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Spinelli FR, Garufi C, Mancuso S, Ceccarelli F, Truglia S, Conti F. Tapering and discontinuation of glucocorticoids in patients with rheumatoid arthritis treated with tofacitinib. Sci Rep 2023; 13:15537. [PMID: 37730835 PMCID: PMC10511736 DOI: 10.1038/s41598-023-42371-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/09/2023] [Indexed: 09/22/2023] Open
Abstract
Although the rapid onset of effect of glucocorticoids (GCs) allows rapid control of rheumatoid arthritis (RA) symptoms, their chronic use may be associated with several adverse events. The 2022 update of EUALR recommendations for the management of patients with RA suggests to reduce and discontinue oral GCs as quickly as possible. Considering GCs as a "bridging therapy" to promptly reduce symptoms and control inflammation, fast-acting drugs such as tofacitinib could allow faster and safer tapering of GCs. The purpose of this pilot study was to evaluate the steroid-sparing effect of adding tofacitinib in patients with RA inadequately responsive to methotrexate taking concomitant GCs. In this open-label pilot study, we enrolled patients with moderate to severe RA on a stable dose of prednisone (5-12.5 mg/day) who started treatment with tofacitinib. After 1 month, in patients who achieved at least a moderate EULAR response (decrease of > 1.2 in DAS28_CRP), GCs was tapered according to a predetermined schedule until complete discontinuation at week 12. Disease activity was assessed after 4, 12, 24 and 48 weeks of treatment. The primary endpoint was the percentage of patients discontinuing GCs after 12 weeks of tofacitinib treatment. We enrolled 30 patients (26 F: 4 M, mean age 60 ± 13 years, mean disease duration 13.2 ± 7.8 years). The primary endpoint was achieved: 9 patients (30%) discontinued GCs at week-12. At week-24, other 12 patients (46%) withdrew GCs. The median prednisone dose decreased from 5 mg/day (interquartile range 5-10 mg) to 2.5 (0-5) mg/day at week 12 and 48 (p < 0.00001 vs baseline). At week 48, 12 out of 30 patients (40%) had discontinued prednisone. The percentage of patients achieving remission or low disease activity increased throughout the follow-up without any difference between patients who discontinued or not the GC. In this cohort of long-standing RA patients treated with tofacitinib, the discontinuation of glucocorticoids was achievable in up to 30% of patients. These results should encourage rheumatologists to consider GCs tapering and discontinuation of GCs, as suggested by the 2022 EULAR recommendations, an achievable goal.
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Affiliation(s)
- Francesca Romana Spinelli
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy.
| | - Cristina Garufi
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Silvia Mancuso
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Fulvia Ceccarelli
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Simona Truglia
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - Fabrizio Conti
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari - Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
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Westhovens R, Connolly SE, Margaux J, Vanden Berghe M, Maertens M, Van den Berghe M, Elbez Y, Chartier M, Baeke F, Robert S, Malaise M. Up to 5-year retention of abatacept in Belgian patients with moderate-to-severe rheumatoid arthritis: a sub-analysis of the international, observational ACTION study. Rheumatol Int 2020; 40:1409-1421. [PMID: 32556473 PMCID: PMC7371673 DOI: 10.1007/s00296-020-04619-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/31/2020] [Indexed: 11/26/2022]
Abstract
Favorable efficacy and safety profiles have been demonstrated for abatacept in patients with rheumatoid arthritis (RA) in randomized controlled trials, but these data require validation during long-term follow-ups in routine clinical practice. This study explored long-term safety and retention rates in RA patients treated with intravenous abatacept in the Belgian cohort of the international AbataCepT In rOutiNe clinical practice (ACTION) study (NCT02109666). This non-interventional, observational, longitudinal study included Belgian patients aged ≥ 18 years with moderate-to-severe RA who started intravenous abatacept treatment as first- or second/further-line biologic therapy in routine clinical practice. Between October 2010 and December 2012, 141 patients were enrolled in this cohort, of whom 135 evaluable patients (6 biologic-naïve; 129 previously exposed to ≥ 1 prior biologic disease modifying anti-rheumatic drugs) were eligible for the descriptive analysis; 131/135 were included in the effectiveness analysis. Mean disease duration was 10.5 years (standard deviation 9.7) before abatacept initiation. RA patients presented with high disease activity and comorbidity rate, having failed multiple previous treatment options. In this cohort, the 5-year abatacept retention rate was 34% (95% confidence interval, 23-45%) per protocol, and 51% (95% confidence interval, 40-61%) when temporary discontinuations of abatacept > 84 days (n = 24) were not considered as treatment discontinuations. After 5 years of abatacept treatment, clinical outcomes were favorable [good/moderate European League Against Rheumatism (EULAR) responses in 91.7% patients]. No new safety signals were detected for abatacept in routine clinical practice. In this difficult-to-treat Belgian RA population, high retention rates, good clinical outcomes and favorable safety profile were observed with abatacept.
