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Long-term trends in rheumatology care : Achievements and deficits in 25 years of the German national rheumatology database. Z Rheumatol 2019; 78:65-72. [PMID: 31407089 DOI: 10.1007/s00393-019-0680-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Since 1993, data on the care and quality of life of patients with inflammatory rheumatic diseases have been collected in the German National Database (NDB) of the regional collaborative rheumatology centers. OBJECTIVE In this review long-term trends on treatment, disease activity and gainful employment of the most common inflammatory rheumatic diseases are presented and the most important analyses from 25 years of the NDB are summarized. METHODS Between 15 and 17 rheumatological institutions take part in the NDB and once a year collect data from a total of more than 10,000 patients. The rheumatologists document the disease status and care, the patients report on their state of health and the effects of the disease. RESULTS The biologics era at the beginning of the twenty-first century has led to changes in the therapeutic spectrum of most inflammatory rheumatic diseases, especially in rheumatoid arthritis and ankylosing spondylitis. Some basic therapies formerly used are hardly used anymore and glucocorticoids are used less frequently. Methotrexate has remained the standard therapy for rheumatoid arthritis over the years. Nowadays, nearly 30% of patients with rheumatoid arthritis receive treatment with biologics. Disease activity, functional and social restrictions have decreased across all diseases. CONCLUSION The improved health status of many patients with rheumatic diseases confirms the high level of care provided by the rheumatism centers involved in the NDB. The increasing specification of measuring instruments and the standardization of documentation systems are major challenges that the NDB will have to face in the coming years if it is to remain in the digital age.
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Lukas C, Mary J, Debandt M, Daïen C, Morel J, Cantagrel A, Fautrel B, Combe B. Predictors of good response to conventional synthetic DMARDs in early seronegative rheumatoid arthritis: data from the ESPOIR cohort. Arthritis Res Ther 2019; 21:243. [PMID: 31730497 PMCID: PMC6858774 DOI: 10.1186/s13075-019-2020-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/01/2019] [Indexed: 12/21/2022] Open
Abstract
Background and objective Early seronegative rheumatoid arthritis (RA) is considered a specific entity, especially regarding diagnostic issues and prognosis. Little is known about its potentially different initial clinical presentation and outcome. We aimed to determine predictors of good response to conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) in seronegative RA patients with early inflammatory arthritis. Patients and methods Patients from the ESPOIR cohort with early inflammatory arthritis fulfilling the 2010 ACR/EULAR classification criteria for RA despite negativity for both rheumatoid factor and anti-CCP antibodies. The primary endpoint was a good or moderate EULAR response assessed after 1 year of follow-up, given at least 3 months of treatment with a csDMARD. Secondary objectives were to compare the early therapeutic response to methotrexate (MTX) and leflunomide (LEF) versus other csDMARDs (hydroxychloroquine, sulfasalazine) and to identify factors associated with functional disability (Health Assessment Questionnaire-Disability Index [HAQ-DI] > 0.5 at 1 year) and structural progression (van der Heijde-modified total Sharp score > 1 and > 5 points at 1 year). Logistic regression analysis was used to determine independent predictors of outcomes. Results One hundred seventy-two patients were analyzed. Overall, 98/172 (57%) patients received MTX during the first year of follow-up. A good or moderate EULAR response at 1 year was associated with early use of csDMARDs (i.e., within 3 months after the first joint swelling) on univariate and multivariable analysis (odds ratio = 2.41 [95% confidence interval 1.07–5.42], p = 0.03). Response rates were not affected by other classical prognostic factors (i.e., baseline DAS28). Presence of erosions at baseline was associated with Sharp score progression > 1 point and > 5 points (both p = 0.03) at 1 year. HAQ-DI ≥ 1 at inclusion and active smoking were significantly associated with HAQ-DI > 0.5 at 1 year. Conclusion Our results suggest that delay in initiation of csDMARD more than baseline clinical, biological, or imaging features predominantly affects the outcome in early seronegative RA. These findings confirm that the usual therapeutic concepts in RA (early treatment, tight control, and treat-to-target) should be applied similarly to both seropositive and seronegative disease forms. Trial registration ClinicalTrials.gov: NCT03666091. Registered September 11, 2018.
