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Tran-Duy A, Ghiti Moghadam M, Oude Voshaar MAH, Vonkeman HE, Boonen A, Clarke P, McColl G, Ten Klooster PM, Zijlstra TR, Lems WF, Riyazi N, Griep EN, Hazes JMW, Landewé R, Bernelot Moens HJ, van Riel PLCM, van de Laar MAFJ, Jansen TL. An Economic Evaluation of Stopping Versus Continuing Tumor Necrosis Factor Inhibitor Treatment in Rheumatoid Arthritis Patients With Disease Remission or Low Disease Activity: Results From a Pragmatic Open-Label Trial. Arthritis Rheumatol 2018; 70:1557-1564. [PMID: 29745059 DOI: 10.1002/art.40546] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 04/24/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate, from a societal perspective, the incremental cost-effectiveness of withdrawing tumor necrosis factor inhibitor (TNFi) treatment compared to continuation of these drugs within a 1-year, randomized trial among rheumatoid arthritis patients with longstanding, stable disease activity or remission. METHODS Data were collected from a pragmatic, open-label trial. Cost-utility analysis was performed using the nonparametric bootstrapping method, and a cost-effectiveness acceptability curve was constructed using the net-monetary benefit framework, where a willingness-to-accept threshold (WTA) was defined as the minimal cost saved that a patient accepted for each quality-adjusted life year (QALY) lost. RESULTS A total of 531 patients were randomized to the stop group and 286 patients to the continuation group. Withdrawal of TNFi treatment resulted in a >60% reduction of the total drug cost, but led to an increase of ∼30% in other health care expenditures. Compared to continuation, stopping TNFi resulted in a mean yearly cost saving of €7,133 (95% confidence interval [95% CI] €6,071, €8,234]) and was associated with a mean loss of QALYs of 0.02 (95% CI 0.002, 0.040). Mean saved cost per QALY lost and per extra flare incurred in the stop group compared to the continuation group was €368,269 (95% CI €155,132, €1,675,909) and €17,670 (95% CI €13,650, €22,721), respectively. At a WTA of €98,438 per QALY lost, the probability that stopping TNFi treatment is cost-effective was 100%. CONCLUSION Although an official WTA is not defined, the mean saved cost of €368,269 per QALY lost seems acceptable in The Netherlands, given existing data on willingness to pay.
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Affiliation(s)
- An Tran-Duy
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Marjan Ghiti Moghadam
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Martijn A H Oude Voshaar
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - Annelies Boonen
- Maastricht University Medical Center and Maastricht University, Maastricht, The Netherlands
| | - Philip Clarke
- University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff McColl
- University of Melbourne, Melbourne, Victoria, Australia
| | - Peter M Ten Klooster
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | | | - Willem F Lems
- VU University Medical Center and Reade Medical Center, Amsterdam, The Netherlands
| | - N Riyazi
- Haga Medical Center, The Hague, The Netherlands
| | - E N Griep
- Antonius Medical Center, Sneek, The Netherlands
| | - J M W Hazes
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | | | - Mart A F J van de Laar
- Arthritis Center Twente, Medisch Spectrum Twente, and University of Twente, Enschede, The Netherlands
| | - T L Jansen
- Viecurie Medical Center, Venlo, The Netherlands
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Bergstra SA, Branco JC, Vega-Morales D, Salomon-Escoto K, Govind N, Allaart CF, Landewé RBM. Inequity in access to bDMARD care and how it influences disease outcomes across countries worldwide: results from the METEOR-registry. Ann Rheum Dis 2018; 77:1413-1420. [DOI: 10.1136/annrheumdis-2018-213289] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 11/03/2022]
Abstract
ObjectiveTo establish in a global setting the relationships between countries’ socioeconomic status (SES), measured biological disease modifying antirheumatic drug (bDMARD)-usage and disease outcomes. To assess if prescription and reimbursement rules and generic access to medication relates to a countries’ bDMARD-usage.MethodsData on disease activity and drug use from countries that had contributed at least 100 patients were extracted from the METEOR database. Mean disease outcomes of all available patients at the final visit were calculated on a per-country basis. A questionnaire was sent to at least two rheumatologists per country inquiring about DMARD-prices, access to treatment and valid regulations for prescription and reimbursement.ResultsData from 20 379 patients living in 12 different countries showed that countries’ SES was positively associated with measured disease activity (meanDAS28), but not always with physical functioning (HAQ-score). A lower country’s SES, stricter rules for prescription and reimbursement of bDMARDs as well as worse affordability of bDMARDs were associated with lower bDMARD-usage. bDMARD-usage was negatively associated with disease activity (although not with physical functioning), but the association was moderate at best.ConclusionsDisease activity in patients with rheumatoid arthritis as well as bDMARD-usage varies across countries worldwide. The (negative) relationship between countries’ bDMARD-usage and level of disease activity is complex and under the influence of many factors, including—but not limited to—countries’ SES, affordability of bDMARDs and valid prescription and reimbursement rules for bDMARDs.
