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Ferrara F, Zovi A, Langella R, Trama U, Nava E, Comentale F, Primiano F, Russo G, Capuozzo M. Analysis of prescriptive monitoring regarding the current therapeutic landscape of rheumatoid arthritis: the experience of an Italian local health authority. Expert Rev Pharmacoecon Outcomes Res 2024:1-7. [PMID: 39340396 DOI: 10.1080/14737167.2024.2411431] [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: 07/20/2024] [Revised: 09/02/2024] [Accepted: 09/03/2024] [Indexed: 09/30/2024]
Abstract
INTRODUCTION Rheumatoid Arthritis (RA) is among the most prevalent chronic inflammatory diseases affecting millions of people with a significant expenditure of resources by National Healthcare Systems. This study aimed to analyze all available treatments exclusively for RA to highlight the costs of each treatment type and raise awareness of the use of biosimilar drugs. METHODS In an Italian healthcare authority, all prescriptions made for the diagnosis of RA were extracted to verify consumption expressed in Defined Daily Dose (DDD) and the expenditure incurred expressed in euros. Consequently, a grouping into three major drug categories has been performed: anti - tumor necrosis factor alpha agents (TNFα), other injectable formulations, and novel oral formulations. RESULTS Prescriptions for the second half-year 2022 and 2023 have been analyzed, with a total cost of almost 7 million euros in the sample considered. All pharmaceutical categories showed an increase in consumption, but only anti- TNFα recorded a decrease in costs from 25% in 2022 to 22% in 2023, thanks to the lower cost of the biosimilar drug. CONCLUSION The costs of RA may represent a significant spending commitment for central governments. As a result, actions are needed to encourage the preferential use of biosimilar drugs.
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Affiliation(s)
| | | | - Roberto Langella
- Italian Society of Hospital Pharmacy (SIFO), SIFO Secretariat of the Lombardy Region, Milan, Italy
| | - Ugo Trama
- General Direction for Health Protection and Coordination of the Campania Regional Health System, Campania Region, Naples, Italy
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Bertrand D, Joly J, Neerinckx B, Durez P, Lenaerts J, Joos R, Thevissen K, Zwaenepoel T, Vanhoof J, Di Romana S, Taelman V, Van Essche E, Corluy L, Ribbens C, Vanden Berghe M, Devinck M, Ajeganova S, Durnez A, Boutsen Y, Margaux J, Peene I, Van Offel J, Doumen M, Pazmino S, De Meyst E, Kulyk M, Creten N, Westhovens R, Verschueren P. Effectiveness of methotrexate and bridging glucocorticoids with or without early introduction of a 6-month course of etanercept in early RA: results of the 2-year, pragmatic, randomised CareRA2020 trial. RMD Open 2024; 10:e004535. [PMID: 39117445 PMCID: PMC11409310 DOI: 10.1136/rmdopen-2024-004535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/17/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVES To investigate if patients with early rheumatoid arthritis responding insufficiently to initial methotrexate (MTX) and bridging glucocorticoids (GCs) could benefit from early but temporary etanercept introduction as a second remission-induction attempt. METHODS CareRA2020 (NCT03649061) was a 2-year, open-label, multicentre, pragmatic randomised controlled trial. Treatment-naïve patients started MTX and GC bridging (COBRA-Slim: CS). Within a time window from week (W) 8 until W32, early insufficient responders (28-joint Disease Activity Score - C-reactive Protein (DAS28-CRP) >3.2 between W8 and W32 or ≥2.6 at W32) were randomised to a Standard-CS strategy (adding leflunomide first) or Bio-induction-CS strategy (adding etanercept for 24 weeks). Additional treatment adaptations followed the treat-to-target principle. Longitudinal disease activity (DAS28-CRP) over 104 weeks (primary outcome), achievement of DAS28-CRP <2.6 28 weeks after randomisation, and biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) use at W104 were compared between randomisation groups. RESULTS Following CS treatment, 142 patients were early responders; 55 early insufficient responders received Standard-CS and 55 Bio-induction-CS. Superiority of Bio-induction-CS over Standard-CS could not be demonstrated (ß=-0.204, (95% CI -0.486 to 0.078), p=0.157) for the primary outcome. More patients on Bio-induction-CS achieved DAS28-CRP <2.6 at 28 weeks after randomisation (59% (95% CI 44% to 72%) vs 44% (95% CI 31% to 59%) in Standard-CS) and they were treated less frequently with b/tsDMARDs at W104 (19/55, 35%) compared with Standard-CS (29/55, 53%). CONCLUSION Half of the patients responded well to initial COBRA-Slim induction therapy. In early insufficient responders, adding etanercept for 6 months did not improve disease control over 104 weeks versus adding leflunomide first. However, temporary introduction of etanercept resulted in improved disease control early after randomisation and less patients on b/tsDMARDs at W104. TRIAL REGISTRATION NUMBER NCT03649061. CTR PILOT APPROVAL BELGIUM S59474, EudraCT number: 2017-004054-41.