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Affiliation(s)
- Cédric Lukas
- Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France.
| | - Julia Mary
- Rheumatology Department, CHU Martinique, Pierre Zobda-Quitman Hospital, 97200, Fort-de-France, Martinique, French West Indies, France
| | - Michel Debandt
- Rheumatology Department, CHU Martinique, Pierre Zobda-Quitman Hospital, 97200, Fort-de-France, Martinique, French West Indies, France
| | - Claire Daïen
- Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France
| | - Jacques Morel
- Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France
| | - Alain Cantagrel
- Rheumatology Department, University Paul Sabatier Toulouse III, Purpan Hospital, 31059, Toulouse, France
| | - Bruno Fautrel
- Sorbonne Université, Institut Pierre Louis d'Epidémiologie et Santé Publique, INSERM UMR S 1136, AP-HP, Groupe hospitalier Pitié Salpêtrière, Service de Rhumatologie, Paris, France
| | - Bernard Combe
- Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France
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[Which patients with rheumatoid arthritis do not receive DMARD treatment? Analysis of data from the German Collaborative Arthritis Centers]. Z Rheumatol 2019; 79:153-159. [PMID: 31511979 DOI: 10.1007/s00393-019-00712-2] [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] [Indexed: 10/26/2022]
Abstract
BACKGROUND The vast majority of patients with rheumatoid arthritis (RA) included in the national database of the German Collaborative Arthritis Centers are treated with disease-modifying antirheumatic drugs (DMARD). The clinical and patient-related characteristics of patients who did not have DMARD treatment in the longer term were investigated. METHODOLOGY Between 2012 and 2016 a total of 10,289 patients with RA were documented. Patient characteristics, disease activity and severity, comorbidities and concomitant treatment were descriptively evaluated. Patients who were without DMARDs for more than 1 year and not in remission (disease activity score 28, simple disease activity index or Boolean remission) were analyzed separately. Logistic regression was used to investigate which variables were associated with DMARD treatment. RESULTS A total of 426 patients were ≤1 year without DMARDs, 1090 > 1 year without DMARDs and 8773 (85%) currently had DMARD treatment. Of the patients who were without DMARDs for more than 1 year, 51% were in remission. Even if no remission criteria were met, the rheumatologists nevertheless found the strived for RA situation in the majority of patients. Of the patients who were without DMARDs for more than 1 year, 13% received glucocorticoid treatment >5 mg/day. In patients with a high degree of severity (odds ratio, OR severe vs. asymptomatic/mild 2.33, 95% confidence interval, CI 1.80;3.02) or positive rheumatoid factor (OR 2.24, CI 1.96;2.56) the chance of receiving DMARD treatment was twice as high. Existing comorbidities did not reduce the chance of receiving DMARD treatment. CONCLUSION The RA patients in the national database who had no DMARDs for more than 1 year were mostly in remission or with low disease activity. Signs of inadequate disease control were found in only 11% of all patients without DMARD treatment.
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Mouterde G, Rincheval N, Lukas C, Daien C, Saraux A, Dieudé P, Morel J, Combe B. Outcome of patients with early arthritis without rheumatoid factor and ACPA and predictors of rheumatoid arthritis in the ESPOIR cohort. Arthritis Res Ther 2019; 21:140. [PMID: 31171038 PMCID: PMC6555707 DOI: 10.1186/s13075-019-1909-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/07/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To describe the disease course of patients with early arthritis without rheumatoid factor (RF) and anti-citrullinated protein auto-antibodies (ACPA) in an inception cohort. To determine baseline predictors of fulfilling 2010 ACR/EULAR criteria for rheumatoid arthritis (RA) for these patients within 3 years. METHOD Patients included in the multicenter ESPOIR cohort were compared at baseline and 3 years by whether they were negative for RF and ACPA ("seronegative") or positive for RF and/or ACPA ("seropositive"). Univariate analysis was used to determine the association between baseline variables in seronegative patients and RA classification. Stepwise multiple logistic regression was used to identify predictors of RA classification within 3 years, estimating odds ratios (ORs). RESULTS Among 354 seronegative patients, 224/340 with available data (65.9%) fulfilled RA classification at baseline and 189/233 (81.1%) at 3 years. As compared with seropositive patients, seronegative patients had lower DAS28 (p = 0.002) and lower modified total Sharp score (mTSS; p = 0.026) at baseline; DAS28 remission was similar (p = 0.634), but radiographic progression rate was lower in seronegative patients (p < 0.001) at 3 years. In seronegative patients, factors predicting RA classification within 3 years were additive (OR = 3.61), bilateral (OR = 2.59) and hand, wrist or forefeet involvement (OR = 3.87); presence of a trigger event (OR = 3.57); pain at rest (OR = 2.76); morning stiffness (OR = 2.62); number of tender joints (OR = 23.73); and mTSS (OR = 2.56). CONCLUSION "Seronegative" patients have less active disease at baseline and less radiographic progression during follow-up than "seropositive" patients. With inflammatory pain, symmetric involvement of numerous small joints and erosive disease, a classification of RA is likely.