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Nikiphorou E, Norton S, Young A, Carpenter L, Dixey J, Walsh DA, Kiely P. Association between rheumatoid arthritis disease activity, progression of functional limitation and long-term risk of orthopaedic surgery: combined analysis of two prospective cohorts supports EULAR treat to target DAS thresholds. Ann Rheum Dis 2016; 75:2080-2086. [PMID: 26979104 PMCID: PMC5136699 DOI: 10.1136/annrheumdis-2015-208669] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 02/18/2016] [Accepted: 02/21/2016] [Indexed: 11/17/2022]
Abstract
Objectives To examine the association between disease activity in early rheumatoid arthritis (RA), functional limitation and long-term orthopaedic episodes. Methods Health Assessment Questionnaire (HAQ) disability scores were collected from two longitudinal early RA inception cohorts in routine care; Early Rheumatoid Arthritis Study and Early Rheumatoid Arthritis Network from 1986 to 2012. The incidence of major and intermediate orthopaedic surgical episodes over 25 years was collected from national data sets. Disease activity was categorised by mean disease activity score (DAS28) annually between years 1 and 5; remission (RDAS≤2.6), low (LDAS>2.6–3.2), low-moderate (LMDAS≥3.2–4.19), high-moderate (HMDAS 4.2–5.1) and high (HDAS>5.1). Results Data from 2045 patients were analysed. Patients in RDAS showed no HAQ progression over 5 years, whereas there was a significant relationship between rising DAS28 category and HAQ at 1 year, and the rate of HAQ progression between years 1 and 5. During 27 986 person-years follow-up, 392 intermediate and 591 major surgeries were observed. Compared with the RDAS category, there was a significantly increased cumulative incidence of intermediate surgery in HDAS (OR 2.59 CI 1.49 to 4.52) and HMDAS (OR 1.8 CI 1.05 to 3.11) categories, and for major surgery in HDAS (OR 2.48 CI 1.5 to 4.11), HMDAS (OR 2.16 CI 1.32 to 3.52) and LMDAS (OR 2.07 CI 1.28 to 3.33) categories. There was no significant difference in HAQ progression or orthopaedic episodes between RDAS and LDAS categories. Conclusions There is an association between disease activity and both poor function and long-term orthopaedic episodes. This illustrates the far from benign consequences of persistent moderate disease activity, and supports European League Against Rheumatism treat to target recommendations to secure low disease activity or remission in all patients.
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Affiliation(s)
- Elena Nikiphorou
- Department of Rheumatology, Whittington Hospital NHS Trust, London, UK.,Early Rheumatoid Arthritis Study, Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Sam Norton
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Division of Health & Social Care Research, Faculty of Life and Medical Science, King's College London, London, UK
| | - Adam Young
- Early Rheumatoid Arthritis Study, Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Lewis Carpenter
- Centre for Lifespan & Chronic Illness Research, University of Hertfordshire, Hatfield, UK
| | - Josh Dixey
- Department of Rheumatology, New Cross Hospital, Wolverhampton, UK
| | | | - Patrick Kiely
- Department of Rheumatology, St Georges University Hospitals NHS Foundation Trust, London, UK
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Johansson K, Eriksson JK, van Vollenhoven R, Miller H, Askling J, Neovius M. Does disease activity at the start of biologic therapy influence health care costs in patients with RA? Rheumatology (Oxford) 2015; 54:1472-7. [PMID: 25796560 DOI: 10.1093/rheumatology/kev021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate whether disease activity at baseline influences health care costs in patients with RA initiating biologic treatment. METHODS In the Swedish Biologics Register, we identified patients with RA with baseline 28-joint DAS (DAS28) recorded and starting their first biologic in 2007-11 [n = 1638 with moderate disease activity (DAS28 3.2-5.1) and n = 1870 with high disease activity (DAS28 > 5.1)]. Data on inpatient and outpatient care and prescription drugs were retrieved from nationwide registers. Mean cost differences were estimated adjusted for age, sex and costs the year before treatment start. RESULTS Patients with high (vs moderate) disease activity were older (60 vs 56 years; P < 0.001), but did not differ in sex distribution (75 vs 74% women; P = 0.99) or disease duration (10 vs 10 years; P = 0.13). The year after initiation of biologics, patients with high (vs moderate) baseline disease activity accumulated 9% higher health care costs, but the difference was not statistically significant after adjustment [€19,333 vs €17,810; adjusted difference €870 (95% CI -2, 1742)]. In the subgroup of patients with up to 4 years of follow-up data, decreasing costs were observed over the follow-up time, but no difference was found between patients with high compared with moderate baseline disease activity [€13,704 vs €12,349; adjusted difference 878 (95% CI -364, 2120)]. Irrespective of baseline disease activity, health care costs were approximately three times higher the year after initiation of biologics than the year before due to increased drug costs. CONCLUSION Over up to 4 years of follow-up, no difference in health care costs was found after adjustment in patients starting their first biologic treatment with high vs moderate baseline disease activity.
