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Vanier A, Smolen JS, Allaart CF, Van Vollenhoven R, Verschueren P, Vastesaeger N, Saevarsdottir S, Visser K, Aletaha D, Combe B, Fautrel B. An updated matrix to predict rapid radiographic progression of early rheumatoid arthritis patients: pooled analyses from several databases. Rheumatology (Oxford) 2019; 59:1842-1852. [DOI: 10.1093/rheumatology/kez542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/19/2019] [Indexed: 01/23/2023] Open
Abstract
Abstract
Objective
In early RA, some patients exhibit rapid radiographic progression (RRP) after one year, associated with poor functional prognosis. Matrices predicting this risk have been proposed, lacking precision or inadequately calibrated. We developed a matrix to predict RRP with high precision and adequate calibration.
Methods
Post-hoc analysis by pooling individual data from cohorts (ESPOIR and Leuven cohorts) and clinical trials (ASPIRE, BeSt and SWEFOT trials). Adult DMARD-naïve patients with active early RA for which the first therapeutic strategy after inclusion was to prescribe methotrexate or leflunomide were included. A logistic regression model to predict RRP was built. The best model was selected by 10-fold stratified cross-validation by maximizing the Area Under the Curve. Calibration and discriminatory power of the model were checked. The probabilities of RRP for each combination of levels of baseline characteristics were estimated.
Results
1306 patients were pooled. 20.6% exhibited RRP. Four predictors were retained: rheumatoid factor positivity, presence of at least one RA erosion on X-rays, CRP > 30mg/l, number of swollen joints. The matrix estimates RRP probability for 36 combinations of level of baseline characteristics with a greatly enhanced precision compared with previously published matrices (95% CI: from ± 0.02 minimum to ± 0.08 maximum) and model calibration is excellent (P = 0.79).
Conclusion
A matrix proposing RRP probability with high precision and excellent calibration in early RA was built. Although the matrix has moderate sensitivity and specificity, it is easily usable and may help physicians and patients to make treatment decisions in daily clinical practice.
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Affiliation(s)
- Antoine Vanier
- Department of Biostatistics Public Health and Medical Informatics, Sorbonne University, APHP, University Hospitals Pitié-Salpêtrière Charles-Foix, Paris
- University Bretagne-Loire, University of Nantes, University of Tours, Inserm UMR U1246 SPHERE ‘Methods in patient-centered outcomes and health research’, Nantes
| | - Josef S Smolen
- Division of Rheumatology and Department of Medicine 3, University of Vienna, Vienna, Austria
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ronald Van Vollenhoven
- Rheumatology Unit, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Solna, Stockholm, Sweden
| | | | | | - Saedis Saevarsdottir
- Rheumatology Unit, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Karen Visser
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology and Department of Medicine 3, University of Vienna, Vienna, Austria
| | - Bernard Combe
- Department of Rheumatology, Montpellier 1 University, Montpellier University Hospital
| | - Bruno Fautrel
- Department of Rheumatology, Sorbonne University, GRC-08 (EEMOIS), APHP, University Hospitals Pitié-Salpêtrière Charles-Foix, Paris, France
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Association of MTHFR C677T and A1298C gene polymorphisms with methotrexate efficiency and toxicity in Algerian rheumatoid arthritis patients. Heliyon 2017; 3:e00467. [PMID: 29264421 PMCID: PMC5727549 DOI: 10.1016/j.heliyon.2017.e00467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/29/2017] [Accepted: 11/23/2017] [Indexed: 11/21/2022] Open
Abstract
Methotrexate (MTX) is the most used drug in rheumatoid arthritis (RA) treatment. However, it shows variability in clinical response, which is explained by an association with genetic polymorphisms. This study aimed to elucidate the role of the two gene polymorphism C677T and A1298C of the methylenetetrahydrofolate reductase (MTHFR) in response to MTX in Algerian RA patients. Study included 54 early RA patient treated with MTX for one year. MTX efficiency and toxicity were evaluated at 6 and 12 months respectively and the two gene polymorphisms were genotyped. No association was found between A1298C polymorphism and MTX toxicity. However, T allele of the C677T polymorphism was associated with the occurrence of MTX adverse effects (p = 0,019, OR: 3,63, 95% CI [1,12 - 12,80]). No association was found between C677T polymorphism and MTX efficiency, while A allele of the A1298C polymorphism was associated with good and moderate response (p = 0,02, OR = 3,28, 95% CI: [1,11– 9,42]). The study of RA biological markers kinetics showed that MTX did not affect antibodies rate unlike inflammatory markers. Our study suggests that MTHFR C677T and A1298C genotyping are associated to MTX toxicity and efficiency, respectively, in RA patients. This offers new perspectives in the personalization of RA treatment in Algeria.