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Affiliation(s)
- Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
| | - Johan Joly
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Barbara Neerinckx
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Jan Lenaerts
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
- Reuma Instituut, Hasselt, Belgium
| | - Rik Joos
- Department of Rheumatology, ZNA Jan Palfijn, Merksem, Belgium
| | - Kristof Thevissen
- Reumacentrum, Genk, Belgium
- Department of Rheumatology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Tom Zwaenepoel
- Department of Rheumatology, OLV Ziekenhuis, Aalst, Oost-Vlaanderen, Belgium
| | | | - Silvana Di Romana
- Department of Rheumatology, CHU Saint-Pierre, Bruxelles, Bruxelles, Belgium
| | - Veerle Taelman
- Department of Rheumatology, Regionaal Ziekenhuis Heilig Hart Leuven, Leuven, Vlaams Brabant, Belgium
| | - Els Van Essche
- Department of Rheumatology, Imeldaziekenhuis, Bonheiden, Belgium
| | - Luk Corluy
- Department of Rheumatology, AZ Herentals, Herentals, Belgium
| | - Clio Ribbens
- Department of Rheumatology, CHU de Liège, Liège, Belgium
| | - Marc Vanden Berghe
- Department of Rheumatology, Grand Hôpital de Charleroi Site Saint-Joseph, Gilly, Hainaut, Belgium
| | - Mieke Devinck
- Department of Rheumatology, AZ Sint-Lucas Brugge, Brugge, West-Vlaanderen, Belgium
| | - Sofia Ajeganova
- Department of Rheumatology, UZ Brussel, Brussel, Belgium
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Anne Durnez
- Department of Rheumatology, AZ Jan Portaels, Vilvoorde, Vlaams Brabant, Belgium
| | - Yves Boutsen
- Department of Rheumatology, CHU UCL Namur, Yvoir, Namur, Belgium
| | - Joëlle Margaux
- Department of Rheumatology, Hôpital Erasme, Bruxelles, Belgium
| | - Isabelle Peene
- Department of Rheumatology, AZ Sint-Jan Brugge AV, Brugge, West-Vlaanderen, Belgium
| | - Jan Van Offel
- Department of Rheumatology, UZA, Edegem, Antwerp, Belgium
| | - Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinology, KU Leuven, Leuven, Flanders, Belgium
| | - Elias De Meyst
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Myroslava Kulyk
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Bogomolets National Medical University, Kiiv, Ukraine
| | | | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
- Department of Rheumatology, UZ Leuven, Leuven, Vlaams-Brabant, Belgium
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Ren S, Xu Y, Dong X, Mu Q, Chen X, Yu Y, Su G. Nanotechnology-empowered combination therapy for rheumatoid arthritis: principles, strategies, and challenges. J Nanobiotechnology 2024; 22:431. [PMID: 39034407 PMCID: PMC11265020 DOI: 10.1186/s12951-024-02670-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/25/2024] [Indexed: 07/23/2024] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease with multifactorial etiology and intricate pathogenesis. In RA, repeated monotherapy is frequently associated with inadequate efficacy, drug resistance, and severe side effects. Therefore, a shift has occurred in clinical practice toward combination therapy. However, conventional combination therapy encounters several hindrances, including low selectivity to arthritic joints, short half-lives, and varying pharmacokinetics among coupled drugs. Emerging nanotechnology offers an incomparable opportunity for developing advanced combination therapy against RA. First, it allows for co-delivering multiple drugs with augmented physicochemical properties, targeted delivery capabilities, and controlled release profiles. Second, it enables therapeutic nanomaterials development, thereby expanding combination regimens to include multifunctional nanomedicines. Lastly, it