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Pinto-Tasende JA, Fernandez-Moreno M, Rego Perez I, Fernandez-Lopez JC, Oreiro-Villar N, De Toro Santos FJ, Blanco-García FJ. Higher Synovial Immunohistochemistry Reactivity of IL-17A, Dkk1, and TGF-β1 in Patients with Early Psoriatic Arthritis and Rheumatoid Arthritis Could Predict the Use of Biologics. Biomedicines 2024; 12:815. [PMID: 38672170 PMCID: PMC11048598 DOI: 10.3390/biomedicines12040815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Delay in diagnosis and therapy in patients with arthritis commonly leads to progressive articular damage. The study aimed to investigate the immunohistochemical reactivity of synovial cytokines associated with inflammation and the bone erosives/neoformatives processes among individuals diagnosed with psoriatic arthritis (PsA), rheumatoid arthritis (RA), osteoarthritis (OA), and radiographic axial spondyloarthritis (r-axSpA), with the intention of identifying potential biomarkers. METHODS Specimens were collected from the inflamed knee joints of patients referred for arthroscopic procedures, and the synovial tissue (ST) was prepared for quantifying protein expression through immunohistochemical analysis (% expressed in Ratio_Area-Intensity) for TGF-β1, IL-17A, Dkk1, BMP2, BMP4, and Wnt5b. The collected data underwent thorough analysis and examination of their predictive capabilities utilising receiver operating characteristic (ROC) curves. RESULTS Valid synovial tissue samples were acquired from 40 patients for IHC quantification analysis. Initially, these patients had not undergone treatment with biologics. However, after 5 years, 4 out of 13 patients diagnosed with PsA and two out of nine patients diagnosed with RA had commenced biologic treatments. Individuals with early PsA who received subsequent biologic treatment exhibited significantly elevated IHC reactivity in ST for TGF-β1 (p = 0.015). Additionally, patients with both PsA and RA who underwent biologic therapy displayed increased IHC reactivity for IL-17A (p = 0.016), TGF-β1 (p = 0.009), and Dkk1 (p = 0.042). ROC curve analysis of IHC reactivity for TGF-β1, Dkk1, and IL-17A in the synovial seems to predict future treatment with biologics in the next 5 years with the area under the curve (AUC) of a combined sum of the three values: AUC: 0.828 (95% CI: 0.689-0.968; p 0.005) S 75% E 84.4%. CONCLUSIONS Higher synovial immunohistochemistry reactivity of IL-17A, Dkk1, and TGF-β1 in patients with early psoriatic arthritis and rheumatoid arthritis may serve as potential indicators for predicting the necessity of utilising biologic treatments.
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Affiliation(s)
- Jose A. Pinto-Tasende
- Department of Rheumatology, Institute of Biomedical Research of A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, Universidade de A Coruña, 15006 A Coruña, Spain; (J.C.F.-L.); (N.O.-V.); (F.J.D.T.S.); (F.J.B.-G.)
| | - Mercedes Fernandez-Moreno
- Institute of Biomedical Research of A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, 15006 A Coruña, Spain; (M.F.-M.); (I.R.P.)
| | - Ignacio Rego Perez
- Institute of Biomedical Research of A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, 15006 A Coruña, Spain; (M.F.-M.); (I.R.P.)
| | - J. Carlos Fernandez-Lopez
- Department of Rheumatology, Institute of Biomedical Research of A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, Universidade de A Coruña, 15006 A Coruña, Spain; (J.C.F.-L.); (N.O.-V.); (F.J.D.T.S.); (F.J.B.-G.)
| | - Natividad Oreiro-Villar
- Department of Rheumatology, Institute of Biomedical Research of A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, Universidade de A Coruña, 15006 A Coruña, Spain; (J.C.F.-L.); (N.O.-V.); (F.J.D.T.S.); (F.J.B.-G.)
| | - F. Javier De Toro Santos
- Department of Rheumatology, Institute of Biomedical Research of A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, Universidade de A Coruña, 15006 A Coruña, Spain; (J.C.F.-L.); (N.O.-V.); (F.J.D.T.S.); (F.J.B.-G.)
| | - Francisco J. Blanco-García
- Department of Rheumatology, Institute of Biomedical Research of A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, Universidade de A Coruña, 15006 A Coruña, Spain; (J.C.F.-L.); (N.O.-V.); (F.J.D.T.S.); (F.J.B.-G.)