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Granger B, Combe B, Le Loet X, Saraux A, Guillemin F, Fautrel B. Performance of matrices developed to identify patients with early rheumatoid arthritis with rapid radiographic progression despite methotrexate therapy: an external validation study based on the ESPOIR cohort data. RMD Open 2016; 2:e000245. [PMID: 27252898 PMCID: PMC4879338 DOI: 10.1136/rmdopen-2016-000245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/07/2016] [Accepted: 04/16/2016] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Use of prediction matrices of risk or rapid radiographic progression (RRP) for early rheumatoid arthritis (RA) in clinical practice could help to better rationalise the first line of treatment. Before use, they must be validated in populations that have not participated in their construction. The main objective is to use the ESPOIR cohort to validate the performance of 3 matrices (ASPIRE, BEST and SONORA) to predict patients at high risk of RRP at 1 year of disease despite initial treatment with methotrexate (MTX). METHODS We selected from the ESPOIR cohort 370 patients receiving MTX or leflunomide (LEF) for ≥3 months within the first year of follow-up. Patients were assessed clinically every 6 months, and structural damage progression seen on radiography was measured by the van der Heijde-modified Sharp score (vSHS) at 1 year. RRP was defined as an increase in the vSHS≥5 points during the first year. RESULTS At 1 year, the mean vSHS score was 1.7±5.0 and 46 patients had RRP. The ASPIRE matrix had only moderate validity in the ESPOIR population, with area under the receiver operating characteristic curve (AUC) <0.7. The AUC for the BEST and SONORA matrices were 0.73 and 0.76. Presence of rheumatoid factor (RF)-or anti-citrullinated protein antibodies (ACPAs) and initial structural damage were always predictive of RRP at 1 year. Disease Activity Score in 28 joints (DAS28) and C reactive protein (ASPIRE threshold) were not associated with RRP. CONCLUSIONS Matrices to identify patients at risk of RRP tested in the ESPOIR cohort seem to perform moderately. There is no matrix that shows clearly superior performance.
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Affiliation(s)
- Benjamin Granger
- Université Pierre et Marie Curie (UPMC)—Paris 6, GRC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
- Department of Biostatistics, Public Health and Medical Information, AP-HP Pitié Salpêtrière Hospital, Paris, France
| | - Bernard Combe
- Department of Rheumatology, Montpellier I University; Lapeyronie Hospital, Montpellier, France
| | - Xavier Le Loet
- Rheumatology Department, Rouen University Hospital & INSERM U905, Institute for Research and Innovation in Biomedicine, Rouen University, Rouen, France
| | - Alain Saraux
- Department of Rheumatology, Brest University, La Cavale Blanche University Hospital, Brest, France
- INSERM ESPRI, ERI29 Université Bretagne Occidentale, Brest, France
| | - Francis Guillemin
- EA 4360 APEMAC, Lorraine University, Paris-Descartes University, Nancy, France
- Faculty of Medicine, CS 50184, 54505 Vandoeuvre-lès-Nancy & Inserm, CIC-EC, CHU de Brabois, 54505 Vandoeuvre-lès-Nancy, Nancy, France
| | - Bruno Fautrel
- Université Pierre et Marie Curie (UPMC)—Paris 6, GRC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
- Department of Rheumatology, Pitié Salpêtrière Hospital, Paris, France
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Metting EI, in ’t Veen JC, Dekhuijzen PR, van Heijst E, Kocks JW, Muilwijk-Kroes JB, Chavannes NH, van der Molen T. Development of a diagnostic decision tree for obstructive pulmonary diseases based on real-life data. ERJ Open Res 2016; 2:00077-2015. [PMID: 27730177 PMCID: PMC5005160 DOI: 10.1183/23120541.00077-2015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 11/21/2015] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to develop and explore the diagnostic accuracy of a decision tree derived from a large real-life primary care population. Data from 9297 primary care patients (45% male, mean age 53±17 years) with suspicion of an obstructive pulmonary disease was derived from an asthma/chronic obstructive pulmonary disease (COPD) service where patients were assessed using spirometry, the Asthma Control Questionnaire, the Clinical COPD Questionnaire, history data and medication use. All patients were diagnosed through the Internet by a pulmonologist. The Chi-squared Automatic Interaction Detection method was used to build the decision tree. The tree was externally validated in another real-life primary care population (n=3215). Our tree correctly diagnosed 79% of the asthma patients, 85% of the COPD patients and 32% of the asthma-COPD overlap syndrome (ACOS) patients. External validation showed a comparable pattern (correct: asthma 78%, COPD 83%, ACOS 24%). Our decision tree is considered to be promising because it was based on real-life primary care patients with a specialist's diagnosis. In most patients the diagnosis could be correctly predicted. Predicting ACOS, however, remained a challenge. The total decision tree can be implemented in computer-assisted diagnostic systems for individual patients. A simplified version of this tree can be used in daily clinical practice as a desk tool.
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Affiliation(s)
- Esther I. Metting
- Dept of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | - Janwillem W.H. Kocks
- Dept of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Niels H. Chavannes
- Leiden University Medical Center, Dept of Public Health and Primary Care, Leiden, The Netherlands
| | - Thys van der Molen
- Dept of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Suematsu A, Tajiri Y, Nakashima T, Taka J, Ochi S, Oda H, Nakamura K, Tanaka S, Takayanagi H. Scientific basis for the efficacy of combined use of antirheumatic drugs against bone destruction in rheumatoid arthritis. Mod Rheumatol 2014. [DOI: 10.3109/s10165-006-0531-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fautrel B, Granger B, Combe B, Saraux A, Guillemin F, Le Loet X. Matrix to predict rapid radiographic progression of early rheumatoid arthritis patients from the community treated with methotrexate or leflunomide: results from the ESPOIR cohort. Arthritis Res Ther 2012; 14:R249. [PMID: 23164197 PMCID: PMC3674616 DOI: 10.1186/ar4092] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 11/06/2012] [Indexed: 12/11/2022] Open
Abstract
Introduction Early rheumatoid arthritis (RA) patients may show rapid radiographic progression (RRP) despite rapid initiation of synthetic disease-modifying anti-rheumatic drugs (DMARDs). The present study aimed to develop a matrix to predict risk of RRP despite early DMARD initiation in real life settings. Methods The ESPOIR cohort included 813 patients from the community with early arthritis for < 6 months; 370 patients had early RA and had received methotrexate or leflunomide during the first year of follow-up. RRP was defined as an increase in the van der Heijde-modified Sharp score (vSHS) ≥ 5 points at 1 year. Determinants of RRP were examined first by bivariate analysis, then multivariate stepwise logistic regression analysis. A visual matrix model was then developed to predict RRP in terms of patient baseline characteristics. Results We analyzed data for 370 patients. The mean Disease Activity Score in 28 joints was 5.4 ± 1.2, 18.1% of patients had typical RA erosion on radiographs and 86.4% satisfied the 2010 criteria of the American College of Rheumatology/European League Against Rheumatism. During the first year, mean change in vSHS was 1.6 ± 5.5, and 41 patients (11.1%) showed RRP. A multivariate logistic regression model enabled the development of a matrix predicting RRP in terms of baseline swollen joint count, C-reactive protein level, anti-citrullinated peptide antibodies status, and erosions seen on radiography for patients with early RA who received DMARDs. Conclusions The ESPOIR matrix may be a useful clinical practice tool to identify patients with early RA at high risk of RRP despite early DMARD initiation.