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Affiliation(s)
- Gaël Mouterde
- Rheumatology Department, CHU Montpellier, Univ Montpellier, Montpellier, France. .,EA 2415, Montpellier, France. .,Rheumatology Department, Lapeyronie Hospital, 371, Avenue du Doyen Gaston Giraud, 34295, Montpellier, Cedex 5, France.
| | - Nathalie Rincheval
- EA 2415, Montpellier, France.,Biostatistics, Epidemiology Unit, Montpellier, France
| | - Cédric Lukas
- Rheumatology Department, CHU Montpellier, Univ Montpellier, Montpellier, France.,EA 2415, Montpellier, France
| | - Claire Daien
- Rheumatology Department, CHU Montpellier, Univ Montpellier, Montpellier, France.,UMR 5535, Montpellier, France
| | - Alain Saraux
- Rheumatology department, CHU de la Cavale Blanche & EA 2216, Brest, France
| | - Philippe Dieudé
- Rheumatology Department & INSERM U699, APHP, Bichat Hospital, Paris, France
| | - Jacques Morel
- Rheumatology Department, CHU Montpellier, Univ Montpellier, Montpellier, France.,UMR 5535, Montpellier, France
| | - Bernard Combe
- Rheumatology Department, CHU Montpellier, Univ Montpellier, Montpellier, France.,UMR 5535, Montpellier, France
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Becetti K, Kwakkenbos L, Carrier ME, Gordon JK, Nguyen JT, Mancuso CA, Mouthon L, Nguyen C, Rannou F, Welling J, Thombs BD, Spiera RF. Physical or Occupational Therapy Use in Systemic Sclerosis: A Scleroderma Patient-centered Intervention Network Cohort Study. J Rheumatol 2019; 46:1605-1613. [PMID: 31043542 DOI: 10.3899/jrheum.181130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is characterized by significant disability because of musculoskeletal involvement. Physical and occupational therapy (PT/OT) have been suggested to improve function. However, the rate of PT/OT use has been shown to be low in SSc. We aimed to identify demographic, medical, and psychological variables associated with PT/OT use in SSc. METHODS Participants were patients with SSc enrolled in the Scleroderma Patient-centered Intervention Network (SPIN) Cohort. We determined the rate and indication of PT/OT use in the 3 months prior to enrollment. Multivariable logistic regression was used to identify variables independently associated with PT/OT use. RESULTS Of the 1627 patients with SSc included in the analysis, 23% used PT/OT in the preceding 3 months. PT/OT use was independently associated with higher education (OR 1.08, 95% CI 1.04-1.12), having moderately severe small joint contractures (OR 2.09, 95% CI 1.45-3.03), severe large joint contractures (OR 2.33, 95% CI 1.14-4.74), fewer digital ulcerations (OR 0.70, 95% CI 0.51-0.95), and higher disability (OR 1.54, 95% CI 1.18-2.02) and pain scores (OR 1.04, 95% CI 1.02-1.06). The highest rate of PT/OT use was reported in France (43%) and the lowest, in the United States (17%). CONCLUSION Despite the potential of PT/OT interventions to improve function, < 1 in 4 patients with SSc enrolled in a large international cohort used PT/OT services in the last 3 months. Patients who used PT/OT had more severe musculoskeletal manifestations and higher pain and disability.