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Affiliation(s)
- R. Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center Leuven, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | | | - J. Margaux
- Rheumatology and Physical Medicine Department, Erasme Hospital, Brussels, Belgium
| | | | | | | | - Y. Elbez
- Excelya, Boulogne-Billancourt, France
| | - M. Chartier
- Bristol-Myers Squibb, Rueil Malmaison, France
| | - F. Baeke
- Bristol-Myers Squibb, Braine-l’Alleud, Belgium
| | - S. Robert
- Bristol-Myers Squibb, Braine-l’Alleud, Belgium
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Identification of Key Differentially Expressed Transcription Factors in Glioblastoma. JOURNAL OF ONCOLOGY 2020; 2020:9235101. [PMID: 32612655 PMCID: PMC7313158 DOI: 10.1155/2020/9235101] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 01/08/2023]
Abstract
Glioblastoma (GBM) is the most frequent malignant brain tumor in adults. Our study focused on uncovering differentially expressed genes (DEGs) and their methylation in order to identify novel diagnostic biomarkers and potential treatment targets. Using GBM RNA-sequencing data from The Cancer Genome Atlas (TCGA) database, DEGs between GBM samples and paracancer tissue samples were analyzed. Enrichment analysis for DEGs and transcription factors (TFs) was performed. A total of 1029 upregulated genes and 1542 downregulated genes were identified, which were associated mainly with multiple tumor-related and immune-related pathways such as cell cycle, mitogen-activated protein kinase signaling pathway, leukocyte transendothelial migration, and autoimmune thyroid disease. These DEGs were enriched for 174 TFs, and six TFs were differentially expressed and identified as key TFs in GBM: HOXA3, EN1, ZIC1, and FOXD3 were upregulated, while HLF and EGR3 were downregulated. A total of 1978 DEGs were involved in the regulatory networks of the six key differentially expressed TFs. High expression of EN1 was associated with shorter overall survival, while high expression of EGR3 was associated with shorter recurrence-free survival. The six TFs were differentially methylated in GBM samples compared with paracancer tissues. Our study identifies numerous DEGs and their associated pathways as potential contributors to GBM, particularly the TFs EN1, EGR3, HOXA3, ZIC1, FOXD3, and HLF. The differential expression of these TFs may be unlikely driven by aberrant methylation. These TFs may be useful as diagnostic markers and treatment targets in GBM, and EN1 and EGR3 may have predictive prognostic value.