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Genetic polymorphisms in key methotrexate pathway genes are associated with response to treatment in rheumatoid arthritis patients. THE PHARMACOGENOMICS JOURNAL 2012; 13:227-34. [PMID: 22450926 PMCID: PMC5604731 DOI: 10.1038/tpj.2012.7] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We investigated the effect of Single Nucleotide Polymorphisms (SNPs) spanning 10 methotrexate (MTX) pathway genes, namely AMPD1, ATIC, DHFR, FPGS, GGH, ITPA, MTHFD1, SHMT1, SLC19A1 (RFC) and TYMS on the outcome of MTX treatment in a UK rheumatoid arthritis (RA) patient cohort. Tagging SNPs were selected and genotyping performed in 309 patients with predefined outcomes to MTX treatment. Of the 129 SNPs tested, 11 associations were detected with efficacy (p-trend ≤ 0.05) including four SNPs in the ATIC gene (rs12995526, rs3821353, rs7563206 and rs16853834), 6 SNPs in the SLC19A1 gene region (rs11702425, rs2838956, rs7499, rs2274808, rs9977268, rs7279445) and a single SNP within the GGH gene (rs12681874). Five SNPs were significantly associated with adverse events; three in the DHFR gene (rs12517451, rs10072026, and rs1643657) and two of borderline significance in the FPGS gene. The results suggest that genetic variations in several key MTX pathway genes may influence response to MTX in RA patients. Further studies will be required to validate these findings and if confirmed these results could contribute towards a better understanding of and ability to predict MTX response in RA.
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Owen SA, Lunt M, Bowes J, Hider SL, Bruce IN, Thomson W, Barton A. MTHFR gene polymorphisms and outcome of methotrexate treatment in patients with rheumatoid arthritis: analysis of key polymorphisms and meta-analysis of C677T and A1298C polymorphisms. THE PHARMACOGENOMICS JOURNAL 2011; 13:137-47. [PMID: 21931346 DOI: 10.1038/tpj.2011.42] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Association of two key variants mapping to the MTHFR gene (C677T (rs1801133) and A1298C (rs1801131)) with response to methotrexate (MTX) remains controversial. We investigated these and other markers spanning the gene as predictors of MTX efficacy and adverse events in a UK rheumatoid arthritis (RA) patient cohort and performed a meta-analysis of the two key variants using all published data. The tagging single nucleotide polymorphisms (SNPs) were genotyped in 309 patients with well-defined outcomes to MTX treatment and 17 studies were included in the meta-analysis. No association of the SNPs tested was detected with MTX efficacy or toxicity in our UK cohort. After combining our data with previous studies by meta-analysis, the random effects pooled odds ratios (OR) for both C677T and A1298C showed no association with efficacy or toxicity for either of the SNPs (efficacy: OR=1.05 (95% confidence interval (CI) 0.83-1.32) and OR=0.81 (95% CI 0.53-1.24), respectively; toxicity: OR=1.38 (95% CI 0.90-2.12) and OR=1.19 (95% CI 0.80-1.78), respectively). The available evidence suggests that the MTHFR C677T and A1298C gene polymorphisms are not reliable predictors of response to MTX treatment in RA patients.
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Affiliation(s)
- S A Owen
- Arthritis Research UK Epidemiology Unit, Manchester Academy of Health Sciences, The University of Manchester, Manchester, UK
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Bykerk VP, Akhavan P, Hazlewood GS, Schieir O, Dooley A, Haraoui B, Khraishi M, Leclercq SA, Légaré J, Mosher DP, Pencharz J, Pope JE, Thomson J, Thorne C, Zummer M, Bombardier C. Canadian Rheumatology Association recommendations for pharmacological management of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs. J Rheumatol 2011; 39:1559-82. [PMID: 21921096 DOI: 10.3899/jrheum.110207] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The Canadian Rheumatology Association (CRA) has developed recommendations for the pharmacological management of rheumatoid arthritis (RA) with traditional and biologic disease-modifying antirheumatic drugs (DMARD) in 2 parts. Part 1 is reported here. METHODS The CRA Therapeutics Committee assembled a national working group of RA clinical experts, researchers, patient consumers, and a general practitioner. Treatment questions were developed a priori based on results of a national needs assessment survey. A systematic review of all clinical practice guidelines and consensus statements regarding treatment with traditional and biologic DMARD in patients with RA published between January 2000 and June 2010 was performed in Medline, Embase, and CINAHL databases, and the grey literature. Guideline quality was assessed by 2 independent reviewers, and guideline characteristics, recommendations, and supporting evidence from observational studies and randomized controlled trials were synthesized into evidence tables. The full working group reviewed the evidence tables and developed recommendations using a modified Delphi technique. RESULTS Five overarching principles and 26 recommendations addressing general RA management strategies and treatment with glucocorticoids and traditional and biologic DMARD were developed for rheumatologists, other primary prescribers of RA drug therapies, and patients with RA. CONCLUSION These recommendations were developed based on a synthesis of international guidelines, supporting evidence, and expert consensus considering the Canadian healthcare context with the intention of promoting best practices and improving healthcare delivery for persons with RA.