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Safy M, de Hair MJH, Jacobs JWG, Buttgereit F, Kraan MC, van Laar JM. Efficacy and safety of selective glucocorticoid receptor modulators in comparison to glucocorticoids in arthritis, a systematic review. PLoS One 2017; 12:e0188810. [PMID: 29267302 PMCID: PMC5739390 DOI: 10.1371/journal.pone.0188810] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 10/23/2017] [Indexed: 12/20/2022] Open
Abstract
Background Long-term treatment with glucocorticoids (GCs) plays an important role in the management of arthritis patients, although the efficacy/safety balance is unfavorable. Alternatives with less (severe) adverse effects but with good efficacy are needed. Selective GC receptor modulators (SGRMs) are designed to engage the GC receptor with dissociative characteristics: transactivation of genes, which is mainly responsible for unwanted effects, is less strong while trans-repression of genes, reducing inflammation, is maintained. It is expected that SGRMs thus have a better efficacy/safety balance than GCs. A systematic review providing an overview of the evidence in arthritis is lacking. Objective To systematically review the current literature on efficacy and safety of oral SGRMs in comparison to GCs in arthritis. Methods A search was performed in Medline, Embase and the Cochrane Library, from inception dates of databases until May 2017. Experimental studies involving animal arthritis models or human material of arthritis patients, as well as clinical studies in arthritis patients were included, provided they reported original data. All types of arthritis were included. Data was extracted on the SGRM studied and on the GC used as reference standard; the design or setting of the study was extracted as well as the efficacy and safety results. Results A total of 207 articles was retrieved of which 17 articles were eligible for our analysis. Two studies concerned randomized controlled trials (RCT), five studies were pre-clinical studies using human material, and 10 studies involved pre-clinical animal models (acute and/or chronic arthritis induced in mice or rats). PF-04171327, the only compound investigated in a clinical trial setting, had a better efficacy/safety balance compared to GCs: better clinical anti-inflammatory efficacy and similar safety. Conclusion Studies assessing both efficacy and safety of SGRMs are scarce. There is limited evidence for dissociation of anti-inflammatory and metabolic effects of the SGRMs studied. Development of many SGRMs is haltered in a preclinical phase. One SGRM showed a better clinical efficacy/safety balance.
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Affiliation(s)
- M Safy
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M J H de Hair
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - M C Kraan
- Department of Rheumatology and Inflammation Research at Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - J M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
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Segan JD, Briggs AM, Chou L, Connelly KL, Seneviwickrama M, Sullivan K, Cicuttini FM, Wluka AE. Patient-perceived health service needs in inflammatory arthritis: A systematic scoping review. Semin Arthritis Rheum 2017; 47:765-777. [PMID: 29174791 DOI: 10.1016/j.semarthrit.2017.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/04/2017] [Accepted: 10/27/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Care that is patient-centred is more likely to be sustainable and associated with improved health outcomes. This approach to care requires an understanding of patients' health service needs, yet few studies have directly investigated the perceived health service needs of people with inflammatory arthritis. OBJECTIVES To systematically identify the existing literature relating to patient perceived health service needs for inflammatory arthritis. METHODS A systematic review of MEDLINE, EMBASE, CINAHL, and PsycINFO was conducted (1990-2016). Studies examining patients' perceived needs relating to health services for inflammatory arthritis were identified. Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Findings were collated and categorized thematically. RESULTS In total, 27 of 1405 (16 qualitative, 9 quantitative, and 2 mixed-methods) studies were relevant. The main areas of perceived need related to (1) Communication: consumers wanted clear, empathic communication, and to be involved with decision-making. (2) Characteristics of ongoing care: adequate consultation length with continuity and timely care were valued. (3) Factors influencing care-seeking included individual attitudes, disease severity, finances and family expectations. (4) Allied health and complementary and alternative medicines (CAM) were perceived as useful by many. The reporting of CAM use to doctors was variable, with several factors contributing to under-reporting. CONCLUSIONS This review identified patients' perceived needs for better communication with their health providers, the heterogeneity of influences determining when care is sought and preferences regarding non-pharmacologic therapies. Aligning patients' perceived needs with evidence-based therapy for people with inflammatory arthritis will be important in optimizing patient outcomes.
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Affiliation(s)
- Julian D Segan
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Commercial Rd, Victoria 3004, Melbourne, Australia
| | - Andrew M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia; MOVE: Muscle, Bone & Joint Health, Victoria, Australia
| | - Louisa Chou
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Commercial Rd, Victoria 3004, Melbourne, Australia
| | - Kathryn L Connelly
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Commercial Rd, Victoria 3004, Melbourne, Australia
| | - Maheeka Seneviwickrama
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Commercial Rd, Victoria 3004, Melbourne, Australia
| | - Kaye Sullivan
- Monash University Library, Monash University, Melbourne, Victoria, Australia
| | - Flavia M Cicuttini
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Commercial Rd, Victoria 3004, Melbourne, Australia
| | - Anita E Wluka
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Commercial Rd, Victoria 3004, Melbourne, Australia.