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Khraishi M, Ivanovic J, Zhang Y, Millson B, Brabant MJ, Woolcott J, Jones H, Curiale C. Real-world utilization of methotrexate or prednisone co-therapy with etanercept among Canadian patients with rheumatoid arthritis: a retrospective cohort study. Curr Med Res Opin 2019; 35:2025-2033. [PMID: 31237785 DOI: 10.1080/03007995.2019.1636543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To evaluate whether initiation of etanercept therapy among patients with rheumatoid arthritis (RA) impacts use of co-therapy with methotrexate or prednisone, and to describe etanercept dosing dynamics compared to product monograph in the Canadian real-world setting. Methods: A retrospective cohort study was conducted using claims-level data from IQVIA Private Drug Plan database, Ontario Public Drug Plan database and Régie de l'assurance maladie du Québec database. Bio-naïve RA patients initiating etanercept between July 2014 and June 2015 were identified and their claims for methotrexate or prednisone were analyzed. Utilization of methotrexate or prednisone was calculated as average weekly dose in milligrams, and compared in the 6 months pre-initiation versus 12 months post-initiation of etanercept. Weekly etanercept dosing of each patient was calculated and analyzed to determine whether patients had at least 20% higher or lower average dose than monograph recommended dose (50 mg/week), and were then flagged as above-monograph or below-monograph, respectively. Results: A total of 2876 patients with RA (66% female, 76% aged 18-65) were included; 62% (n = 1,140) used methotrexate and 27% used prednisone (n = 498) both pre- and post-initiation of etanercept. In methotrexate patients, the average weekly dose dispensed was 25.4 mg in the 6 months pre-etanercept, and 25.0 mg in the 12 months post-etanercept initiation (p = .5282). In prednisone patients, the average weekly dose dispensed reduced from 122.6 mg pre-etanercept to 107.1 mg post-etanercept initiation (p = .2173). Among patients who were already on methotrexate or prednisone, after initiating on etanercept 16% (n = 213) and 34% (n = 254) of patients stopped methotrexate and prednisone, respectively. When compared to the recommended dose, 12% (n = 168) of patients were below-monograph and 7.1% of patients were above-monograph during their first year of etanercept therapy. Average etanercept dosing was consistently lower than product monograph during the follow-up year. Conclusions: Patients had a modest but not statistically significant decrease in prescribed doses of co-therapy with methotrexate and prednisone when etanercept was added to patients' therapy. In addition, 12-14% of patients stopped their co-therapy with methotrexate or prednisone. Further study is needed to understand the impact on patient outcomes and safety.
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Affiliation(s)
- Majed Khraishi
- Faculty of Medicine, Memorial University of Newfoundland , St. Johns , NL , USA
| | | | - Yvonne Zhang
- Health Access and Outcomes, IQVIA , Kanata , ON , USA
| | - Brad Millson
- Health Access and Outcomes, IQVIA , Kanata , ON , USA
| | | | - John Woolcott
- Health Economics and Outcomes Research, Pfizer Inc. , Collegeville , PA , USA
| | - Heather Jones
- Inflammation and Immunology, Global Medical Affairs, Pfizer Inc. , Collegeville , PA , USA
| | - Cinzia Curiale
- Inflammation and Immunology, IDM Region Medical Affairs , Roma , Italy
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Jones G, Hall S, Bird P, Littlejohn G, Tymms K, Youssef P, Chung E, Barrett R, Button P. A retrospective review of the persistence on bDMARDs prescribed for the treatment of rheumatoid arthritis in the Australian population. Int J Rheum Dis 2017; 21:1581-1590. [PMID: 29205926 DOI: 10.1111/1756-185x.13243] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To describe the persistence of biologic disease modifying anti-rheumatic drugs (bDMARDs) in Australian rheumatoid arthritis (RA) patients, and assess the influence of methotrexate and other conventional DMARD (cDMARD) concomitant medications, and treatment line on bDMARD persistence and glucocorticoids usage. METHOD RA patients, from the 10% Australian Medicare random sample, aged ≥18 for whom bDMARDs were dispensed were included. Individual sub-cutaneous (SC) anti-tumor necrosis factor-α (anti-TNFα) agents were combined as they were equivalent. RESULTS Data from 1230 patients were analyzed. For all patients the 12-month persistence rates (based on Kaplan-Meier estimates) were 76% for intravenous (IV) tocilizumab, 63% abatacept (SC/IV), 61% SC-anti-TNFs and 36% IV-infliximab. Persistence rates on first-line bDMARDs were 79% (tocilizumab and abatacept), 64% (SC-anti-TNFs) and 13% (infliximab); rates were sustained for tocilizumab but dropped to 49% for abatacept and 51% for SC-anti-TNFs in the second-line setting. Median treatment persistence was 40 months tocilizumab (95% CI: 30-ND), 33 months abatacept (95% CI: 20-ND); 22 months SC-anti-TNF (95% Cl: 18-27), and 4 months infliximab (95% CI: 2-13). Longer persistence was observed for SC-anti-TNFs and abatacept combined with methotrexate or other cDMARDs. For tocilizumab, persistence was robust with or without concomitant medications. The median oral glucocorticoid doses decreased from 4.1 mg/day (min 0, max 21) to 2.0 mg/day (min 0, max 17.3) over 2 years. CONCLUSIONS Treatment persistence was longer on tocilizumab followed by abatacept then SC-anti-TNF therapy and was influenced by co-therapy. Glucocorticoid dosage decreased with bDMARD use. This real-world data highlights that persistence on bDMARDs differs according to biologics mode of action and co-therapy.