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Affiliation(s)
- Vivian P Bykerk
- Mount Sinai Hospital, The Rebecca McDonald Centre for Arthritis and Autoimmune Disease, Toronto, Canada.
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Le Loët X, Brazier M, Mejjad O, Boumier P, Daragon A, Gayet A, Pouplin S, Tron F, Zarnitsky C, Vittecoq O, Menard JF, Fardellone P. Serum IgA rheumatoid factor and pyridinoline in very early arthritis as predictors of erosion(s) at two years: a simple model of prediction from a conservatively treated community-based inception cohort. Arthritis Care Res (Hoboken) 2011; 62:1739-47. [PMID: 20740612 DOI: 10.1002/acr.20321] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify, in conservatively treated, very early arthritis patients, predictors of ≥1 erosion(s) at 2 years, and to construct a prediction model. METHODS Community-based adults (n=310) who had never taken disease-modifying antirheumatic drugs (DMARDs) or steroids with swelling of ≥2 joints persisting for >4 weeks and lasting <6 months were recruited. Erosion status was assessed at 0, 6, 12, and 24 months; evaluations were comprised of clinical criteria (Disease Activity Score, Health Assessment Questionnaire), C-reactive protein level, erythrocyte sedimentation rate, autoantibodies, bone and cartilage markers, hand densitometry, and HLA class II shared epitopes. Patients meeting American College of Rheumatology rheumatoid arthritis (RA) criteria or with undifferentiated arthritis (UA) were followed and treated conservatively: one-third of RA patients and three-fourths of UA patients received no DMARDs during 2 years; a biologic agent was given to 1.8% of the patients during the first year. The main judgment criterion was ≥1 erosion(s) at 2 years. RESULTS At 2 years, 219 patients were assessed; 31.3% with RA and 10.6% with UA had ≥1 erosion(s). Logistic regression analysis at that time showed erosion(s) strongly associated with serum IgA rheumatoid factor (IgA-RF) and pyridinoline levels for the 190 patients with no baseline erosions, with the corresponding receiver operating characteristic curve having an area under the curve of 0.77 (95% confidence interval 0.64-0.86). A prediction model was constructed with IgA-RF thresholds of 5 and 25 IU/ml and a pyridinoline threshold of 10 nM/liter; odds ratios ranged from 1 for IgA-RF<5 IU/ml and pyridinoline <10 nM/liter to 50.75 for the association of IgA-RF≥5 IU/ml and pyridinoline≥10 nM/liter. CONCLUSION This model, using serum IgA-RF and pyridinoline concentrations, was able to predict≥1 erosion(s) at 2 years in very early arthritis patients.
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Affiliation(s)
- Xavier Le Loët
- INSERM Unit 905 and Rouen University Hospital, Rouen, France.
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Evaluation and management of early inflammatory polyarthritis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Significant advances in our understanding of RA and its management have been made in the past decade, resulting in earlier intervention with biologic DMARDs, particularly in patients with evidence of aggressive, erosive disease. Here, one such biologic therapy, the T-cell co-stimulation modulator abatacept, is discussed, exploring clinical evidence published to date on its use in patients with very early arthritis/early RA who are MTX naïve, and in patients with established RA and an inadequate response to MTX or TNF antagonists. Data from relevant clinical trials are overviewed, discussing the clinical efficacy of abatacept in early disease, the clinical outcomes over long-term treatment in different patient populations and the effects of abatacept on structural damage. Findings from integrated safety analyses of abatacept clinical trial data, representing 10 366 patient-years of exposure are described, and clinically important safety events, including serious infections, malignancies and autoimmune events, are highlighted. It is concluded that abatacept represents an effective treatment option with an established safety profile across different patient populations, including patients with both early and erosive RA and those with established disease. Furthermore, efficacy data from studies in patients with early disease suggest that the risk–benefit profile of abatacept may be more favourable when introduced earlier in the treatment paradigm.
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Affiliation(s)
- Michael Schiff
- School of Medicine, University of Colorado, Denver, CO, USA.