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Bevan S. Economic impact of musculoskeletal disorders (MSDs) on work in Europe. Best Pract Res Clin Rheumatol 2015; 29:356-73. [DOI: 10.1016/j.berh.2015.08.002] [Citation(s) in RCA: 274] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Characteristics of rheumatoid arthritis in Algeria: a multicenter study. Rheumatol Int 2014; 34:1235-9. [PMID: 24633899 DOI: 10.1007/s00296-014-2981-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Abstract
The aim of this study was to compare the epidemiology of rheumatoid arthritis (RA) in North Africa to that of Western countries. We have enrolled in a cross-sectional study all consecutive patients presenting with the diagnosis of RA according to the 1987 ACR criteria, and during a 5-month period, patients were included in 11 centers across northern Algeria. Demographics, clinical data, and health assessment questionnaires (HAQ) were collected for each patient. We have estimated means, standard deviations, and 95 % confidence intervals for all parameters. Of the 249 patients (213 females and 36 males) enrolled in the study, 10 (4 %) had juvenile onset of the disease. The mean age was 50.1 ± 14.5 years, and the mean duration of RA was 8.4 ± 7.8 years. In terms of comorbidities, 18.9 % of patients reported hypertension and 5.2 % had diabetes. The mean DAS28 at inclusion was 4.3 (95 % CI 4.1-4.5); 14.0 % were in remission (DAS28 ≤ 2.6). The mean HAQ score was 0.81 ± 0.82. Rheumatoid factor was positive in 78.5 % of cases, and anti-citrullinated protein/peptide antibodies, when measured, was positive in 69.0 % of cases. Seronegative patients were older and had a relatively less severe disease. For treatment, 89.7 % of patients were taking disease-modifying anti-rheumatic drugs and only 4 % were taking biologics (rituximab); 90.8 % of patients were taking glucocorticoids, and none of the patients satisfied the recommended calcium intake guidelines. RA in Algeria is more common in women. Compared to reports from Western countries, RA in Algeria appears to be less aggressive, with more dominant seronegative oligoarthritis forms. The remission rate is comparable to that of Western populations.
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Inanır A, Yigit S, Sariyildiz MA, Sogut E. Outcomes of Turkish Ankylosing Spondylitis Patients. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2013. [DOI: 10.29333/ejgm/82245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
BACKGROUND Although physical therapy is a proven and recommended intervention for managing rheumatoid arthritis (RA), few studies have explored correlates of physical therapy service use among people with RA. OBJECTIVE The purposes of this study were: (1) to describe physical therapy use among people with RA and (2) to identify biopsychosocial factors associated with physical therapy use. It was expected that use of physical therapy services would be lower than previously reported, considering recent medical advancements, and that including contextual factors may lead to identification of new factors associated with physical therapy use. DESIGN This was a cohort study. METHODS Of 1,032 patients prospectively recruited from a large hospital registry, 772 completed baseline and laboratory assessments, received a physical examination, and completed a 1-year follow-up survey regarding physical therapy service use. Measures included: demographics (ie, age, sex, marital status, race, employment, disability status, insurance, income, comorbidities, and education), disease duration, RA medications, self-efficacy (assessed with the Arthritis Self-Efficacy Scale), social support (assessed with the Berkman-Syme Social Network Index), function (assessed with the Multi-Dimensional Health Assessment Questionnaire), and disease activity (assessed with the Rheumatoid Arthritis Disease Activity Index). Self-reported use of physical therapy (yes/no) was assessed at the 1-year follow-up. A staged regression approach, based on a theoretical model, was used to select and enter variables into the regression to develop a parsimonious set of predictors. RESULTS The patients were well educated and had modestly high incomes, and most had health insurance. Approximately 15.3% of the patients used physical therapy services during the designated follow-up period. Using multivariable modeling, the most significant predictors of physical therapy service use were moderate to high disease activity (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.1-1.8), less than a college education (OR=0.5, 95% CI=0.2-0.8), greater social networks (OR=2.1, 95% CI=1.3-3.5), and being on disability (OR=2.4, 95% CI=1.3-4.6). LIMITATIONS The limitations of this study were use of a convenience sample and the potential for misclassification of physical therapy service use. CONCLUSIONS Patients with less than college education were less likely to receive physical therapy services, and those with more active disease, those who were on disability, and those who had greater social networks were more likely to receive physical therapy services.