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Husni ME, Chang E, Broder MS, Paydar C, Bognar K, Desai P, Klyachkin Y, Khilfeh I. Biologic Initiation Rate in Systemic-Naïve Psoriatic Arthritis Patients Starting Treatment with Apremilast vs Methotrexate: 1-Year Retrospective Analysis of a US Claims Database. Open Access Rheumatol 2022; 14:123-132. [PMID: 35734243 PMCID: PMC9207121 DOI: 10.2147/oarrr.s342123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the rate of biologic initiation after commencing treatment with apremilast (APR) vs methotrexate (MTX), in systemic-naïve patients with psoriatic arthritis (PsA). Patients and Methods Systemic-naïve patients with PsA who started treatment with either APR or MTX between 01/01/2015 and 12/31/2018 were analyzed using claims data from the IBM® MarketScan® Commercial and Medicare Supplemental databases (2014-2019). PsA patients were identified via diagnosis codes; the first prescription date for APR or MTX was the index date. Patient demographics, clinical characteristics, healthcare utilization during the year pre-index (baseline) and the year post-index (follow-up), and median time to biologic initiation were reported descriptively. The rates and risk of biologic initiation during follow-up were compared between APR and MTX users by logistic and Cox regressions, respectively. Models were adjusted for demographics, clinical and utilization measures during the baseline period. Results A total of 2116 patients with PsA newly treated with APR (n = 534) or MTX (n = 1582) were identified. Mean age was similar (50.5 vs 50.4; P = 0.938), and proportion of females was higher for APR vs MTX users (59.4% vs 54.0%; P = 0.031). Mean time to biologic initiation among patients who initiated during follow-up was 194.1 vs 138.7 days between APR vs MTX users (P < 0.001). After adjusting for confounders, the likelihood of biologic initiation was 58% lower (OR, 0.42 [95% CI, 0.32-0.54]; P < 0.001) with APR, with a significantly lower predicted rate of biologic initiation among APR users when compared to MTX users during follow-up (20.0% [95% CI, 16.6-23.9%] vs 37.5% [95% CI, 35.0-40.1%]). Additionally, APR users had a lower risk of biologic initiation than MTX users (HR, 0.46 [95% CI, 0.37-0.57]; P < 0.001) during the 1-year follow-up. Conclusion Systemic-naïve patients with PsA have a lower rate of, and longer time to, biologic initiation over one-year following APR initiation, compared to those initiating MTX.
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Affiliation(s)
| | - Eunice Chang
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | - Michael S Broder
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | - Caleb Paydar
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | - Katalin Bognar
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
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Kaplan D, Husni E, Chang E, S Broder M, Paydar C, Bognar K, Yan J, Richter S, Desai P, Khilfeh I. Biologic initiation rates in systemic-naive psoriasis patients after first-line apremilast versus methotrexate use. J Comp Eff Res 2022; 11:575-582. [PMID: 35514324 DOI: 10.2217/cer-2021-0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare rates of biologic initiation after commencing treatment with apremilast (APR) versus methotrexate (MTX) in systemic-naive patients with psoriasis (PsO). Methods: This was a retrospective cohort study of systemic-naive patients with PsO who initiated treatment with APR or MTX between 1 January 2015 and 31 March 2018. Outcomes: Adjusted rates of biologic initiation during follow-up were compared by logistic and Cox regressions. Results: APR initiators had 58% lower likelihood of biologic initiation (odds ratio: 0.42; 95% CI: 0.37-0.48; p < 0.001), lower adjusted biologic initiation rate (14.4% [95% CI: 13.2-15.7%] vs 28.6% [95% CI: 26.8-30.5%]), lower risk of biologic initiation (hazard ratio: 0.45; 95% CI: 0.40-0.51; p < 0.001) compared with MTX initiators. Conclusion: Systemic-naive patients with PsO have a lower rate of biologic initiation over 1 year following APR initiation.