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Rantalaiho V, Kautiainen H, Virta L, Korpela M, Möttönen T, Puolakka K. Trends in treatment strategies and the usage of different disease-modifying anti-rheumatic drugs in early rheumatoid arthritis in Finland. Results from a nationwide register in 2000-2007. Scand J Rheumatol 2010; 40:16-21. [PMID: 20726683 DOI: 10.3109/03009742.2010.486768] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To determine which disease-modifying anti-rheumatic drugs (DMARDs) are currently used by Finnish rheumatologists to treat early rheumatoid arthritis (RA). METHODS Information on sex, date of birth, and date of special medicine reimbursement decision for all new RA patients was collected from a nationwide register maintained by the Social Insurance Institution (SII) during the time period from 1 January 2000 to 31 December 2007. Patient cohorts were registered in 2-year time periods (2000-01, 2002-03, 2004-05, 2006-07) and DMARDs purchased by the patient cohorts during the first year after the date of reimbursement decision for RA were registered. The frequencies of early drug treatment strategies (combination of DMARDs, single DMARD, or no DMARDs) were evaluated. RESULTS A total of 14 878 (68.0% female, 62.6% rheumatoid factor (RF)-positive) patients were identified. Between 2000 and 2001 the most commonly used treatment strategy for early RA during the first 3 months was single DMARD treatment (56.1%) and the most commonly used DMARD during the first year was sulfasalazine (63.0%), while between 2006 and 2007 the respective treatments were combination DMARDs (55.3%) and methotrexate (69.0%). The change in treatment strategies as well as in DMARDs used was highly significant (p < 0.001 for linearity). At the end of the study period only 4.9% of the patients with early RA were not receiving DMARDs during the first 3 months. CONCLUSIONS Currently, combination therapy including methotrexate is the most commonly prescribed treatment strategy for early RA in Finland. In recent years, an increasing number of active drug treatments have been taken into practice.
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Affiliation(s)
- V Rantalaiho
- Department of Internal Medicine, Centre for Rheumatic Diseases, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland.
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Bader-Meunier B, Wouters C, Job-Deslandre C, Cimaz R, Hofer M, Pillet P, Quartier P. Recommandations pour la prise en charge des formes oligoarticulaire et polyarticulaires (en dehors de la polyarthrite rhumatoïde) d’arthrite juvénile idiopathique. Arch Pediatr 2010; 17:1085-9. [DOI: 10.1016/j.arcped.2010.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/22/2010] [Accepted: 04/02/2010] [Indexed: 11/16/2022]
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Prediction of response to disease modifying antirheumatic drugs in rheumatoid arthritis. Joint Bone Spine 2010; 77:558-63. [PMID: 20478729 DOI: 10.1016/j.jbspin.2010.02.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 02/24/2010] [Indexed: 01/06/2023]
Abstract
AIM To investigate potential predictors of response to conventional DMARDs in RA. METHODS Study design - 6-month follow-up prospective study. PARTICIPANTS RA patients with active disease. INTERVENTION AND FOLLOW-UP: Introduction of one DMARD. Response to treatment evaluated at 6 months (ACR20 criteria). ANALYSIS Potential predictors of response, patients' demographics, disease activity, percentages of PBMC subsets expressing P-gp, serum IL-1β, IL-6, IL-8, IL-10, IL-12, TNF-α levels, were evaluated using univariate and multivariate logistic regression analysis. ROC curve analyses were performed in order to obtain thresholds allowing the prediction of response. RESULTS Forty-two patients (mean age = 57 ± 13 years, mean disease duration = 5.4 ± 7.2 years) were included. MTX was given to 30. The response to therapy was predicted by the baseline serum level of TNF-α (mean = 30.2 pg/ml ± 18 in non-responders vs. 11.9 pg/ml ± 11.2 in responders). The threshold, which predicted with the best accuracy the response to treatment, was 20.1 pg/ml (sensitivity, specificity, positive and negative predictive values of 75, 78.9, 83.3, and 69.2%, respectively; AUC = 80.3%, 95% CI = 62.8-97.7%). Similar results were obtained in the subgroups of patients treated with MTX and patients with early RA of less than 3 years duration. CONCLUSION In the present work, the serum concentration of TNF-α was related to further response to DMARDs. Other works are needed for confirmation and to assess whether such biomarker could be used to predict the response to DMARDs at the individual level.
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de Bandt M, Fautrel B, Maillefert JF, Berthelot JM, Combe B, Flipo RM, Lioté F, Meyer O, Saraux A, Wendling D, Le Loët X, Guillemin F. Determining a low disease activity threshold for decision to maintain disease-modifying antirheumatic drug treatment unchanged in rheumatoid arthritis patients. Arthritis Res Ther 2009; 11:R157. [PMID: 19849865 PMCID: PMC2787280 DOI: 10.1186/ar2836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 08/24/2009] [Accepted: 10/23/2009] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The aim of this study was to determine a low disease activity threshold--a 28-joint disease activity score (DAS28) value--for the decision to maintain unchanged disease-modifying antirheumatic drug (DMARD) treatment in rheumatoid arthritis patients, based on expert opinion. METHODS Nine hundred and sixty-seven case scenarios with various levels for each component of the DAS28 (resulting in a disease activity score between 2 and 3.2) were presented to 44 panelists. For each scenario, panelists had to decide whether or not DMARD treatment (excluding steroids) could be maintained unchanged. In each scenario, for decision, the participants were given the DAS28 parameters, without knowledge of the resultant DAS28. The relationship between panelists' decision, DAS28 value, and components of the score were analysed by multiple logistic regression analysis. Each panelist analysed 160 randomised scenarios. Intra-rater and inter-rater reproducibility were assessed. RESULTS Forty-four panelists participated in the study. Inter-panelist agreement was good (kappa = 0.63; 95% confidence interval = 0.61 to 0.65). Intra-panelist agreement was excellent (kappa = 0.87; 95% confidence interval = 0.82 to 0.92). Quasi-perfect agreement was observed for DAS28 < or = 2.4, less pronounced between 2.5 and 2.9, and almost no agreement for DAS28 > 3.0. For values below 2.5, panelists agreed to maintain unchanged DMARDs; for values above 2.5, discrepancies occurred more frequently as the DAS28 value increased. Multivariate analysis confirmed the relationship between panelist's decision, DAS28 value and components of the DAS28. Between DAS28 of 2.4 and 3.2, a major determinant for panelists' decision was swollen joint count. Female and public practice physicians decided more often to maintain treatment unchanged. CONCLUSIONS As a conclusion, panelists suggested that in clinical practice there is no need to change DMARD treatment in rheumatoid arthritis patients with DAS28 < or = 2.4.