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Affiliation(s)
- Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Paul Bird
- University of New South Wales and Combined Rheumatology Practice, Kogarah, NSW, Australia
| | - Geoff Littlejohn
- Monash University and Monash Medical Centre, Clayton, Victoria, Australia
| | - Kathleen Tymms
- Australian National University and Canberra Rheumatology, Canberra, ACT, Australia
| | - Peter Youssef
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Rina Barrett
- Roche Products Pty Limited, Sydney, NSW, Australia
| | - Peter Button
- Roche Products Pty Limited, Sydney, NSW, Australia
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Black RJ, Lester S, Buchbinder R, Barrett C, Lassere M, March L, Whittle S, Hill CL. Factors associated with oral glucocorticoid use in patients with rheumatoid arthritis: a drug use study from a prospective national biologics registry. Arthritis Res Ther 2017; 19:253. [PMID: 29141677 PMCID: PMC5688724 DOI: 10.1186/s13075-017-1461-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 10/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background Glucocorticoids (GCs) are used in ~ 60% of patients with rheumatoid arthritis (RA). Although disease-modifying, they also have significant adverse effects. Understanding factors associated with GC use may help minimise exposure. The aims of the present study were to describe oral GC use in RA; determine any change in use over time; and determine factors associated with oral GC use, commencement or cessation. Methods Adult patients with RA were identified in the Australian Rheumatology Association Database (ARAD), a national Australian registry that collects long-term outcome data from patients with inflammatory arthritis. Patients were categorised by their ARAD date of entry (DOE), with population-averaged logistic regression and transition state analysis used to determine any change in GC use over time. Fixed-effects panel regression was used to examine whether GC current use was associated with pain/arthritis activity/Health Assessment Questionnaire (HAQ) scores or medication use. Transition state analysis was used to assess whether these factors influenced the commencement or cessation of GCs. Results A total of 3699 patients with RA completed a baseline ARAD questionnaire (73% female, mean age 57 years). The probability of GC use decreased over time according to ARAD DOE: September 2001 to March 2005, 55% (95% CI 52–58%); March 2005 to September 2008, 47% (45–49%); September 2008 to March 2012, 42% (39–45%); and March 2012 to October 2015, 39% (34–43%) (p < 0.001). Conventional synthetic disease-modifying anti-rheumatic drugs (OR 10.13; 95% CI 8.22–12.47), non-steroidal anti-inflammatory drugs (1.18; 1.02–1.37) and opioids (2.14; 1.84–2.48) were associated with GC current use, as were lower pain scores (0.94; 0.90–0.98), higher arthritis activity scores (1.09; 1.05–1.14) and poorer HAQ scores (1.52; 1.30–1.79). Use of biologic disease-modifying anti-rheumatic drugs (bDMARDs) was not associated with GC current use (0.98; 0.83–1.15) or GC cessation (HR 0.87; 95% CI 0.75–1.01), but it was associated with GC commencement (0.54; 0.47–0.62). Conclusions The probability of oral GC use decreased over time, with reduced commencement and increased cessation of GCs. The modest effect of bDMARDs on GC cessation was not statistically significant. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1461-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rachel J Black
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, Adelaide, 5000, Australia. .,Division of Medicine, The University of Adelaide, Adelaide, Australia.