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Affiliation(s)
- David Kaplan
- Adult & Pediatric Dermatology, Overland Park, KS 66211, USA
| | - Elaine Husni
- Cleveland Clinic Department of Rheumatic and Immunologic Diseases, Cleveland, OH 44195, USA
| | - Eunice Chang
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
| | - Michael S Broder
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
| | - Caleb Paydar
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
| | - Kata Bognar
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
| | - Jessie Yan
- Roche, South San Francisco, CA 94080, USA
| | | | - Pooja Desai
- Janssen Pharmaceuticals, Titusville, NJ 08560, USA
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Kedra J, Granger B, Emilie S, Gaujoux-Viala C, Rat AC, Combe B, Fautrel B. Time to initiation of biologic disease-modifying antirheumatic drugs in the French cohort ESPOIR. Joint Bone Spine 2020; 88:105060. [PMID: 32755722 DOI: 10.1016/j.jbspin.2020.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the time to initiation of biologic disease-modifying anti-rheumatic drugs (bDMARDs) in ESPOIR, the French cohort of patients with rheumatoid arthritis (RA), and factors associated with the timing of bDMARD initiation. METHODS In total, 658 patients with early RA satisfying the 2010 ACR/EULAR criteria were included between 2003 and 2005 and followed annually for 10 years (end of follow up: 2013-2015). The timing of bDMARD introduction and predictors of use were analysed by the Kaplan-Meier method based on Cox proportional-hazard models. RESULTS Overall, 178 patients (31.0%, 95% confidence interval [27.0-34.7]) initiated a bDMARD during the 10-year follow-up, with a mean delay of 43.6 months. The penetration rate was higher during the first 2 years of follow-up (6% between the first and second year, approximately 3.3% each year between the second and seventh year, and<2.0% after the eighth year). The first-used bDMARD was etanercept for 72 patients and adalimumab for 71. On multivariate analysis, Disease Activity Score in 28 joints, radiologic progression and positivity for anti-citrullinated protein antibodies were significantly associated with rapid initiation of a bDMARD (P<0.0001), whereas older age at first joint pain was inversely associated (P<0.0001). CONCLUSIONS Although access to bDMARDs is widespread in France, less than one third of patients with early RA in the ESPOIR cohort initiated a bDMARD over the 10-year follow-up. Poor prognostic factors for RA were associated with more rapid initiation, as expected.
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Affiliation(s)
- Joanna Kedra
- Sorbonne Université, Institut Pierre Louis d'Épidémiologie et de Santé Publique (iPLESP), UMR S1136, Paris, France; AP-HP, Pitié Salpêtrière hospital, Rheumatology department, Paris, France.
| | - Benjamin Granger
- Sorbonne Université, Institut Pierre Louis d'Épidémiologie et de Santé Publique (iPLESP), UMR S1136, Paris, France; AP-HP, Pitié Salpêtrière hospital, Public Health department, Paris, France
| | - Stéphanie Emilie
- Department of internal medicine, Intercommunal Hospital Center of Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Cécile Gaujoux-Viala
- IDESP, Montpellier University, and Nîmes University Hospital, Rheumatology Dept, Nimes, France
| | - Anne-Christine Rat
- University of Caen Normandie, UMR-S 1075, Université de Lorraine, EA 4360 and Caen University Hospital, Rheumatology department, Caen, France
| | - Bernard Combe
- Montpellier University, CHU de Montpellier, Rheumatology Dept, Montpellier, France
| | - Bruno Fautrel
- Sorbonne Université, Institut Pierre Louis d'Épidémiologie et de Santé Publique (iPLESP), UMR S1136, Paris, France; AP-HP, Pitié Salpêtrière hospital, Rheumatology department, Paris, France
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Dregan A, Matcham F, Harber-Aschan L, Rayner L, Brailean A, Davis K, Hatch S, Pariante C, Armstrong D, Stewart R, Hotopf M. Common mental disorders within chronic inflammatory disorders: a primary care database prospective investigation. Ann Rheum Dis 2019; 78:688-695. [DOI: 10.1136/annrheumdis-2018-214676] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/24/2019] [Accepted: 02/17/2019] [Indexed: 01/30/2023]
Abstract
ObjectiveThere is inconsistent evidence about the association between inflammatory disorders and depression and anxiety onset in a primary care context. The study aimed to evaluate the risk of depression and anxiety within multisystem and organ-specific inflammatory disorders.MethodsThis is a prospective cohort study with primary care patients from the UK Clinical Practice Research Datalink diagnosed with an inflammatory disorder between 1 January 2001 and 31 December 2016. These patients were matched on age, gender, practice and index date with patients without an inflammatory disorder. The study exposures were seven chronic inflammatory disorders. Clinical diagnosis of depression and anxiety represented the outcome measures of interest.ResultsAmong 538 707 participants, the incidence of depression ranged from 14 per 1000 person-years (severe psoriasis) to 9 per 1000 person-years (systemic vasculitis), substantively higher compared with their comparison group (5–7 per 1000 person-years). HRs of multiple depression and anxiety events were 16% higher within inflammatory disorders (HR, 1.16, 95% CI 1.12 to 1.21, p<0.001) compared with the matched comparison group. The incidence of depression and anxiety was strongly associated with the age at inflammatory disorder onset. The overall HR estimate for depression was 1.90 (95% CI 1.66 to 2.17, p<0.001) within early-onset disorder (<40 years of age) and 0.93 (95% CI 0.90 to 1.09, p=0.80) within late-onset disorder (≥60 years of age).ConclusionsPrimary care patients with inflammatory disorders have elevated rates of depression and anxiety incidence, particularly those patients with early-onset inflammatory disorders. This finding may reflect the impact of the underlying disease on patients’ quality of life, although the precise mechanisms require further investigation.
