192. [PMID: 29559711 DOI: 10.1038/nrrheum.2018.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Vivian P Bykerk
- Weill Cornell Medical College, New York, NY, USA.,The Inflammatory Arthritis Center, Hospital for Special Surgery, New York, NY, USA
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