| | - Susan Lester
- Division of Medicine, The University of Adelaide, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia.,Department of Epidemiology & Preventive Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | | | - Marissa Lassere
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Lyn March
- Northern Clinical School, Institute of Bone and Joint Research, University of Sydney, Department of Rheumatology, Royal North Shore Hospital, Sydney, Australia
| | - Samuel Whittle
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, Australia
| | - Catherine L Hill
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, Adelaide, 5000, Australia.,Division of Medicine, The University of Adelaide, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, Australia
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Abstract
The use of biologics such as anti-tumor necrosis factor and oral Janus kinase inhibitors have revolutionized the treatment of rheumatoid arthritis (RA). The risk of malignancies such as lymphomas, lung cancer, and nonmelanoma skin cancers (NMSCs) is greater in patients with RA compared with the general population. The incidence of all malignancy (excluding NMSC) was similar in tofacitinib users compared with the general population. The rates of overall and site-specific malignancies in patients with RA treated with tofacitinib are similar to what is expected in the RA population and not different from disease-modifying antirheumatic drugs and biologics.
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Affiliation(s)
- Padmapriya Sivaraman
- Department of Internal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA; Division of Rheumatology, Presbyterian Hospital, 8200 Walnut Hill Ln, Dallas, TX 75231, USA; Metroplex Clinical Research Center, 8144 Walnut Hill Ln, #800, Dallas, TX 75231, USA.
| | - Stanley B Cohen
- Department of Internal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA; Division of Rheumatology, Presbyterian Hospital, 8200 Walnut Hill Ln, Dallas, TX 75231, USA; Metroplex Clinical Research Center, 8144 Walnut Hill Ln, #800, Dallas, TX 75231, USA
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Alten R, Nüßlein H, Galeazzi M, Lorenz HM, Nurmohamed MT, Bensen WG, Burmester GR, Peter HH, Pavelka K, Chartier M, Poncet C, Rauch C, Elbez Y, Le Bars M. Decreased use of glucocorticoids in biological-experienced patients with rheumatoid arthritis who initiated intravenous abatacept: results from the 2-year ACTION study. RMD Open 2016; 2:e000228. [PMID: 26925253 PMCID: PMC4762207 DOI: 10.1136/rmdopen-2015-000228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 12/19/2015] [Indexed: 11/19/2022] Open
Abstract
Introduction Prolonged glucocorticoid use may increase the risk of adverse safety outcomes, including cardiovascular events. The European League Against Rheumatism and the Canadian Rheumatology Association advise tapering glucocorticoid dose as rapidly as clinically feasible. There is a paucity of published data on RA that adequately describe concomitant treatment patterns. Methods ACTION (AbataCepT In rOutiNe clinical practice) is a non-interventional cohort study of patients from Europe and Canada that investigated the long-term retention of intravenous abatacept in clinical practice. We assessed concomitant glucocorticoids in patients with established RA who had participated in ACTION and received ≥1 biological agent prior to abatacept initiation. Results The analysis included 1009 patients. Glucocorticoids were prescribed at abatacept initiation in 734 (72.7%) patients at a median 7.5 mg/day dose (n=692). Of the patients who remained on abatacept at 24 months, 40.7% were able to decrease their dose of glucocorticoids, including 26.9% who decreased their dose from >5 mg/day to ≤5 mg/day. Conclusion Reduction and/or cessation of glucocorticoid therapy is possible with intravenous abatacept in clinical practice.