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Tummers M, van Hoorn R, Levering C, Booth A, van der Wilt GJ, Kievit W. Optimal search strategies for identifying moderators and predictors of treatment effects in PubMed. Health Info Libr J 2018; 36:318-340. [PMID: 30006959 DOI: 10.1111/hir.12230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/07/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment effects differ across patients. To guide selection of treatments for patients, it is essential to acknowledge these differences and identify moderators or predictors. Our aim was to generate optimal search strategies (commonly known as filters) for PubMed to retrieve papers identifying moderators and predictors of treatment effects. METHODS Six journals were hand-searched for articles on moderators or predictors. Selected articles were randomly allocated to a development and validation set. Search terms were extracted from the development set and tested for their performance. Search filters were created from combinations of these terms and tested in the validation set. RESULTS Of 4407 articles, 198 were considered to be relevant. The most sensitive filter in the development set '("Epidemiologic Methods" [MeSH] OR assign* OR control*[tiab] OR trial*[tiab]) AND therapy*[sh]' yielded in the validation set a sensitivity of 89% [88%-90%] and a specificity of 80% [79%-82%]. CONCLUSIONS The search filters created in this study can help to efficiently retrieve evidence on moderators and predictors of treatment effect. Testing of the filters in multiple domains should reveal robustness across disciplines. These filters can facilitate the retrieval of evidence on moderators and predictors of treatment effects, helping the implementation of stratified or personalised health care.
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Affiliation(s)
- Marcia Tummers
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ralph van Hoorn
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Charlotte Levering
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andrew Booth
- School of Health and Related Research (ScHARR), Health Economics and Decision Science (HEDS), University of Sheffield Regent Court, Sheffield, UK
| | - Gert Jan van der Wilt
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wietske Kievit
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Png WY, Kwan YH, Lim KK, Chew EH, Lui NL, Tan CS, Østbye T, Thumboo J, Fong W. A systematic review of the factors associated with the initiation of biologicals in patients with rheumatological conditions. Eur J Hosp Pharm 2018; 26:163-169. [PMID: 31428325 DOI: 10.1136/ejhpharm-2017-001431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/26/2018] [Accepted: 04/05/2018] [Indexed: 11/04/2022] Open
Abstract
Objectives Biologicals play a crucial role in managing some of the rheumatological diseases, thus it is important for clinicians, healthcare institutions and policy-makers to understand why biologicals are initiated or refused so as to make better decisions to improve patients' disease outcomes. Although there have been many studies investigating factors associated with the initiation of biologicals for patients with rheumatological conditions, there have been no systematic reviews that provide a comprehensive summary. We aim to provide a summary of factors associated with biologicals' initiation for patients with rheumatological conditions. Methods We performed a literature search in PubMed, Embase and PsycINFO. We identified and screened studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Factors were presented according to patient, disease-related, therapy-related, healthcare team-related and system in-place factors. Results A total 1755 articles were reviewed and 24 articles were found to be relevant to our objective. Forty four factors reviewed were placed into five main categories: patient factors (n=13); disease-related factors (n=11); therapy-related factors (n=7); healthcare team-related factors (n=4) and system in-place-related factors (n=9). The factors studied by the published papers found to be associated with decisions to initiate biologicals varied widely. Conclusion Forty two factors of five different categories were found to be associated with biologicals' initiation for patients with rheumatological conditions. Clinicians need to be mindful of the complex nature of these factors to optimise therapy of patients with rheumatological conditions. Healthcare institutions and policy- makers ought to be aware of any potential barriers to successful biologicals' treatment and address them accordingly.