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Affiliation(s)
| | | | - Ronald van Vollenhoven
- CLINTRID and Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Johan Askling
- Clinical Epidemiology Unit, Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Tran-Duy A, Boonen A, Kievit W, van Riel PLCM, van de Laar MAFJ, Severens JL. Modelling outcomes of complex treatment strategies following a clinical guideline for treatment decisions in patients with rheumatoid arthritis. PHARMACOECONOMICS 2014; 32:1015-1028. [PMID: 24972589 DOI: 10.1007/s40273-014-0184-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Management of rheumatoid arthritis (RA) is characterised by a sequence of disease-modifying antirheumatic drugs (DMARDs) and biological response modifiers (BRMs). In most of the Western countries, the drug sequences are determined based on disease activity and treatment history of the patients. A model for realistic patient outcomes should reflect the treatment pathways relevant for patients with specific characteristics. OBJECTIVE This study aimed at developing a model that could simulate long-term patient outcomes and cost effectiveness of treatment strategies with and without inclusion of BRMs following a clinical guideline for treatment decisions. METHODS Discrete event simulation taking into account patient characteristics and treatment history was used for model development. Treatment effect on disease activity, costs, health utilities and times to events were estimated using Dutch observational studies. Long-term progression of physical functioning was quantified using a linear mixed-effects model. Costs and health utilities were estimated using two-part models. The treatment strategy recommended by the Dutch Society for Rheumatology where both DMARDs and BRMs were available (Strategy 2) was compared with the treatment strategy without BRMs (Strategy 1). Ten thousand theoretical patients were tracked individually until death. In the probabilistic sensitivity analysis, Monte Carlo simulations were performed with 1,000 sets of parameters sampled from appropriate probability distributions. RESULTS The simulated changes over time in disease activity and physical functioning were plausible. The incremental cost per quality-adjusted life-year gained of Strategy 2 compared with Strategy 1 was <euro>124,011. At a willingness-to-pay threshold higher than <euro>119,167, Strategy 2 dominated Strategy 1 in terms of cost effectiveness but the probability that the Strategy 2 is cost effective never exceeded 0.87. CONCLUSIONS It is possible to model the outcomes of complex treatment strategies based on a clinical guideline for the management of RA. Following the Dutch guideline and using real-life data, inclusion of BRMs in the treatment strategy for RA appeared to be less favourable in our model than in most of the existing models that compared drug sequences independent of patient characteristics and used data from randomised controlled clinical trials. Despite complexity and demand for extensive data, our modelling approach can help to identify the knowledge gaps in clinical guidelines for RA management and priorities for future research.
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Affiliation(s)
- An Tran-Duy
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands,
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Relative risk of myelodysplastic syndromes in patients with autoimmune disorders in the General Practice Research Database. Cancer Epidemiol 2014; 38:544-9. [DOI: 10.1016/j.canep.2014.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 08/04/2014] [Accepted: 08/07/2014] [Indexed: 12/17/2022]
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Guillemin F, Carruthers E, Li LC. Determinants of MSK health and disability – Social determinants of inequities in MSK health. Best Pract Res Clin Rheumatol 2014; 28:411-33. [DOI: 10.1016/j.berh.2014.08.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Interchangeability of 28-joint disease activity scores using the erythrocyte sedimentation rate or the C-reactive protein as inflammatory marker. Clin Rheumatol 2014; 33:783-9. [DOI: 10.1007/s10067-014-2538-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/24/2014] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
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Combe B, Logeart I, Belkacemi MC, Dadoun S, Schaeverbeke T, Daurès JP, Dougados M. Comparison of the long-term outcome for patients with rheumatoid arthritis with persistent moderate disease activity or disease remission during the first year after diagnosis: data from the ESPOIR cohort. Ann Rheum Dis 2014; 74:724-9. [DOI: 10.1136/annrheumdis-2013-204178] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Laires PA, Exposto F, Mesquita R, Martins AP, Cunha-Miranda L, Fonseca JE. Patients' access to biologics in rheumatoid arthritis: a comparison between Portugal and other European countries. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:875-85. [PMID: 22986992 DOI: 10.1007/s10198-012-0432-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 08/28/2012] [Indexed: 05/23/2023]
Abstract
BACKGROUND Despite the widespread availability of biologics across Europe, rheumatoid arthritis (RA) patients' access to these drugs differs significantly among countries. OBJECTIVES To compare the proportion of RA patients treated with biologics across Europe and investigate the factors that most influence it, with focus on the Portuguese case, reportedly with low access rates to biologics. METHODS The biologics' market was characterized for 15 selected European countries. Variables potentially influencing patients' access to biologics (PAB) in RA were also collected, including demographic, disease, economic, funding and biologics' market-related data. A multivariable regression model identified the factors that best explain PAB. Based on these determinants, a cluster analysis was performed to group the countries with most similar behaviour regarding PAB allowing the evaluation of Portugal's relative position among these countries. RESULTS The regression model (R(2) = 0.953) indicated that PAB in selected countries is explained mostly by its gross domestic product (GDP) per capita, the usage of methotrexate (MTX) and the biologics' distribution channel. Current MTX usage in Portugal shows similarity with practice from UK, France, Germany or Spain 5 years before, explaining why PAB in Portugal stood at 7% in 2010, 12 percentage points below the average of selected countries. CONCLUSIONS Variations in RA PAB were found across selected countries with Portugal showing the lowest proportion. GDP per capita, biologics distribution channel and consumption of MTX appear to be the best explanatory factors for these fluctuations in European countries.