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Affiliation(s)
- Michel de Bandt
- Centre hospitalier d'Aulnay sous Bois, Service de Rhumatologie, Boulevard Ballanger, Aulnay sous Bois F-93600, France
| | - Bruno Fautrel
- APHP-GH Pitié Salpêtrière, Service de Rhumatologie, UFR de Médecine, Université Paris VI - Pierre et Marie Curie, 83 boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - Jean Francis Maillefert
- Centre Hospitalo-Universitaire du Dijon, Hôpital du Bocage, Service de Rhumatologie, 3 rue du faubourg Raynes, Dijon F-21000, France
| | - Jean Marie Berthelot
- INSERM ERI 7 (EA 3822), Centre Hospitalo-Universitaire de Nantes, Hotel-Dieu, Service de Rhumatologie, 1 Place Alexis Ricordeau, Nantes F-44000, France
| | - Bernard Combe
- Centre Hospitalo-Universitaire du Montpellier, Hôpital Lapeyronie, Service de Rhumatologie, 371 avenue du Doyen Gaston Giraud, Montpellier F-34000, France
| | - René-Marc Flipo
- Centre Régional Hospitalo-Universitaire de Lille, Service de Rhumatologie, Rue du Pr E Laine, Lille F-59000, France
| | - Frédéric Lioté
- Hôpital Lariboisière, Centre Viggo-Petersen, Service de Rhumatologie, 2 rue A Paré, Paris F-75010, France
| | - Olivier Meyer
- UFR de Médecine - Bichat Lariboisière, Université Paris 7, APHP, Groupe hospitalier Bichat - Claude Bernard, Service de Rhumatologie, 46 rue H Huchard, Paris F-75018, France
| | - Alain Saraux
- Centre Hospitalo-Universitaire de Brest, Hôpital de la Cavale Blanche, Service de Rhumatologie, rue T Prigent, Brest F-29000, France
| | - Daniel Wendling
- EA3186 - Agents pathogènes et Inflammation, Université de Franche-Comté, Centre Hospitalo - Universitaire de Besançon, Hôpital Jean Minjoz, Service de Rhumatologie, 1 Bd Fleming, Besançon F-25000, France
| | - Xavier Le Loët
- Department of Rheumatology, Rouen University Hospital & Inserm U905 (IFRMP 23), University of Rouen, 1 rue de Germont, Rouen F-76230, France
| | - Francis Guillemin
- INSERM CIC-EC, CHU de Nancy - Hôpital Marin, 92 av Mal de Lattre de Tassigny, 54035 Nancy cedex, France
- Université Henri Poincaré Nancy I, EA4003, Ecole de Santé Publique, Faculté de Médecine de Nancy, Nancy F-54000, France
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Bansard C, Lequerre T, Daveau M, Boyer O, Tron F, Salier JP, Vittecoq O, Le-Loet X. Can rheumatoid arthritis responsiveness to methotrexate and biologics be predicted? Rheumatology (Oxford) 2009; 48:1021-8. [DOI: 10.1093/rheumatology/kep112] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Hersh A, Yazdany J. Clinical practice guidelines and diagnostic uncertainty in the management of early rheumatoid arthritis. J Rheumatol 2009; 36:863-4. [PMID: 19435968 DOI: 10.3899/jrheum.090287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Fautrel B, Guillemin F, Meyer O, de Bandt M, Berthelot JM, Flipo RM, Lioté F, Maillefert JF, Wendling D, Saraux A, Combe B, Le loët X. Choice of second-line disease-modifying antirheumatic drugs after failure of methotrexate therapy for rheumatoid arthritis: A decision tree for clinical practice based on rheumatologists' preferences. ACTA ACUST UNITED AC 2009; 61:425-34. [DOI: 10.1002/art.24588] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Benhamou M, Rincheval N, Roy C, Foltz V, Rozenberg S, Sibilia J, Schaeverbeke T, Bourgeois P, Ravaud P, Fautrel B. The gap between practice and guidelines in the choice of first-line disease modifying antirheumatic drug in early rheumatoid arthritis: results from the ESPOIR cohort. J Rheumatol 2009; 36:934-42. [PMID: 19286850 DOI: 10.3899/jrheum.080762] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare rheumatologists' prescription for first disease modifying antirheumatic drug (DMARD) in early rheumatoid arthritis (RA) in real-life settings with 2 clinical practice guidelines (CPG), the French Society of Rheumatology/STPR 2004 and EULAR/ESCISIT 2007, and thus assess the gap between practices and guidelines. Method. ESPOIR was a French multicenter cohort study of 813 patients with early arthritis between 2002 and 2005. "Definite" and "probable" RA were defined according to ACR criteria and the level of diagnostic certainty. The objectives were to assess conformity between the observed first-line DMARD prescribed for those patients and the DMARD recommended in the guidelines; and to conduct a mail survey of patients' usual rheumatologists to investigate the reasons for their nonconformity with guidelines. RESULTS In total 627 patients with definite or probable RA were identified. Conformity rates were 58% for STPR guidelines and 54% for EULAR guidelines. At 6 months, 83 (34%) patients with early RA did not receive any DMARD. Main determinants associated with conformity to guidelines were disease activity and presence of severity-predictive factors. The main reason leading to a discrepancy between guidelines and daily practice appeared to be diagnostic uncertainty, i.e., the difficulty to reliably assess RA diagnosis as early as the first visits to the rheumatologist. CONCLUSION There is a substantial gap between CPG and rheumatologists' daily practice concerning the first DMARD to prescribe in early RA. This is explained mainly by diagnostic uncertainty. More attention should be paid in future guidelines to the diagnostic difficulties of early RA.