facilitates the construction of all-in-one nanoplatforms assembled with multiple modalities, such as phototherapy, sonodynamic therapy, and imaging. Thus, nanotechnology offers a promising solution to the current bottleneck in both RA treatment and diagnosis. This review summarizes the rationale, advantages, and recent advances in nano-empowered combination therapy for RA. It also discusses safety considerations, drug-drug interactions, and the potential for clinical translation. Additionally, it provides design tips and an outlook on future developments in nano-empowered combination therapy. The objective of this review is to achieve a comprehensive understanding of the mechanisms underlying combination therapy for RA and unlock the maximum potential of nanotechnology, thereby facilitating the smooth transition of research findings from the laboratory to clinical practice.
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Affiliation(s)
- Shujing Ren
- Department of Pharmacy, Affiliated Hospital 2 of Nantong University, Nantong, 226000, PR China
| | - Yuhang Xu
- School of Pharmacy, Nantong University, Nantong, 226000, PR China
| | - Xingpeng Dong
- School of Pharmacy, Nantong University, Nantong, 226000, PR China
| | - Qingxin Mu
- Department of Pharmaceutics, University of Washington, Seattle, WA, 98195, USA
| | - Xia Chen
- Department of Pharmacy, Affiliated Hospital 2 of Nantong University, Nantong, 226000, PR China.
| | - Yanyan Yu
- School of Pharmacy, Nantong University, Nantong, 226000, PR China.
| | - Gaoxing Su
- School of Pharmacy, Nantong University, Nantong, 226000, PR China.
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van Ouwerkerk L, Bergstra SA, Maarseveen TD, Huizinga TWJ, Knevel R, Allaart CF. Is glucocorticoid bridging therapy associated with later use of glucocorticoids and biological DMARDs during the disease course of patients with rheumatoid arthritis in daily practice? A real-world data analysis. Semin Arthritis Rheum 2024; 64:152305. [PMID: 37992515 DOI: 10.1016/j.semarthrit.2023.152305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/19/2023] [Accepted: 10/31/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To evaluate if initially starting glucocorticoid (GC) bridging leads to a higher probability of long-term GC and biological (b)DMARD use in rheumatoid arthritis (RA)-patients. METHODS Electronical health records data from newly diagnosed RA-patients from the Leiden University Medical Center were used. Patients who started GC as part of initial treatment (iGC group) and who did not (niGC group) were compared in terms of GC and bDMARD use later in the disease course. Multivariable adjustment was performed to account for confounding by indication. RESULTS 465/932 newly diagnosed RA-patients (50 %) were treated with GC as initial treatment step. Patients in the iGC group were older, included fewer females, had a higher disease activity at baseline compared to the niGC group plus a more rapid decrease in DAS28 in the first 6 months. During follow-up, 42 % of the iGC group started a second course of GC and 17 % started a bDMARD, compared to 34 % and 13 % In the niGC group. The hazard to start a bDMARD later in the disease course was not significantly different between the two groups in two time periods (0.34 95 %CI(0.09;1.21) resp. 1.48 95 %CI (0.98;2.22)), but the hazard to (re)start GC later on was higher for the iGC group (aHR 1.37 95 %CI(1.09;1.73)). CONCLUSION In this daily practice cohort of newly diagnosed RA patients, patients in the iGC group had a more rapid DAS28 decrease and an increased probability of starting GC later on compared to the niGC group. The probability of bDMARD use was not significantly increased.