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Affiliation(s)
- P A Laires
- Outcomes Research, Merck Sharp & Dohme, Edificio Vasco da Gama, nº 19 , 2770-192, Paço de Arcos, Portugal,
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Aga AB, Lie E, Uhlig T, Olsen IC, Wierød A, Kalstad S, Rødevand E, Mikkelsen K, Kvien TK, Haavardsholm EA. Time trends in disease activity, response and remission rates in rheumatoid arthritis during the past decade: results from the NOR-DMARD study 2000–2010. Ann Rheum Dis 2013; 74:381-8. [DOI: 10.1136/annrheumdis-2013-204020] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Putrik P, Ramiro S, Kvien TK, Sokka T, Uhlig T, Boonen A. Variations in criteria regulating treatment with reimbursed biologic DMARDs across European countries. Are differences related to country's wealth? Ann Rheum Dis 2013; 73:2010-21. [PMID: 23940213 DOI: 10.1136/annrheumdis-2013-203819] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To explore criteria regulating treatment with reimbursed biologic disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) across Europe and to relate criteria to indicators of national socioeconomic welfare. METHODS A cross-sectional study among 46 European countries. One expert from each country completed a questionnaire on criteria regulating the start, maintenance/stop and switch of reimbursed bDMARDs. A composite score was developed to evaluate the level of restrictions in prescription of a first bDMARD (0=highly restricted, 5=most liberal). The level of restrictiveness was correlated with national socioeconomic welfare indicators. RESULTS In 10 countries (22%), no bDMARD was reimbursed. Among 36 countries with at least one biologic reimbursed, 23(64%) had no requirement for disease duration to initiate a biologic. Half of the countries required a failure of two synthetic DMARDs to qualify for therapy. 31 countries specified a minimum level of disease activity to be fulfilled and in 20 (56%) countries cut-off for disease activity score with 28-joint assessment was higher than 3.2. Four countries (11%) had the maximum composite score (most liberal) and 20 (56%) scored between 0 and 2 (more restrictive). Criteria for initiation of a bDMARD were negatively associated with countries' socioeconomic welfare (-0.34 to -0.64), and a moderate positive correlation was found between the composite score and welfare indicators (0.59-0.72). Only some countries had regulations for stopping (n=14(39%)) or switching (n=19(53%)). CONCLUSIONS Clinical criteria regulating prescription of bDMARDs in RA differ significantly across Europe. Countries with lower socioeconomic welfare tend to have stricter eligibility criteria, pointing to inequities in access to treatment.
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Affiliation(s)
- Polina Putrik
- Department of Health Promotion and Education, Maastricht University, School for Public Health and Primary Care (CAPHRI), Maastricht, The Netherlands
| | - Sofia Ramiro
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Department of Rheumatology, Hospital Garcia de Orta, Almada, Portugal
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Tuulikki Sokka
- Department of Medicine, Jyväskylä Central Hospital, Jyvaskyla, Finland
| | - Till Uhlig
- Department of Rheumatology, National Research Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center and School for Public Health & Primary Care (CAPHRI), University Maastricht, Maastricht, The Netherlands
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Rheumatoid arthritis. Triple therapy or etanercept after methotrexate failure in RA? Nat Rev Rheumatol 2013; 9:510-2. [PMID: 23897440 DOI: 10.1038/nrrheum.2013.118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Since the 1990s, patients with rheumatoid arthritis have been treated with at least one DMARD. Methotrexate, which is usually the first-line treatment, elicits good or even excellent clinical results in 20–30% of patients—but in most patients it does not. Thus, an important question is what to do after methotrexate failure.