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Affiliation(s)
- Mathilde Benhamou
- Department of Rheumatology, University of Paris VI, Pitie Salpetriere Hospital, Paris, France
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Costos directos de la artritis reumatoide temprana en el primer año de atención: simulación de tres situaciones clínicas en un hospital universitario de tercer nivel en Colombia. BIOMEDICA 2009. [DOI: 10.7705/biomedica.v29i1.40] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Leuchten N, Aringer M. [Rheumatoid arthritis today]. Internist (Berl) 2008; 49:1471-80; quiz 1481. [PMID: 18985308 DOI: 10.1007/s00108-008-2228-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Advances in the therapy of rheumatoid arthritis with disease modifying antirheumatic drugs (DMARD) such as methotrexate and biological response modifiers in particular, have turned a chronic progressive disease with significant invalidity and mortality into one that can be well controlled. To prevent irreversible damage, early diagnosis is essential. DMARD therapy needs to be instituted within three months after symptom onset - a clinical and organisational challenge. Long term DMARD therapy is monitored using standardized scores and modified whenever not sufficiently successful. Analgesia, physiotherapy and occupational therapy as well as orthopaedic surgery play important roles in the management of rheumatoid arthritis. Consequent multimodal therapy can decisively influence the course of the disease and prevent or at least minimize damage.
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Affiliation(s)
- N Leuchten
- Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
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Trocmé C, Marotte H, Baillet A, Pallot-Prades B, Garin J, Grange L, Miossec P, Tebib J, Berger F, Nissen MJ, Juvin R, Morel F, Gaudin P. Apolipoprotein A-I and platelet factor 4 are biomarkers for infliximab response in rheumatoid arthritis. Ann Rheum Dis 2008; 68:1328-33. [PMID: 18664547 DOI: 10.1136/ard.2008.093153] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The use of biologicals such as infliximab has dramatically improved the treatment of rheumatoid arthritis (RA). However, factors predictive of therapeutic response need to be identified. A proteomic study was performed prior to infliximab therapy to identify a panel of candidate protein biomarkers of RA predictive of treatment response. METHODS Plasma profiles of 60 patients with RA (28 non-responders (as defined by the American College of Rheumatology 20% improvement criteria (ACR20)) negative and 32 responders (ACR70 positive) to infliximab) were studied by surface enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI-TOF MS) technology on two types of arrays, an anion exchange array (SAX2) and a nickel affinity array (IMAC3-Ni). Biomarker characterisation was carried out using classical biochemical methods (purification by ammonium sulfate precipitation or metal affinity chromatography) and identification by matrix assisted laser desorption/ionisation time-of-flight (MALDI-TOF) MS analysis. RESULTS Two distinct protein profiles were observed on both arrays and several proteins were differentially expressed in both patient populations. Five proteins at 3.86, 7.77, 7.97, 8.14 and 74.07 kDa were overexpressed in the non-responder group, whereas one at 28 kDa was increased in the responder population (sensitivity>56%, specificity>77.5%). Moreover, combination of several biomarkers improved the sensitivity and specificity of the detection of patient response to over 97%. The 28 kDa protein was characterised as apolipoprotein A-I and the 7.77 kDa biomarker was identified as platelet factor 4. CONCLUSIONS Six plasma biomarkers are characterised, enabling the detection of patient response to infliximab with high sensitivity and specificity. Apolipoprotein A-1 was predictive of a good response to infliximab, whereas platelet factor 4 was associated with non-responders.
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Affiliation(s)
- C Trocmé
- GREPI CNRS UMR 5525, INSERM IFR 130, Université J Fourier, Grenoble, France
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Suematsu A, Tajiri Y, Nakashima T, Taka J, Ochi S, Oda H, Nakamura K, Tanaka S, Takayanagi H. Scientific basis for the efficacy of combined use of antirheumatic drugs against bone destruction in rheumatoid arthritis. Mod Rheumatol 2007; 17:17-23. [PMID: 17278017 DOI: 10.1007/s10165-006-0531-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Accepted: 10/18/2006] [Indexed: 10/23/2022]
Abstract
Finding a means to ameliorate and prevent bone destruction is one of the urgent issues in the treatment of rheumatoid arthritis. Recent studies revealed bone-resorbing osteoclasts to be essential for arthritic bone destruction, but to date there has been scarce experimental evidence for the underlying mechanism of the bone-protective effect of antirheumatic drugs. Here we examined the effects of one or a combination of disease-modifying antirheumatic drugs (DMARDs) on osteoclast differentiation to provide a cellular and molecular basis for their efficacy against bone destruction. The effects on osteoclast precursor cells and osteoclastogenesis-supporting cells were distinguished by two in vitro osteoclast culture systems. Methotrexate (MTX), bucillamine (Buc) and salazosulphapyridine (SASP) inhibited osteoclastogenesis by acting on osteoclast precursor cells and interfering with receptor activator of NF-kappaB ligand (RANKL)-mediated induction of the nuclear factor of activated T cells (NFAT) c1. MTX and SASP also suppressed RANKL expression on osteoclastogenesis-supporting mesenchymal cells. Interestingly, the combination of three antirheumatic drugs exerted a marked inhibitory effect on osteoclastogenesis even at a low dose at which there was much less of an effect when administered individually. These results are consistent with the reported efficacy of combined DMARDs therapy in humans and suggest that osteoclast culture systems are useful tools to provide an experimental basis for the bone-protective effects of antirheumatic drugs.