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Affiliation(s)
- Wan Yu Png
- Department of Pharmacy, National University of Singapore, Singapore
| | - Yu Heng Kwan
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Ka Keat Lim
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Eng Hui Chew
- Department of Pharmacy, National University of Singapore, Singapore
| | - Nai Lee Lui
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Truls Østbye
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Julian Thumboo
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
| | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore
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Severity indices in rheumatoid arthritis: A systematic review. ACTA ACUST UNITED AC 2017; 15:146-151. [PMID: 28807652 DOI: 10.1016/j.reuma.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify tools designed to evaluate the severity of patients with rheumatoid arthritis (RA) in order to use them in the investigation of prognostic markers in early arthritis. METHODS We conducted a systematic review of studies that developed/validated an index for RA disease severity. They were analyzed using the COSMIN checklist to assess their methodological quality. In addition, all the variables included were evaluated for their clarity of definition, feasibility and probability of being present in each outcome during the first 2 years of the disease course. To estimate redundancy, variables were grouped by domains. RESULTS After reviewing 3,519 articles, 3 studies were included. The first study, the PAS, assessed whether current and lifetime treatment with disease-modifying antirheumatic drugs and/or biologics accurately predicted RA severity, as measured by the patient-reported PAS. Treatment variables did not fully distinguish patients in the highest and lowest quartiles of PAS scores. Another severity index, the Claims-Based Index for RA Severity (CIRAS), included the variables age, sex, Felty's syndrome, number of rehabilitation and rheumatology visits, test for inflammatory markers, number of chemistry panels/platelet counts ordered and rheumatoid factor test. The correlation was low (r=0.56) with an index previously validated by the same research group, the RA medical records-based index of severity (RARBIS), with Disease Activity Score-C-reactive protein (DAS28-PCR) (r=0.07) and Multidimensional Health Assessment Questionnaire (MD-HAQ) (r=0.008). Finally, the RARBIS, used to validate the CIRAS, was devised as an RA severity index based on medical records. It includes as domains surgery, radiology, extra-articular manifestations, clinical and laboratory variables, previously chosen by an expert panel. RARBIS had a weak correlation with treatment intensity (r=0.35) and with DAS28 (r=0.41). CONCLUSION There is no index to assess the severity of RA based on the course of the first 2 years of follow-up that is adapted to the current strategy of therapeutic management of this disease. Therefore, we believe it is reasonable to develop a new ad hoc severity index for patients with early arthritis.
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Bello AE, Perkins EL, Jay R, Efthimiou P. Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis. Open Access Rheumatol 2017; 9:67-79. [PMID: 28435338 PMCID: PMC5386601 DOI: 10.2147/oarrr.s131668] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methotrexate (MTX) remains the cornerstone therapy for patients with rheumatoid arthritis (RA), with well-established safety and efficacy profiles and support in international guidelines. Clinical and radiologic results indicate benefits of MTX monotherapy and combination with other agents, yet patients may not receive optimal dosing, duration, or route of administration to maximize their response to this drug. This review highlights best practices for MTX use in RA patients. First, to improve the response to oral MTX, a high initial dose should be administered followed by rapid titration. Importantly, this approach does not appear to compromise safety or tolerability for patients. Treatment with oral MTX, with appropriate dose titration, then should be continued for at least 6 months (as long as the patient experiences some response to treatment within 3 months) to achieve an accurate assessment of treatment efficacy. If oral MTX treatment fails due to intolerability or inadequate response, the patient may be "rescued" by switching to subcutaneous delivery of MTX. Consideration should also be given to starting with subcutaneous MTX given its favorable bioavailability and pharmacodynamic profile over oral delivery. Either initiation of subcutaneous MTX therapy or switching from oral to subcutaneous administration improves persistence with treatment. Upon transition from oral to subcutaneous delivery, MTX dosage should be maintained, rather than increased, and titration should be performed as needed. Similarly, if another RA treatment is necessary to control the disease, the MTX dosage and route of administration should be maintained, with titration as needed.