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Impact of socioeconomic gradients within and between countries on health of patients with rheumatoid arthritis (RA): Lessons from QUEST RA. Best Pract Res Clin Rheumatol 2012; 26:705-20. [DOI: 10.1016/j.berh.2012.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 12/29/2022]
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Balsa A, García-Arias M. Is there a place for nonbiological drugs in the treatment of rheumatoid arthritis? Ther Adv Musculoskelet Dis 2012; 2:307-13. [PMID: 22870456 DOI: 10.1177/1759720x10384434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alejandro Balsa
- Rheumatology Unit, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
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Iannone F, Gremese E, Atzeni F, Biasi D, Botsios C, Cipriani P, Ferri C, Foschi V, Galeazzi M, Gerli R, Giardina A, Marchesoni A, Salaffi F, Ziglioli T, Lapadula G. Longterm retention of tumor necrosis factor-α inhibitor therapy in a large italian cohort of patients with rheumatoid arthritis from the GISEA registry: an appraisal of predictors. J Rheumatol 2012; 39:1179-84. [PMID: 22467933 DOI: 10.3899/jrheum.111125] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate 4-year retention rates of tumor necrosis factor-α (TNF-α) inhibitors adalimumab, etanercept, and infliximab among patients with longstanding rheumatoid arthritis (RA), as derived from an Italian national registry. METHODS The clinical records of 853 adult patients with RA in the GISEA (Gruppo Italiano Studio Early Arthritis) registry were prospectively analyzed to compare drug survival rates and the baseline factors that may predict adherence to therapy. RESULTS In 2003 and 2004, 324 patients started treatment with adalimumab, 311 with etanercept, and 218 with infliximab. After 4 years, the global retention rate of anti-TNF-α therapy was 42%. Etanercept survival (51.4%) was significantly better than that of infliximab (37.6%) or adalimumab (36.4%; p < 0.0001). Accordingly, the mean duration of therapy was significantly longer for etanercept (3.1 ± 2 yrs) than for adalimumab (2.6 ± 2 yrs) or infliximab (2.7 ± 2 yrs; p < 0.05). The use of concomitant disease-modifying antirheumatic drugs, mainly methotrexate, and the presence of comorbidities significantly predicted drug continuation (p < 0.01), whereas a high Disease Activity Score did not. CONCLUSION The 4-year global drug survival of adalimumab, etanercept, and infliximab was lower than 50%, with etanercept having the best retention rate. The main positive predictor of adherence to anti-TNF-α therapy was the concomitant use of methotrexate. Our study provides further evidence that the real-life treatment of patients with RA may be different from that of randomized clinical trials.
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González-Álvaro I, Ortiz AM, Alvaro-Gracia JM, Castañeda S, Díaz-Sánchez B, Carvajal I, García-Vadillo JA, Humbría A, López-Bote JP, Patiño E, Tomero EG, Vicente EF, Sabando P, García-Vicuña R. Interleukin 15 levels in serum may predict a severe disease course in patients with early arthritis. PLoS One 2011; 6:e29492. [PMID: 22242124 PMCID: PMC3248461 DOI: 10.1371/journal.pone.0029492] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 11/29/2011] [Indexed: 11/28/2022] Open
Abstract
Background Interleukin-15 (IL-15) is thought to be involved in the physiopathological mechanisms of RA and it can be detected in the serum and the synovial fluid of inflamed joints in patients with RA but not in patients with osteoarthritis or other inflammatory joint diseases. Therefore, the objective of this work is to analyse whether serum IL-15 (sIL-15) levels serve as a biomarker of disease severity in patients with early arthritis (EA). Methodology and Results Data from 190 patients in an EA register were analysed (77.2% female; median age 53 years; 6-month median disease duration at entry). Clinical and treatment information was recorded systematically, especially the prescription of disease modifying anti-rheumatic drugs. Two multivariate longitudinal analyses were performed with different dependent variables: 1) DAS28 and 2) a variable reflecting intensive treatment. Both included sIL-15 as predictive variable and other variables associated with disease severity, including rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibodies (ACPA). Of the 171 patients (638 visits analysed) completing the follow-up, 71% suffered rheumatoid arthritis and 29% were considered as undifferentiated arthritis. Elevated sIL-15 was detected in 29% of this population and this biomarker did not overlap extensively with RF or ACPA. High sIL-15 levels (β Coefficient [95% confidence interval]: 0.12 [0.06–0.18]; p<0.001) or ACPA (0.34 [0.01–0.67]; p = 0.044) were significantly and independently associated with a higher DAS28 during follow-up, after adjusting for confounding variables such as gender, age and treatment. In addition, those patients with elevated sIL-15 had a significantly higher risk of receiving intensive treatment (RR 1.78, 95% confidence interval 1.18–2.7; p = 0.007). Conclusions Patients with EA displaying high baseline sIL-15 suffered a more severe disease and received more intensive treatment. Thus, sIL-15 may be a biomarker for patients that are candidates for early and more intensive treatment.
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van den Berg R, Stanislawska-Biernat E, van der Heijde DMFM. Comparison of recommendations for the use of anti-tumour necrosis factor therapy in ankylosing spondylitis in 23 countries worldwide. Rheumatology (Oxford) 2011; 50:2270-7. [DOI: 10.1093/rheumatology/ker270] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Patel AM, Moreland LW. Certolizumab pegol: a new biologic targeting rheumatoid arthritis. Expert Rev Clin Immunol 2011; 6:855-66. [PMID: 20979550 DOI: 10.1586/eci.10.69] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The past decade has been an exciting period for clinical research and patient care in rheumatoid arthritis. This is mostly due to targeted biologic agents that have changed the outcome of this disease. Certolizumab pegol (Cimzia(®), UCB Inc., GA, USA), which targets TNF-α with a different mechanism of action than widely used biologics, was initially investigated for Crohn's disease but has now been shown to be effective for rheumatoid arthritis. There have been three significant clinical trials demonstrating the efficacy of certolizumab pegol in active rheumatoid arthritis; two with combination methotrexate and one with monotherapy. This article will summarize the data from those trials and compare some of the characteristics of certolizumab pegol to conventional disease-modifying antirheumatic drugs and other biologic agents. Treatment recommendations are beyond the scope of this review; however, with many options available, there will be annotations on current trends in the care of this chronic disease.