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Defizite der ergotherapeutischen Routineversorgung bei rheumatischen Erkrankungen. Z Rheumatol 2009; 69:435-42. [DOI: 10.1007/s00393-009-0594-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Westhoff G, Schneider M, Raspe H, Zeidler H, Runge C, Volmer T, Zink A. Advance and unmet need of health care for patients with rheumatoid arthritis in the German population--results from the German Rheumatoid Arthritis Population Survey (GRAPS). Rheumatology (Oxford) 2009; 48:650-7. [PMID: 19321515 DOI: 10.1093/rheumatology/kep045] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To assess the quality of health care for RA patients in the general population of Germany. METHODS A three-stage population survey was conducted to identify individuals with RA using a health care access panel (18-79 years; n = 70,112). A 20-item postal screening questionnaire of musculoskeletal symptoms and diagnoses was followed by a detailed questionnaire for those who indicated the possibility of having RA. Respondents who fulfilled the modified ACR decision tree, who reported an RA diagnosis, care by a rheumatologist or the use of DMARDs were asked to participate in a clinical examination by rheumatologists who diagnosed the participants and rated the adequacy of treatment. RESULTS RA could not be ruled out in 1177 cases, of which 643 agreed to participate in the clinical examination, which was finally attended by 317 participants. Attendees did not differ with regard to any health or treatment measure from those who did not attend. Forty-one RA patients were detected. Of them, 93% had seen a rheumatologist at least once and 63% within the last 12 months. A total of 73% had received DMARD therapy at some time and 59% were currently receiving it. An unmet need for DMARDs was discovered in 29% of the RA attendees. It pertained almost exclusively to the seronegative cases of which 29% had a need to start and 17% to increase a DMARD therapy according to the opinion of the examining rheumatologist. CONCLUSION Health care for RA patients has improved significantly since the last German RA survey in 1989. However, DMARD prescription still does not meet clinical recommendations, specifically in RF-negative patients. Since seronegative RA is a treatable disease, this group should not be overlooked.
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Affiliation(s)
- Gisela Westhoff
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany.
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Moreland L. Clinical trials report. Curr Rheumatol Rep 2008. [DOI: 10.1007/s11926-008-0061-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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[News from the rehabilitation field]. Z Rheumatol 2008; 67:539-41. [PMID: 18836733 DOI: 10.1007/s00393-008-0317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bodur H, Ataman S, Akbulut L, Evcik D, Kavuncu V, Kaya T, Günaydin R, Kuran B, Kotevoğlu N, Bal A, Aydoğ E, Altay Z, Uğurlu H, Kocabaş H, Olmez N, Yazgan P, Gürsoy S, Madenci E, Ozel S, Delialioğlu SU. Characteristics and medical management of patients with rheumatoid arthritis and ankylosing spondylitis. Clin Rheumatol 2008; 27:1119-25. [PMID: 18357499 DOI: 10.1007/s10067-008-0877-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 01/09/2008] [Accepted: 02/28/2008] [Indexed: 11/30/2022]
Abstract
Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are chronic, progressive, systemic inflammatory rheumatic diseases that lead to serious disability. The objective of this study was to investigate the demographic and clinical characteristics of the patients with RA and AS who were treated in tertiary hospitals in Turkey and to analyze their current medical management. A total of 562 RA and 216 AS patients were evaluated. The mean age of RA patients was 52.1 +/- 12.6 years. The female to male ratio was 3.7:1. Of the RA patients, 72.2% had positive rheumatoid factor (RF), 62.9% had high C-reactive protein, and 75.2% had radiological erosion. The ratio of patients with Disease Activity Score (DAS) 28 >3.2 was 73.9% and of those with Health Assessment Questionnaire (HAQ) > or =1.5 was 20.9%. There was a statistically significant increase in RF positivity and HAQ scores in the group with higher DAS 28 score. Frequency of extraarticular manifestations was 22.4%. The ratio of the patients receiving disease modifying antirheumatic drugs (DMARD) was 93.1%, and 6.9% of the patients were using anti-tumor necrosis factor (TNF) blocking agents. In AS, the mean age of the patients was 38.1 +/- 10.6, and the female to male ratio was 1:2.5. The time elapsed between the first symptom and diagnosis was 4.3 years. The ratio of peripheral joint involvement was 29.4%. Major histocompatibility complex, class I, B 27 was investigated in 31.1% of patients and the rate of positivity was 91%. In 52.4% of the patients, Bath AS Disease Activity Index (BASDAI) was > or =4. The erythrocyte sedimentation rate, Bath AS Functional Index, and peripheral involvement were significantly higher in the group with BASDAI > or =4. Frequency of extraarticular involvement was 21.2% in AS patients. In the treatment schedule, 77.5% of AS patients were receiving sulphasalazine, 15% methotrexate, and 9.9% anti-TNF agents. Despite widespread use of DMARD, we observed high disease activity in more than half of the RA and AS patients. These results may be due to relatively insufficient usage of anti-TNF agents in our patients and therefore these results mostly reflect the traditional treatments. In conclusion, analysis of disease characteristics will inform us about the disease severity and activity in RA and AS patients and could help in selecting candidate patients for biological treatments.