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Affiliation(s)
| | | | - Randy Jay
- Arizona Arthritis & Rheumatology Associates, Phoenix, AZ
| | - Petros Efthimiou
- Division of Rheumatology, New York Methodist Hospital, Brooklyn, NY, USA
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Calip GS, Adimadhyam S, Xing S, Rincon JC, Lee WJ, Anguiano RH. Medication adherence and persistence over time with self-administered TNF-alpha inhibitors among young adult, middle-aged, and older patients with rheumatologic conditions. Semin Arthritis Rheum 2017; 47:157-164. [PMID: 28410817 DOI: 10.1016/j.semarthrit.2017.03.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 02/01/2017] [Accepted: 03/15/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Self-injectable TNF inhibitors are increasingly used early in the chronic treatment of moderate to severe rheumatologic conditions. We estimated medication adherence/persistence over time following initiation in young adult and older adult patients with rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis. METHODS We conducted a retrospective cohort study of patients aged 18+ years newly initiating etanercept, adalimumab, certolizumab pegol, or golimumab using the Truven Health MarketScan Database between 2009 and 2013. Pharmacy dispensing data were used to calculate 12-month medication possession ratios (MPR) and determine adherence (MPR ≥ 0.80) for up to 3 years after starting therapy. Persistence over each 12-month interval was defined as not having a ≥92-day treatment gap. Multivariable generalized estimating equation models were used to calculate odds ratios (OR) and robust 95% confidence intervals (CI) for associations between patient characteristics and repeated adherence/persistence measures over time. RESULTS Among 53,477 new users, 14% were young adults (18-34 years), 49% middle-aged (35-54 years), and 37% older adults (55+ years). Overall, 37% of patients were adherent and 83% were persistent in the first year of therapy. The lowest adherence (17%) and persistence (70%) were observed among young adult patients by Year +3. Compared to older adults, middle-aged (OR = 0.73, 95% CI: 0.71-0.76) and young adults (OR = 0.50, 95% CI: 0.47-0.53) were less likely to be adherent. Higher Charlson comorbidity scores, hospitalizations, and emergency department visits were associated with non-adherence/non-persistence. CONCLUSIONS We observed low adherence to self-administered TNF inhibitors but most patients remained persistent over time. Further efforts to improve adherence in young adults and patients with greater comorbidity are needed.
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Affiliation(s)
- Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612; Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA.
| | - Sruthi Adimadhyam
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Shan Xing
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Julian C Rincon
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Wan-Ju Lee
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Rebekah H Anguiano
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
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González-Álvaro I, Ortiz AM, Seoane IV, García-Vicuña R, Martínez C, Gomariz RP. Biomarkers predicting a need for intensive treatment in patients with early arthritis. Curr Pharm Des 2015; 21:170-81. [PMID: 25163741 PMCID: PMC4298237 DOI: 10.2174/1381612820666140825123104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 08/13/2014] [Indexed: 12/29/2022]
Abstract
The heterogeneous nature of rheumatoid arthritis (RA) complicates early recognition and treatment. In recent years, a growing body of evidence has demonstrated that intervention during the window of opportunity can improve the response to treatment and slow—or even stop—irreversible structural changes. Advances in therapy, such as biologic agents, and changing approaches to the disease, such as the treat to target and tight control strategies, have led to better outcomes resulting from personalized treatment to patients with different prognostic markers. The various biomarkers identified either facilitate early diagnosis or make it possible to adjust management to disease activity or poor outcomes. However, no single biomarker can bridge the gap between disease onset and prescription of the first DMARD, and traditional biomarkers do not identify all patients requiring early aggressive treatment. Furthermore, the outcomes of early arthritis cohorts are largely biased by the treatment prescribed to patients; therefore, new challenges arise in the search for prognostic biomarkers. Herein, we discuss the value of traditional and new biomarkers and suggest the need for intensive treatment as a new surrogate marker of poor prognosis that can guide therapeutic decisions in the early stages of RA.
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Affiliation(s)
| | | | | | | | | | - R P Gomariz
- Rheumatology Service, Hospital Universitario de La Princesa, IIS Princesa, Madrid, Spain.