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Affiliation(s)
- Ayako Suematsu
- Department of Cell Signaling, Graduate School, Tokyo Medical and Dental University and COE Program for Frontier Research on Molecular Destruction and Reconstruction of Tooth and Bone, 1-5-45 Yushima, Tokyo 113-8549, Japan
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Meyer O, de Bandt M, Berthelot JM, Cantagrel A, Combe B, Fautrel B, Flipo RM, Lioté F, Maillefert JF, Saraux A, Wendling D, Guillemin F, Le Loët X. Clinical practice format for choosing a second-line disease modifying anti-rheumatic drug in early rheumatoid arthritis after failure of 6months' first-line DMARD therapy. Joint Bone Spine 2007; 74:73-8. [PMID: 17194614 DOI: 10.1016/j.jbspin.2006.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 05/23/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND The objective was to develop a clinical practice format for choosing a second-line disease-modifying anti-rheumatic drug (DMARD) after a 6-month course of a first-line DMARD in patients with early RA. METHODS A panel of 34 experts selected treatment option from various scenarios using the Thurstone pairwise method. The experts had to choose between two proposed DMARDs without proposing other options. The scenarios were obtained using the three items: DAS28, rheumatoid factor status and radiographic structural damage. A sample of 240 among 480 scenarios for each expert was taken at random. Responses given by at least 20% of the experts were considered pertinent. RESULTS Recommendations for choosing a second DMARD for early RA after failure of a 6-month course of a first-line DMARD were established according to 4 parameters: type of first-line DMARD, activity, RF status and radiographic joint damage. The results of this study suggest that in patients with early RA who fail a 6-month course of first-line DMARD therapy, the best options may be addition of corticosteroid when disease activity is moderate to high and switching to a biologic agent when further radiographic joint damage occurs, particularly in patients with positive tests for RF. CONCLUSION Although our scenarios did not include step-up (add instead of substitute) strategies, except for corticosteroids, we feel that the format presented here can optimise the management of patients with early RA seen in clinical practice.
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Affiliation(s)
- Olivier Meyer
- Department of Rheumatology, AP-HP, Bichat Paris 7 University Hospital, CHU Bichat, 46 rue Henri Huchard, 75018 Paris, France.
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Sanmartí Sala R. [Not Available]. REUMATOLOGIA CLINICA 2007; 3:1-3. [PMID: 21794389 DOI: 10.1016/s1699-258x(07)73592-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Accepted: 09/07/2006] [Indexed: 05/31/2023]
Affiliation(s)
- Raimon Sanmartí Sala
- Unidad de Artritis. Servicio de Reumatología. Hospital Clínic. Barcelona. España
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Fautrel B, Constantin A, Morel J, Vittecoq O, Cantagrel A, Combe B, Dougados M, Le Loët X, Mariette X, Pham T, Puéchal X, Sibilia J, Soubrier M, Ravaud P. Recommendations of the French Society for Rheumatology. TNFalpha antagonist therapy in rheumatoid arthritis. Joint Bone Spine 2006; 73:433-41. [PMID: 16798046 DOI: 10.1016/j.jbspin.2006.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 04/18/2006] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To develop recommendations for TNFalpha-antagonist therapy in patients with rheumatoid arthritis (RA) seen in everyday practice, under the aegis of the French Society for Rheumatology. METHOD We used the methods recommended by the French Agency for Healthcare Accreditation and Evaluation, the AGREE collaboration, and the European League against Rheumatism (EULAR). The recommendations focus on patient selection, monitoring, and treatment adjustments. RESULTS Criteria for selecting patients eligible for TNFalpha-antagonist treatment of RA include: 1) a definitive diagnosis of RA; 2) disease activity for longer than 1 month, including presence of objective signs of inflammation; or radiographic progression; 3) previous failure of methotrexate in the highest tolerated dosage or of another disease-modifying antirheumatic drug in patients with contraindications to methotrexate; 4) absence of contraindications to TNFalpha-antagonist therapy. When starting TNFalpha-antagonist therapy 1) a thorough baseline evaluation should be conducted; 2) any of the three available agents can be used, as no differences in efficacy have been identified in patient populations; 3) concomitant methotrexate therapy is recommended regardless of the TNFalpha antagonist used; and 4) patients should receive standardized follow-up at regular intervals. Treatment adjustments should be based on the following: 1) the treatment objective is achievement of a EULAR response; 2) when such a response is not achieved, the dosage or dosing interval can be changed, or the patient can be switched to another TNFalpha antagonist; 3) in patients who experience intolerance to a TNFalpha antagonist, another TNFalpha antagonist may be tried, depending on the nature of the adverse event; 4) occurrence of a remission should lead to a reduction in symptomatic medications, most notably glucocorticoids where used; in the event of a prolonged remission, either the TNFalpha antagonist or the concomitant disease-modifying antirheumatic drug may be reduced. CONCLUSION These recommendations are intended to help physicians use TNFalpha antagonists in their everyday practice with RA patients. They do not constitute regulations.
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Affiliation(s)
- Bruno Fautrel
- Service de Rhumatologie, Groupe Hospitalier Pitié-Salpêtrière, UFR de Médecine, Université Pierre et Marie-Curie-Paris-VI, 83, Boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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