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Affiliation(s)
- Rieke Alten
- Department of Rheumatology , Schlosspark-Klinik, University Medicine , Berlin , Germany
| | - Hubert Nüßlein
- Department of Clinical Immunology and Rheumatology , University of Erlangen-Nuremberg , Nuremberg , Germany
| | - Mauro Galeazzi
- Department of Rheumatology , University of Siena , Siena , Italy
| | | | - Michael T Nurmohamed
- Department of Rheumatology , VU University Medical Center/Jan van Breemen Research Institute , Amsterdam , The Netherlands
| | - William G Bensen
- Department of Rheumatology , St Joseph's Hospital and McMaster University , Hamilton, Ontario , Canada
| | - Gerd R Burmester
- Department of Rheumatology and Immunology , Charité-Universitätsmedizin , Berlin , Germany
| | - Hans-Hartmut Peter
- Center for Chronic Immunodeficiency, University Medical Center , Freiburg , Germany
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University , Prague , Czech Republic
| | - Mélanie Chartier
- Department of Real-World Research , Chiltern International , Neuilly , France
| | - Coralie Poncet
- Department of Biostatistics , DOCS International , Nanterre , France
| | - Christiane Rauch
- Department of Medical Immunoscience , Bristol-Myers Squibb , Munich , Germany
| | | | - Manuela Le Bars
- Department of Medical Affairs , Bristol-Myers Squibb , Rueil-Malmaison , France
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Black RJ, Joseph RM, Brown B, Movahedi M, Lunt M, Dixon WG. Half of U.K. patients with rheumatoid arthritis are prescribed oral glucocorticoid therapy in primary care: a retrospective drug utilisation study. Arthritis Res Ther 2015; 17:375. [PMID: 26702817 PMCID: PMC4718024 DOI: 10.1186/s13075-015-0895-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/10/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) have shared care between rheumatologists and general practitioners (GPs). Rheumatologists guide immunosuppressive therapy, whilst GPs rely on analgesia and glucocorticoid (GC) therapy to manage active disease. The objective of this study was to describe patterns of GC prescribing for patients with RA in primary care and to determine the influence of patient characteristics and prescriber. METHODS Incident RA patients were identified within the Clinical Practice Research Datalink, a United Kingdom (UK) primary care research database. Descriptive statistics identified patterns of oral GC prescribing. Prescribers were categorised by their tendency to prescribe GCs (high/low). Logistic regression was used to identify baseline characteristics associated with GC prescriptions during follow-up and to examine whether baseline characteristics influenced prescribing differently in high versus low prescribers. RESULTS A total of 7777 patients (47%) received ≥1 GC prescription during follow-up. The average daily dose was 7.5 mg (IQR 5-15.3 mg). Of those who received GCs, >50% were prescribed >10 mg/day and 20 % >30 mg/day. The median proportion of time spent on GCs was 26.3% (IQR 3.8-70.0%). Age and cardiovascular disease (CVD) were associated with increased likelihood of receiving GCs. High prescribers more commonly prescribed GC therapy in older patients and patients with hypertension. CONCLUSIONS Half of patients with incident RA received GCs in primary care. Average GC use was 7.5 mg for 25% of the time, perhaps higher usage than rheumatologists and GPs might expect. GCs were prescribed more commonly in certain high-risk populations, including older patients and those with CVD.
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Affiliation(s)
- Rachel J Black
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,Department of Medicine, The University of Adelaide, Adelaide, SA, 5005, Australia. .,Department of Rheumatology, The Basil Hetzel Institute for Translational Health Research, Woodville Rd, Woodville South, SA, 5011, Australia.
| | - Rebecca M Joseph
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, 29 Grafton Street, Manchester, M13 9WU, UK.
| | - Benjamin Brown
- Health e-Research Centre, Farr Institute for Health Informatics Research, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Mohammad Movahedi
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK.
| | - Mark Lunt
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK.
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, 29 Grafton Street, Manchester, M13 9WU, UK. .,Health e-Research Centre, Farr Institute for Health Informatics Research, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK. .,Department of Rheumatology, Salford Royal NHS Foundation Trust , Stott Lane, Salford, M6 8HD, UK.
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Dejager L, Dendoncker K, Eggermont M, Souffriau J, Van Hauwermeiren F, Willart M, Van Wonterghem E, Naessens T, Ballegeer M, Vandevyver S, Hammad H, Lambrecht B, De Bosscher K, Grooten J, Libert C. Neutralizing TNFα restores glucocorticoid sensitivity in a mouse model of neutrophilic airway inflammation. Mucosal Immunol 2015; 8:1212-25. [PMID: 25760421 DOI: 10.1038/mi.2015.12] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 01/04/2015] [Indexed: 02/04/2023]
Abstract
Asthma is a heterogeneous disorder, evidenced by distinct types of inflammation resulting in different responsiveness to therapy with glucocorticoids (GCs). Tumor necrosis factor α (TNFα) is involved in asthma pathogenesis, but anti-TNFα therapies have not proven broadly effective. The effects of anti-TNFα treatment on steroid resistance have never been assessed. We investigated the role of TNFα blockade using etanercept in the responsiveness to GCs in two ovalbumin-based mouse models of airway hyperinflammation. The first model is GC sensitive and T helper type 2 (Th2)/eosinophil driven, whereas the second reflects GC-insensitive, Th1/neutrophil-predominant asthma subphenotypes. We found that TNFα blockade restores the therapeutic effects of GCs in the GC-insensitive model. An adoptive transfer indicated that the TNFα-induced GC insensitivity occurs in the non-myeloid compartment. Early during airway hyperinflammation, mice are GC insensitive specifically at the level of thymic stromal lymphopoietin (Tslp) transcriptional repression, and this insensitivity is reverted when TNFα is neutralized. Interestingly, TSLP knockout mice displayed increased inflammation in the GC-insensitive model, suggesting a limited therapeutic application of TSLP-neutralizing antibodies in subsets of patients suffering from Th2-mediated asthma. In conclusion, we demonstrate that TNFα reduces the responsiveness to GCs in a mouse model of neutrophilic airway inflammation. Thus antagonizing TNFα may offer a new strategy for therapeutic intervention in GC-resistant asthma.