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Affiliation(s)
- H Bodur
- Physical Medicine and Rehabilitation (PMR) Department, Ankara Numune Training and Research Hospital, Mürsel Uluç Ankara, Turkey.
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18
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Fiehn C, Jacki S, Heilig B, Lampe M, Wiesmüller G, Richter C, Röther E, Rochel E, Gao I. Eight versus 16-week re-evaluation period in rheumatoid arthritis patients treated with leflunomide or methotrexate accompanied by moderate dose prednisone. Rheumatol Int 2007; 27:975-9. [PMID: 17429636 DOI: 10.1007/s00296-007-0347-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Accepted: 03/07/2007] [Indexed: 10/23/2022]
Abstract
In a step-up approach of DMARD treatment of RA a fast response and an early DMARD switch in the case of non-response is important. Therefore, we performed an open trial in which we compared an 8-week and a 16-week observation period during treatment of RA with MTX or LEF, both given in intensified starting doses and accompanied by moderate dose prednisone. MTX and LEF naïve patients with RA (mean time since diagnosis: 2.3 years) were randomised to receive either LEF in a 3-day-loading dose of 100 mg/day followed by 20 mg/day (n = 19) or MTX intramuscularly in a dose of 25 mg once weekly (n = 21). All patients received concomitant treatment with oral prednisone in an initial dose of 20 mg/day with weekly dose reductions of 5 mg/day. The disease activity was re-evaluated 8 and 16 weeks after the start of the treatment. Mean DAS28 before the start of treatment was 5.36 +/- 0.8 for the MTX-group and 5.46 +/- 0.8 for the LEF-group. After 8 weeks of treatment the DAS28 in the MTX-group was 2.59 +/- 1.0 and 3.16 +/- 0.8 in the LEF group (difference not significant). The mean DAS28 at re-evaluation 16 weeks after the starting of treatment (2.58 +/- 1.5 for the MTX-group and 3.25 +/- 1.16 for the LEF-group) was significantly different neither in between the both treatment groups nor in comparison to the week 8 evaluation. Efficiency of RA treatment with MTX or LEF in intensified doses and in combination with moderate dose prednisone can be sufficiently judged 8 weeks after its initiation.
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Affiliation(s)
- C Fiehn
- Association of Rheumatologists (Berufsverband der Rheumatologen), Baden-Württemberg, Germany.
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Kirchberger I, Glaessel A, Stucki G, Cieza A. Validation of the comprehensive international classification of functioning, disability and health core set for rheumatoid arthritis: the perspective of physical therapists. Phys Ther 2007; 87:368-84. [PMID: 17311887 DOI: 10.2522/ptj.20050237] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND PURPOSE The Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Rheumatoid Arthritis (RA) represents the typical spectrum of problems in the functioning of patients with RA. The objective of this study was to validate this ICF Core Set from the perspective of physical therapists. METHODS Physical therapists were asked about their intervention goals in a 3-round Delphi survey. Intervention goals were compiled, and the physical therapists were asked whether they considered the goal classes to be relevant. The goal classes then were linked to the ICF. RESULTS A total of 82 physical therapists in 12 countries named 562 intervention goals. A total of 45 goal classes covering all ICF components were identified. The goal classes addressing muscle tone, balance and coordination, and psychological distress were not represented in the ICF Core Set for RA. DISCUSSION AND CONCLUSION The validity of the ICF Core Set for RA was largely supported. However, some categories currently not covered by the ICF Core Set for RA will need to be investigated further.
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Affiliation(s)
- Inge Kirchberger
- ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), Ludwig-Maximilians University, Munich
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20
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Braun J, Kästner P, Flaxenberg P, Währisch J, Hanke P, Demary W, von Hinüber U, Rockwitz K, Heitz W, Pichlmeier U, Guimbal-Schmolck C, Brandt A. Comparison of the clinical efficacy and safety of subcutaneous versus oral administration of methotrexate in patients with active rheumatoid arthritis: Results of a six-month, multicenter, randomized, double-blind, controlled, phase IV trial. ACTA ACUST UNITED AC 2007; 58:73-81. [PMID: 18163521 DOI: 10.1002/art.23144] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J Braun
- Rheumazentrum Ruhrgebiet, Herne, Germany.