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Affiliation(s)
- L van Ouwerkerk
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands.
| | - S A Bergstra
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - T D Maarseveen
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - T W J Huizinga
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - R Knevel
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - C F Allaart
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
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Westhovens R, Verschueren P. Lessons from negative phase 3 trials in rheumatoid arthritis anno 2023. Ann Rheum Dis 2023; 82:1503-1505. [PMID: 37903542 DOI: 10.1136/ard-2023-224904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 10/19/2023] [Indexed: 11/01/2023]
Affiliation(s)
- René Westhovens
- University Hospitals Leuven and KU Leuven Belgium, Leuven, Belgium
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6
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Jain S, Dhir V. Correspondence on 'Five-year treat-to-target outcomes after methotrexate induction therapy with or without other csDMARDs and temporary glucocorticoids for rheumatoid arthritis in the CareRA trial'. Ann Rheum Dis 2023; 82:e162. [PMID: 34193404 DOI: 10.1136/annrheumdis-2021-220816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Siddharth Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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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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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: 29] [Impact Index Per Article: 29.0] [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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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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Doumen M, Pazmino S, Bertrand D, De Cock D, Joly J, Westhovens R, Verschueren P. Longitudinal trajectories of fatigue in early RA: the role of inflammation, perceived disease impact and early treatment response. Ann Rheum Dis 2022; 81:1385-1391. [PMID: 35725296 DOI: 10.1136/annrheumdis-2022-222517] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/07/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Fatigue is common in rheumatoid arthritis (RA). We aimed to explore its longitudinal course, predictors and association with disease activity in early RA. METHODS Data came from the 2-year treat-to-target trial CareRA (Care in early RA) and its 3-year extension. Fatigue was measured on Visual Analogue Scale, Multidimensional Fatigue Inventory and Short Form-36 (SF-36) vitality. Longitudinal fatigue trajectories were identified with multivariate growth mixture modelling. Early predictors of fatigue and the association of fatigue and its trajectories with disease activity and clinical/psychosocial outcomes were studied with linear mixed models and multilevel mediation. RESULTS We included 356 and 244 patients in the 2-year and 5-year analyses, respectively. Four fatigue trajectories were identified: rapid, gradual, transient improvement and early deterioration, including 10%, 14%, 56% and 20% of patients. Worse pain, mental health and emotional functioning were seen in the early deterioration group. Higher pain, patient global assessment (PGA) and disability (Health Assessment Questionnaire), lower SF-36 mental components, and fewer swollen joints at baseline predicted higher fatigue over 5 years, while early disease remission strongly improved 5-year fatigue. The association between Simple Disease Activity Index and fatigue was mediated by PGA, pain, mental health and sleep quality. CONCLUSIONS Although fatigue evolves dynamically over time in early RA, most patients do not achieve sustained fatigue improvement despite intensive disease-modifying antirheumatic drug therapy. Higher 5-year fatigue levels were seen in patients with more perceived disease impact and fewer swollen joints at baseline. Conversely, early inflammatory disease control strongly improved long-term fatigue, pointing towards an early window of opportunity to prevent persistent fatigue.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium .,Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Delphine Bertrand
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Diederik De Cock
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Public Health, Biostatistics and Medical Informatics Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Johan Joly
- Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - René Westhovens
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
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Monaco A, Choi D, Uzun S, Maitland A, Riley B. Association of mast-cell-related conditions with hypermobile syndromes: a review of the literature. Immunol Res 2022; 70:419-431. [PMID: 35449490 PMCID: PMC9022617 DOI: 10.1007/s12026-022-09280-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/11/2022] [Indexed: 11/26/2022]
Abstract
Ehlers-Danlos syndrome (EDS) is a group of related connective tissue disorders consisting of 13 subtypes, each with its own unique phenotypic and genetic variation. The overlap of symptoms and multitude of EDS variations makes it difficult for patients to achieve a diagnosis early in the course of their disease. The most common form, hypermobile type EDS (hEDS) and its variant, hypermobile spectrum disorder (HSD), are correlated with rheumatologic and inflammatory conditions. Evidence is still needed to determine the pathophysiology of hEDS; however, the association among these conditions and their prevalence in hEDS/HSD may be explained through consideration of persistent chronic inflammation contributing to a disruption of the connective tissue. Aberrant mast cell activation has been shown to play a role in disruption of connective tissue integrity through activity of its mediators including histamine and tryptase which affects multiple organ systems resulting in mast cell activation disorders (MCAD). The overlap of findings associated with MCAD and the immune-mediated and rheumatologic conditions in patients with hEDS/HSD may provide an explanation for the relationship among these conditions and the presence of chronic inflammatory processes in these patients. It is clear that a multidisciplinary approach is required for the treatment of patients with EDS. However, it is also important for clinicians to consider the summarized symptoms and MCAD-associated characteristics in patients with multiple complaints as possible manifestations of connective tissue disorders, in order to potentially aid in establishing an early diagnosis of EDS.