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Affiliation(s)
- L Dejager
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - K Dendoncker
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - M Eggermont
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - J Souffriau
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - F Van Hauwermeiren
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - M Willart
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - E Van Wonterghem
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - T Naessens
- Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - M Ballegeer
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - S Vandevyver
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - H Hammad
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Respiratory Medicine, Ghent University, Ghent, Belgium
| | - B Lambrecht
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Respiratory Medicine, Ghent University, Ghent, Belgium.,Department Pulmonary Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - K De Bosscher
- Cytokine Receptor Laboratory, Department of Medical Protein Research, VIB, Ghent, Belgium.,Cytokine Receptor Lab, Department of Biochemistry, Ghent University, Ghent, Belgium
| | - J Grooten
- Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - C Libert
- Inflammation Research Center, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
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11
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Fortunet C, Pers YM, Lambert J, Godfrin-Valnet M, Constant E, Devilliers H, Gaudin P, Jorgensen C, Prades BP, Wendling D, Maillefert JF. Tocilizumab induces corticosteroid sparing in rheumatoid arthritis patients in clinical practice. Rheumatology (Oxford) 2014; 54:672-7. [DOI: 10.1093/rheumatology/keu339] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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12
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Therapeutic options after treatment failure in rheumatoid arthritis or spondyloarthritides. Adv Ther 2014; 31:780-802. [PMID: 25112460 DOI: 10.1007/s12325-014-0142-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 02/08/2023]
Abstract
The prognosis for patients with rheumatoid arthritis or spondyloarthritides has improved dramatically due to earlier diagnosis, recognition of the need to treat early with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), alone or in combinations, the establishment of treatment targets, and the development of biological DMARDs (bDMARDs). Many patients are now able to achieve clinical remission or low disease activity with therapy, and reduce or eliminate systemic corticosteroid use. Guidelines recommend methotrexate as a first-line agent for the initial treatment of rheumatoid arthritis; however, a majority of patients will require a change of csDMARD or step up to combination therapy with the addition of another csDMARD or a bDMARD. However, treatment failure is common and switching to a different therapy may be required. The large number of available treatment options, combined with a lack of comparative data, makes the choice of a new therapy complex and often not evidence based. We summarize and discuss evidence to inform treatment decisions in patients who require a change in therapy, including baseline factors that may predict response to therapy.
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13
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Baschant U, Culemann S, Tuckermann J. Molecular determinants of glucocorticoid actions in inflammatory joint diseases. Mol Cell Endocrinol 2013; 380:108-18. [PMID: 23769823 DOI: 10.1016/j.mce.2013.06.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/07/2013] [Indexed: 12/31/2022]
Abstract
Since their discovery in 1948, glucocorticoids have been widely used clinically to treat inflammatory disorders like rheumatoid arthritis. However, their usefulness, especially in rheumatoid arthritis therapy, is hampered by severe side effects on bone leading to glucocorticoid-induced osteoporosis. The molecular and cellular mechanisms mediating the beneficial and adverse effects remain poorly understood. Nevertheless, advanced molecular biological analyses and in vivo approaches using conditional mutant mice have helped to unravel in part the underlying mechanisms of immunosuppression and side effects of glucocorticoid therapy in arthritis, thereby contributing to an improved understanding of these therapeutically important hormones.