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Affiliation(s)
- Aarat M Patel
- Division of Rheumatology and Clinical Immunology, Division of Pediatric Rheumatology, University of Pittsburgh, Children's Hospital, Suite 3000, 400 45th Street, Pittsburgh, PA 15201, USA.
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Hoebert JM, Mantel-Teeuwisse AK, van Dijk L, Laing RO, Leufkens HG. Quality and completeness of utilisation data on biological agents across European countries: tumour necrosis factor alpha inhibitors as a case study. Pharmacoepidemiol Drug Saf 2011; 20:265-71. [DOI: 10.1002/pds.2093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 10/26/2010] [Accepted: 11/23/2010] [Indexed: 11/10/2022]
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Pease C, Pope JE, Truong D, Bombardier C, Widdifield J, Thorne JC, Paul Haraoui B, Psaradellis E, Sampalis J, Bonner A. Comparison of anti-TNF treatment initiation in rheumatoid arthritis databases demonstrates wide country variability in patient parameters at initiation of anti-TNF therapy. Semin Arthritis Rheum 2010; 41:81-9. [PMID: 21168187 DOI: 10.1016/j.semarthrit.2010.09.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 08/06/2010] [Accepted: 09/29/2010] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Characteristics of Canadian RA patients started on anti-tumor necrosis factor (TNF) treatment were compared with 12 other countries. METHODS Data from the Optimization of HUMIRA trial (OH) were compared with Canadian real world studies [Ontario Biologics Research Initiative (OBRI) and the Real-Life Evaluation of Rheumatoid Arthritis in Canadians Receiving HUMIRA (REACH)], and to data from American, Australian, British, Czech, Danish, Dutch, Finnish, German, Italian, Norwegian, Spanish, and Swedish RA databases. Patient characteristics and temporal trends at initiation of anti-TNF therapy were compared between countries. RESULTS Baseline Disease Activity Scores (DAS28) varied from 5.3 to 6.6. Lower disease severity was noted in databases from countries with less restrictive anti-TNF coverage: Dutch [based on previous disease-modifying antirheumatic drugs (DMARD) use, DAS28, swollen joint count (SJC), tender joint count (TJC), Health Assessment Questionnaire Disability Index (HAQ-DI), Danish (previous DMARD use, DAS28), Norwegian (DAS28, SJC, TJC, visual analog scale (VAS) of global health), and Swedish (DAS28, SJC, TJC, HAQ-DI)]. RA databases showed lower disease scores than did OH (P < 0.05). The US databases also showed lower disease severity (CORRONA: previous DMARD use, SJC, TJC; National Data Bank for Rheumatic Diseases: HAQ, P < 0.001). The UK and Czech Republic had restrictive coverage and higher mean baseline DAS28 than OH (P < 0.001). Baseline DAS28 in the registries with published data lowered over time (British, Norwegian, Danish, and Swedish) but less for the British (P < 0.001). CONCLUSIONS These results confirm that regional variation exists between the 13 countries analyzed in the initiation of treatment with anti-TNF agents among RA patients and suggest that in some cases this variation may be increasing. In some countries the mean baseline disease severity declined over time and regional reimbursement policies and differences in physician preferences may be influencing initiation of anti-TNF therapy in RA.
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Affiliation(s)
- Chris Pease
- Department of Medicine, University of Western Ontario, London, ON, Canada
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Uhlig T, Lems W, Dijkmans BAC, Kvien TK, Woolf AD, OSTRA group. Differences in utility and other disease severity levels in patients with rheumatoid arthritis from three European countries. Scand J Rheumatol Suppl 2010; 39:433-4. [DOI: 10.3109/03009741003781993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Patel AM, Moreland LW. Interleukin-6 inhibition for treatment of rheumatoid arthritis: a review of tocilizumab therapy. Drug Des Devel Ther 2010; 4:263-78. [PMID: 21116333 PMCID: PMC2990387 DOI: 10.2147/dddt.s14099] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The dawn of the biologic era has been an exciting period for clinical research and patient care in rheumatoid arthritis (RA). Targeted biologic therapies have changed the outcome of this disease and made remission a realistic outcome for many patients. Tocilizumab (TCZ, Actemra(®)), is a humanized monoclonal antibody against the interleukin 6 receptor and has been approved in many countries for the treatment of moderate to severe RA. There have been a number of important clinical trials demonstrating the efficacy of TCZ in active rheumatoid arthritis. This review summarizes the data on efficacy, patient-reported outcomes, adverse events, and safety from some of these trials. Current trends in clinical practice will be discussed. It is difficult to place TCZ and many new medications in the algorithm of treatment at present. However, the next few years will hopefully reveal their role as we better define abnormal immune processes in individuals with RA.
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Affiliation(s)
- Aarat M Patel
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA 15201, USA.