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Affiliation(s)
- Ashley Monaco
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA.
| | - Diane Choi
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA
| | - Serife Uzun
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA
| | - Anne Maitland
- Division of Medicine, Icahn School of Medicine at Mount Sinai, Gustave L. Levy Place, New York, NY, 10029, USA
| | - Bernadette Riley
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA
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12
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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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13
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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: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/14/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the success rate of glucocorticoid (GC) discontinuation during follow-up in observational cohorts and clinical trials using temporary GC as part of initial therapy ('bridging') in newly diagnosed patients with rheumatoid arthritis (RA). METHODS Systematic literature searches were conducted to identify observational cohorts and clinical trials including patients with RA treated with initial GC bridging therapy, defined as discontinuation of GC within 1 year. Patient percentages still using GC were considered the reverse of successful discontinuation. Random effects meta-analyses were performed stratified by time point. RESULTS The scoping literature search for observational cohort studies could not identify studies answering the research question. The literature search for clinical trials identified 7160 abstracts, resulting in 10 included studies, with varying type and dose of GC and varying tapering schedules, of which 4 reported sufficient data on GC discontinuation or use after the bridging phase. The pooled proportion of patients who were still or again using GC was 22% (95% CI 8% to 37%, based on four trials) at 12 months and 10% at 24 months (95% CI -1 to 22, based on two trials). Heterogeneity was substantial (I²≥65%). CONCLUSION The success rate of GC discontinuation after bridging as part of initial treatment of RA has been described in a limited number of studies. Reports on observational cohorts did not answer the research question. In clinical trials, protocolised discontinuation was mostly successful, although 22% of the patients who started GC bridging therapy still or again used GC at 12 months, and 10% at 24 months.
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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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14
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Giollo A, Fuzzi E, Doria A. Methotrexate in early rheumatoid arthritis: Is the anchor drug still holding? Autoimmun Rev 2022; 21:103031. [PMID: 34995761 DOI: 10.1016/j.autrev.2022.103031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/02/2022] [Indexed: 12/29/2022]
Abstract
Treat-to-target (T2T) is currently the most fashionable strategy for treatment-naïve, early rheumatoid arthritis (RA) patients. A T2T approach can lead to a complete and drug-free disease remission, whereas failure to obtain remission leads to damage early in the disease course. Hence, one should try to achieve high remission rates as early as possible, implementing the best therapeutic strategies available. Methotrexate (MTX) combined with glucocorticoid bridging is the mainstay of T2T. However, MTX is often used suboptimally in RA patients for many reasons, including poor tolerability, low compliance, and safety issues. Recent evidence has suggested that novel targeted synthetic DMARDs (tsDMARDs) such as the Janus-kinase (JAK) inhibitors in combination with glucocorticoids yielded better outcomes in early RA than conventional treatment. Such an approach may have advantages in terms of patients' outcomes, though some concerns about serious adverse events need to be addressed.
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Affiliation(s)
- Alessandro Giollo
- Division of Rheumatology, Department of Medicine, University of Padova Hospital Trust, Padova, Italy.
| | - Enrico Fuzzi
- Division of Rheumatology, Department of Medicine, University of Padova Hospital Trust, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova Hospital Trust, Padova, Italy.