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Affiliation(s)
- Ulrike Baschant
- Institute of General Zoology and Endocrinology, University of Ulm, Zentrum für Biomedizinische Forschung, Helmholtzstraße 8/1, D-89081 Ulm, Germany
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14
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Kawai VK, Grijalva CG, Arbogast PG, Curtis JR, Solomon DH, Delzell E, Chen L, Ouellet-Hellstrom R, Herrinton L, Liu L, Mitchel EF, Stein CM, Griffin MR. Changes in cotherapies after initiation of disease-modifying antirheumatic drug therapy in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken) 2011; 63:1415-24. [DOI: 10.1002/acr.20550] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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15
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Hoes JN, Jacobs JWG, Buttgereit F, Bijlsma JWJ. Current view of glucocorticoid co-therapy with DMARDs in rheumatoid arthritis. Nat Rev Rheumatol 2011; 6:693-702. [PMID: 21119718 DOI: 10.1038/nrrheum.2010.179] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Glucocorticoids are widely used anti-inflammatory and immunosuppressive drugs for rheumatoid arthritis (RA). The disease-modifying potential of low to medium doses of glucocorticoids has been reconfirmed in the past decade, and co-administration of DMARDs and glucocorticoids has become standard in many treatment protocols, especially those for early disease stages but also for long-standing RA. The glucocorticoid regimens used range from continuous low doses to intermittent high doses. Studies of the rationale for and clinical use of glucocorticoids as co-therapy with DMARDs in RA have shown that this approach has a place in modern (tight control) treatment strategies, and that glucocorticoid co-therapy has disease-modifying effects during the first 2 years of treatment in patients with early RA. Furthermore, medium and high doses of glucocorticoids are useful for bridging the interval between initiation of DMARDs and onset of their therapeutic effect. Intra-articular glucocorticoids give good local control and have been used in tight control strategies. New glucocorticoid compounds are becoming available for clinical use that might have an enhanced risk:benefit ratio. Better monitoring of glucocorticoid use will also improve this ratio, and help to allay both patient and rheumatologist concerns about treatment-related adverse effects.
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Affiliation(s)
- Jos N Hoes
- University Medical Center Utrecht, Department of Rheumatology & Clinical Immunology, F02.127, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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16
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Whitehouse MW. Anti-inflammatory glucocorticoid drugs: reflections after 60 years. Inflammopharmacology 2010; 19:1-19. [PMID: 21072600 DOI: 10.1007/s10787-010-0056-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 09/19/2010] [Indexed: 12/14/2022]
Abstract
This review considers the problem of the serious concomitant side effects of powerful anti-inflammatory drugs modelled upon the principal human glucocorticoid hormone, cortisol. The very nature of the original bio-assays to validate their cortisol-like hormonal and anti-inflammatory activities ensured that pleiotropic toxins were selected for clinical studies. Other complicating factors have been (1) considerable reliance on bio-assays conducted in laboratory animals that primarily secrete corticosterone, not cortisol, as their principal anti-inflammatory adrenal hormone; (2) some differences in the binding of xenobiotic cortisol analogues (vis á vis cortisol) to transport proteins, detoxifying enzymes and even some intra-cellular receptors; (3) the "rogue" properties of these hormonal xenobiotics, acting independently of--but still able to suppress--hormonal mechanisms regulating endogenous cortisol; and (4) problems of intrinsic/acquired "steroid resistance", diminishing their clinical efficacy, but not necessarily all their toxicities. The rather gloomy conclusion is that devising new drugs to reproduce the effect of multi-potent hormones may be a recipe for disaster, in contexts other than simply remedying an endocrine deficiency. Promising new developments include "designed" combination therapies that allow some reduction in total steroid doses (and hopefully their side effects); sharpening strategies to limit the actual duration of steroid administration; and resurgent interest in searching for more selective analogues (both steroidal and non-steroid) with less harmful side effects. Some oversights and neglected areas of research are also considered. Overall, it now seems timely to engage in some drastic rethinking about (retaining?) these "licensed toxins" as fundamental therapies for chronic inflammation.
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