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Nørgaard M, Larsson H, Pedersen L, Granath F, Askling J, Kieler H, Ekbom A, Sørensen HT, Stephansson O. Rheumatoid arthritis and birth outcomes: a Danish and Swedish nationwide prevalence study. J Intern Med 2010; 268:329-37. [PMID: 20456595 DOI: 10.1111/j.1365-2796.2010.02239.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To examine the prevalence of preterm birth, infants with low Apgar score, small for gestational age (SGA) birth, stillbirth and congenital abnormalities in women with rheumatoid arthritis (RA) compared with women without RA. DESIGN Prevalence study. SETTING Combined Sweden and Denmark nationwide from 1994 to 2006. SUBJECTS We included 871,579 women with a first-time singleton birth identified through population-based healthcare databases. MAIN OUTCOME MEASURES We compared the prevalence of preterm birth, low Apgar score (<7 at 5 min), SGA birth, stillbirth and congenital abnormalities amongst women with RA compared with women without RA using prevalence odds ratio (OR) with 95% confidence interval (95% CI), whilst controlling for maternal age, smoking, parental cohabitation and year. We stratified analyses by period of birth (1994-1997, 1998-2001 and 2002-2006). RESULTS Amongst 1199 women with RA, 7.8% gave birth between 32 and 36 gestational weeks (adjusted OR, 1.44; 95% CI, 1.14-1.82), 1.4% gave birth before gestational week 32 (adjusted OR, 1.55; 95% CI, 0.97-2.47), 1.6% had an infant with a low Apgar score (OR, 0.99; 95% CI, 0.95-1.65), 5.9% had an SGA birth (adjusted OR, 1.56; 95% CI, 1.2-2.01), 0.9% experienced stillbirth (adjusted OR, 2.07; 95% CI, 0.98-4.35) and 4.3% gave birth to an infant with congenital abnormalities (adjusted OR,1.32; 95% CI, 0.98-1.79). The OR for congenital abnormalities decreased from 2.57 (95% CI, 1.59-4.16) in 1994-1997 to 1.00 (95% CI, 0.64-1.56) in 2002-2006. CONCLUSIONS Women with RA had a high prevalence of most adverse birth outcomes. This could be due to inflammatory activity, medical treatment or other factors not controlled for.
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Affiliation(s)
- M Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.
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Conaghan PG, Hensor EMA, Keenan AM, Morgan AW, Emery P. Persistently moderate DAS-28 is not benign: loss of function occurs in early RA despite step-up DMARD therapy. Rheumatology (Oxford) 2010; 49:1894-9. [PMID: 20542894 DOI: 10.1093/rheumatology/keq178] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Current UK management of RA initially employs conventional DMARDs, with biological therapy reserved for DMARD-resistant RA patients with persistently high 28-joint disease activity score (DAS-28). The aim of this study was to examine the effect on patient-reported function of persistently moderate DAS-28 despite modern step-up DMARD therapy in an early arthritis cohort. METHODS Data were obtained from the Yorkshire Early Arthritis Register, a cohort of early (<12 months) RA patients treated with dose-escalated DMARDs. Change in HAQ exceeding the minimum clinically important difference (MCID) was determined for three values of MCID (0.22, 0.31 and 0.49). Changes in HAQ over Months 6-12 were compared between patients whose DAS-28(ESR) was persistently high (> 5.1 at 6- and/or 9-month visits and at the 12-month visit), persistently moderate (>3.2 and ≤ 5.1) or persistently low (≤ 3.2). RESULTS We selected 194 patients for this analysis. Deteriorating HAQ scores were observed in 10.9% of patients with persistently low DAS-28 compared with 21.4% (persistently moderate DAS-28) and 46.7% (persistently high DAS-28), respectively, for MCID = 0.22; 7.3, 14.3 and 20.0% for MCID = 0.31; 5.5, 10.7 and 11.1% for MCID = 0.49. CONCLUSIONS A high DAS-28 was generally associated with a greater degree of functional decline, but persistent moderate elevation of DAS-28 was associated with important functional deterioration in 10-21% of early RA patients (depending on choice of MCID) following a modern DMARD protocol. A proportion of patients with persistently moderate DAS-28 may therefore benefit from more aggressive therapy than that allowed by current UK recommendations.
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Affiliation(s)
- Philip G Conaghan
- Section of Musculoskeletal Disease, Chapel Allerton Hospital, Leeds, UK.