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Arnold MB, Bykerk VP, Boire G, Haraoui BP, Hitchon C, Thorne C, Keystone EC, Pope JE. Are there differences between young- and older-onset early inflammatory arthritis and do these impact outcomes? An analysis from the CATCH cohort. Rheumatology (Oxford) 2014; 53:1075-86. [DOI: 10.1093/rheumatology/ket449] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ntatsaki E, Mooney J, Scott DGI, Watts RA. Systemic rheumatoid vasculitis in the era of modern immunosuppressive therapy. Rheumatology (Oxford) 2013; 53:145-52. [DOI: 10.1093/rheumatology/ket326] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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14
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Combe B, Rincheval N, Benessiano J, Berenbaum F, Cantagrel A, Daurès JP, Dougados M, Fardellone P, Fautrel B, Flipo RM, Goupille P, Guillemin F, Le Loët X, Logeart I, Mariette X, Meyer O, Ravaud P, Saraux A, Schaeverbeke T, Sibilia J. Five-year Favorable Outcome of Patients with Early Rheumatoid Arthritis in the 2000s: Data from the ESPOIR Cohort. J Rheumatol 2013; 40:1650-7. [DOI: 10.3899/jrheum.121515] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective.To report the 5-year outcome of a large prospective cohort of patients with very early rheumatoid arthritis (RA), and to identify factors predictive of outcome.Methods.Patients were recruited if they had early arthritis of < 6 months’ duration, had a high probability of developing RA, and had never been prescribed disease-modifying antirheumatic drugs (DMARD) or steroids. Logistic regression analysis was used to determine factors that predict outcome.Results.We included 813 patients from December 2002 to April 2005. Age was 48.1 ± 12.6 years, delay before referral 103.1 ± 52.4 days, 28-joint Disease Activity Score (DAS28) 5.1 ± 1.3, Health Assessment Questionnaire (HAQ) 1.0 ± 0.7; 45.8% and 38.7% had rheumatoid factor or antibodies to cyclic citrullinated peptide (anti-CCP), respectively; 22% had hand or foot erosions; 78.5% fulfilled the American College of Rheumatology/European League Against Rheumatism criteria for RA at baseline and 93.8% during followup. At 5 years, 573 patients were evaluated. The outcome was mild for most patients: disease activity (median DAS28 = 2.5) and HAQ disability (median 0.3) were well controlled over time; 50.6% achieved DAS28 remission and 64.7% low disease activity. Radiographic progression was low (2.9 Sharp unit/year) and only a few patients required joint surgery. Nevertheless, some patients developed new comorbidities. During the 5 years, 82.7% of patients had received at least 1 DMARD (methotrexate, 65.9%), 18.3% a biological DMARD, and about 60% prednisone at least once. Anti-CCP was the best predictor of remaining in the cohort for 5 years, of prescription of synthetic or biologic DMARD, and of radiographic progression.Conclusion.The 5-year outcome of an early RA cohort in the 2000s was described. Anti-CCP was a robust predictor of outcome. The generally good 5-year outcome could be related to early referral and early effective treatment, key processes in the management of early RA in daily practice.
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Romão VC, Canhão H, Fonseca JE. Old drugs, old problems: where do we stand in prediction of rheumatoid arthritis responsiveness to methotrexate and other synthetic DMARDs? BMC Med 2013; 11:17. [PMID: 23343013 PMCID: PMC3606422 DOI: 10.1186/1741-7015-11-17] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 01/23/2013] [Indexed: 02/08/2023] Open
Abstract
Methotrexate (MTX) is the central drug in the management of rheumatoid arthritis (RA) and other immune mediated inflammatory diseases. It is widely used either in monotherapy or in association with other synthetic and biologic disease modifying anti-rheumatic drugs (DMARDs). Although comprehensive clinical experience exists for MTX and synthetic DMARDs, to date it has not been possible to preview correctly whether or not a patient will respond to treatment with these drugs. Predicting response to MTX and other DMARDs would allow the selection of patients based on their likelihood of response, thus enabling individualized therapy and avoiding unnecessary adverse effects and elevated costs. However, studies analyzing this issue have struggled to obtain consistent, replicable results and no factor has yet been recognized to individually distinguish responders from nonresponders at treatment start. Variables possibly influencing drug effectiveness may be disease-, patient- or treatment-related, clinical or biological (genetic and nongenetic). In this review we summarize current evidence on predictors of response to MTX and other synthetic DMARDs, discuss possible causes for the heterogeneity observed and address its translation into daily clinical practice.
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Affiliation(s)
- Vasco Crispim Romão
- Rheumatology Research Unit, Instituto de Medicina Molecular - Faculdade de Medicina da Universidade de Lisboa, Edifício Egas Moniz - Av, Prof, Egas Moniz, Lisboa 1649-028, Portugal
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Verstappen SM, Symmons DP. What is the outcome of RA in 2011 and can we predict it? Best Pract Res Clin Rheumatol 2011; 25:485-96. [DOI: 10.1016/j.berh.2011.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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