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15
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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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16
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Doumen M, De Cock D, Pazmino S, Bertrand D, Joly J, Westhovens R, Verschueren P. Treatment response and several patient-reported outcomes are early determinants of future self-efficacy in rheumatoid arthritis. Arthritis Res Ther 2021; 23:269. [PMID: 34706771 PMCID: PMC8549201 DOI: 10.1186/s13075-021-02651-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-efficacy, or patients' confidence in their ability to control disease and its consequences, was recently prioritised in EULAR recommendations for inflammatory arthritis self-management strategies. However, it remains unclear which factors influence self-efficacy in early rheumatoid arthritis (RA). METHODS Data were analysed from the 2-year RCT Care in early RA (CareRA), which studied remission-induction treatment regimens for early RA. Participants completed the Arthritis Self-Efficacy Scale (ASES), Short-Form 36 (SF-36), Revised Illness Perception Questionnaire (IPQ-R), Utrecht Coping List (UCL), RAQoL and Health Assessment Questionnaire (HAQ). Depending on time to first remission (DAS28-CRP < 2.6) and persistence of remission, treatment response was defined as persistent response, secondary failure, delayed response, late response or non-response. The association between ASES scores and clinical/psychosocial factors was explored with Spearman correlation and multivariate linear mixed models. Baseline predictors of week 104 ASES were identified with exploratory linear regression followed by multiple regression of significant predictors adjusted for DAS28-CRP, HAQ, treatment arm, treatment response, cumulative CRP/SJC28 and demographic/serologic confounders. RESULTS All 379 patients had a recent diagnosis of RA and were DMARD-naïve at study initiation. Most patients were women (69%) and RF/ACPA-positive (66%), and the mean (SD) age was 52 (13) years. For all tested outcome measures, better perceived health correlated with higher self-efficacy. While patient-reported factors (HAQ, SF-36, RAQoL, IPQ-R, pain, fatigue and patient's global assessment) showed moderate/strong correlations with ASES scores, correlations with physician-reported factors (physician's global assessment, SJC28), TJC28 and DAS28-CRP were weak. Only more favourable outcomes on patient-reported factors and DAS28-CRP were associated with higher ASES scores at each time point. An earlier, persistent treatment response predicted higher ASES scores at both weeks 52 and 104. Significant baseline predictors of week 104 ASES included HAQ; SF-36 mental component score, vitality, mental health and role emotional; IPQ-R illness coherence, treatment control, emotional representations and consequences; UCL Passive reacting; and the RAQoL. CONCLUSIONS Patient-reported outcomes and treatment response were early determinants of long-term self-efficacy in an early RA trial. These results provide further relevance for the window of opportunity in an early treat-to-target strategy and could help to timely identify patients who might benefit from self-management interventions. TRIAL REGISTRATION EudraCT 2008-007225-39.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, KU Leuven, Skeletal Biology and Engineering Research Centre, ON IV Herestraat 49 - bus 805, 3000, Leuven, Belgium.
- Rheumatology, University Hospitals Leuven, Leuven, Belgium.
| | - Diederik De Cock
- Department of Development and Regeneration, KU Leuven, Skeletal Biology and Engineering Research Centre, ON IV Herestraat 49 - bus 805, 3000, Leuven, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, KU Leuven, Skeletal Biology and Engineering Research Centre, ON IV Herestraat 49 - bus 805, 3000, Leuven, Belgium
| | - Delphine Bertrand
- Department of Development and Regeneration, KU Leuven, Skeletal Biology and Engineering Research Centre, ON IV Herestraat 49 - bus 805, 3000, Leuven, Belgium
| | - Johan Joly
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - René Westhovens
- Department of Development and Regeneration, KU Leuven, Skeletal Biology and Engineering Research Centre, ON IV Herestraat 49 - bus 805, 3000, Leuven, Belgium
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, KU Leuven, Skeletal Biology and Engineering Research Centre, ON IV Herestraat 49 - bus 805, 3000, Leuven, Belgium
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
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17
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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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