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Hensor EMA, Emery P, Bingham SJ, Conaghan PG. Discrepancies in categorizing rheumatoid arthritis patients by DAS-28(ESR) and DAS-28(CRP): can they be reduced? Rheumatology (Oxford) 2010; 49:1521-9. [PMID: 20435650 DOI: 10.1093/rheumatology/keq117] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The 28-joint disease activity score (DAS-28) guides the use of biologics in RA. The aims of this study were to investigate agreement between the ESR- and CRP-based DAS-28 definitions, and to examine how this agreement may be improved. METHODS Data were obtained from registers of early (n = 520) and established RA (n = 364) patients. Agreement over disease activity levels (remission, low, moderate and high) at baseline and 6 months, and EULAR responder status at 6 months, were assessed in the early cohort. Two alternative DAS-28(CRP) definitions, obtained through linear regression analyses at baseline in the early RA patients, were validated with 6-month data from both the cohorts. RESULTS In early RA patients, despite a high percentage of exact agreement over DAS-28 categories (88.2%), 38 (30.4%) of 125 patients with 'moderate' DAS-28(CRP) at baseline had 'high' DAS-28(ESR). This agreement was improved by modifying the DAS-28(CRP) definition, and by incorporating age and gender: e.g. in early RA patients with moderate original DAS-28(CRP), 30.4% had 'high' DAS-28(ESR), whereas 3.2% had 'low' DAS-28(ESR); following DAS-28(CRP) transformation both proportions were 6.6%. Incorporating age and gender did not improve agreement over EULAR response states. CONCLUSION The DAS-28(ESR) and DAS-28(CRP) definitions differ substantially in classifying RA patients as having moderate or high disease activity, with the ESR definition resulting in a higher proportion of high DAS-28 especially in women. Our results suggest that modifying the DAS-28(CRP) definition may improve agreement with DAS-28(ESR). There are important implications for meta-analyses and for therapy driven by DAS scores.
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Affiliation(s)
- Elizabeth M A Hensor
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, UK.
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Deighton C, Hyrich K, Ding T, Ledingham J, Lunt M, Luqmani R, Kiely P, Bukhari M, Abernethy R, Ostor A, Bosworth A, Gadsby K, McKenna F, Finney D, Dixey J. BSR and BHPR rheumatoid arthritis guidelines on eligibility criteria for the first biological therapy. Rheumatology (Oxford) 2010:keq006b. [PMID: 20308120 DOI: 10.1093/rheumatology/keq006b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Affiliation(s)
- Chris Deighton
- Rheumatology Department, Royal Derby Hospital, Derby, ARC Epidemiology Unit, University of Manchester, Manchester, Rheumatology Unit, Queen Alexandra Hospital, Portsmouth, Rheumatology Department, Nuffield Orthopaedic Centre, Oxford, Rheumatology Department, St George's Healthcare, London, Rheumatology Department, Royal Lancaster Infirmary, Lancaster, Rheumatology Department, St Helens Hospital, St Helens, Rheumatology Department, Addenbrooke's Hospital, Cambridge, National Rheumatoid Arthritis Society, Maidenhead, Department of Rheumatology, Trafford General Hospital, Manchester, Rheumatology Unit, Worthing and Southlands NHS Trust, Worthing and Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
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Kavanaugh A, Keystone E, Feng J, Hooper M. Is a 12-week trial sufficient to evaluate clinical responses to etanercept or MTX treatment in early RA? Rheumatology (Oxford) 2010; 49:1201-3. [DOI: 10.1093/rheumatology/keq036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Castrejón Fernández I, Martínez-López JA, Ortiz García AM, Carmona Ortells L, García-Vicuña R, González-Álvaro I. [Influence of gender on treatment response in a cohort of patients with early rheumatoid arthritis in the area 2 of Madrid]. ACTA ACUST UNITED AC 2010; 6:134-40. [PMID: 21794699 DOI: 10.1016/j.reuma.2009.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Revised: 07/20/2009] [Accepted: 09/03/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the differences between the responses to treatment using DAS28 based on erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in male and female patients. We then analyzed the individual behaviour of each component in a cohort of early arthritis patients in zone 2 of Madrid. PATIENTS AND METHODS We studied a total of 134 patients (77.6% women) who met the American College of Rheumatology (ACR) criteria for the diagnosis of rheumatoid arthritis (RA) belonging to an early arthritis register of the Hospital de La Princesa. We performed 4 visits following a standardized protocol which included necessary variables to calculate the DAS28 with ESR and CRP as well as determining the treatment received by the patients. We analyzed the differences in responses to treatment in males and females using both indexes, as well as their component and the assessment of the disease by the physician. RESULTS Women had higher disease activity and disability at baseline. Although they received more intensive treatment, their average value of DAS28 remained significantly higher compared to men during the follow-up. By contrast, the global disease assessment evaluated by the patient and by the physician remained similar in both gender. When we analyze the DAS28 components separately, it was observed that this discrepancy was due mainly to the tender joints count and the ESR. CONCLUSIONS Women with early RA have higher DAS28ESR scores as a result of higher tender joint counts and ESR. This may represent bias when assessing the response to treatment using the DAS28ESR.
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Abstract
Few, if any, areas of medical therapeutics have witnessed such dramatic changes as those that have occurred in the therapy of rheumatoid arthritis (RA) during the past two decades. Improvements in clinical trials methodologies, the introduction of no fewer than nine biologic agents with distinct mechanisms of action, and the development of better strategies for the use of such agents have all contributed to the new age in RA therapeutics. Here, we review these developments and attempt to describe the current landscape of RA therapy in terms of available treatments, agreed-upon principles of RA management, as well as some important controversies in this field. Despite the great pace at which developments are moving, a treatment-free remission for patients with RA remains an elusive goal and unmet medical needs remain. The quest for better therapies for this potentially devastating disease is still as important as ever; research in this exciting area is ongoing, and it is reasonable to hope that, during the next decade, developments will lead to improved, rationally designed, targeted therapies for RA.
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