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21
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Chan V, Tett SE. How is leflunomide prescribed and used in Australia? Analysis of prescribing and adverse effect reporting. Pharmacoepidemiol Drug Saf 2006; 15:485-93. [PMID: 16700081 DOI: 10.1002/pds.1252] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE To evaluate the use of leflunomide in the Australian community since introduction in 2000. Trends in adverse drug reaction (ADR) reporting were also studied. METHODS Annual Australian prescription and dispensing statistics were analysed. Drug utilisation was estimated as defined daily doses (DDD)/1000 inhabitants/day. ADR data from the Therapeutic Goods Administration's Adverse Drug Reactions Advisory Committee (ADRAC) national monitoring system were compared with the World Health Organisation (WHO) Vigibase records. RESULTS Leflunomide use in Australia (dispensing data) increased from 0.2 in 2000 to 0.4 DDD/1000 inhabitants/day in 2002. The same overall pattern was observed in the 'authority to prescribe' data. From 2000-2002, prescribing of the starter pack (3 x 100 mg loading dose plus 30 x 20 mg tablets) declined (down 74%); likewise for the 20 mg (30 tablets) pack. Gradual increases were noted for the 10 mg (30 tablets) pack (up 40%). Approximately 135 reports, detailing about 370 individual ADR, were generated annually. Gastro-intestinal disorders predominated, accounting for 24% of reactions reported to ADRAC. Skin and appendages disorders constituted 14% of reported reactions. Deaths in leflunomide users were attributed to a combination of haematological and gastro-intestinal complications, but it was not possible to ascertain other medication usage or contributing factors. Trends observed with the ADRAC reports were consistent with the WHO database. CONCLUSIONS Leflunomide was the first registered DMARD in Australia in over a decade and its use has increased within the community. The ADR reports might have contributed to Australian rheumatologists gradually abandoning loading patients with high doses of leflunomide in favour of starting therapy at lower doses.
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Affiliation(s)
- Vivien Chan
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
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22
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Lopes-Martins RAB, Albertini R, Lopes-Martins PSL, de Carvalho FAS, Neto HCCF, Iversen VV, Bjordal JM. Steroid receptor antagonist mifepristone inhibits the anti-inflammatory effects of photoradiation. Photomed Laser Surg 2006; 24:197-201. [PMID: 16706699 DOI: 10.1089/pho.2006.24.197] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We designed an animal pleurisy study to assess if the anti-inflammatory effect of photoradiation could be affected by concomitant use of the cortisol antagonist mifepristone. BACKGROUND DATA Although interactions between photoradiation and pharmacological agents are largely unknown, parallel use of steroids and photoradiation is common in the treatment of inflammatory disorders such as arthritis and tendinitis. METHODS Forty BALB/c male mice were randomly divided in five groups. Inflammation was induced by carrageenan administered by intrathoracic injections. Four groups received carrageenan, and one control group received injections of sterile saline solution. At 1, 2, and 3 h after injections, photoradiation irradiation was performed with a dose of 7.5 J/cm(2). Two of the carrageenan-injected groups were pre-treated with orally administered mifepristone. RESULTS Total leukocyte cell counts revealed that in carrageenan-induced pleurisy, photoradiation significantly reduced the number of leukocyte cells (p < 0.0001, mean 34.5 [95% CI: 32.8-36.2] versus 87.7 [95% CI: 81.0-94.4]), and that the effect of photoradiation could be totally blocked by adding the cortisol antagonist mifepristone (p < 0.0001, mean 34.5 [95% CI: 32.1-36.9] versus 82.9 [95%CI: 70.5-95.3]). CONCLUSION The steroid receptor antagonist mifepristone significantly inhibited the anti-inflammatory effect of photoradiation. Commonly used glucocorticoids are also known to down-regulate steroid receptors, and further clinical studies are necessary to elucidate how this interaction may decrease the effect size of photoradiation over time. For this reason, we also suggest that, until further clinical data can be provided, clinical photoradiation trials should exclude patients who have received steroid therapy within 6 months before recruitment.
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Affiliation(s)
- Rodrigo Alvaro Brandão Lopes-Martins
- Laboratory of Pharmacology and Phototherapy, Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, Cidade Universitária Armando de Salles Oliveira, Brazil
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23
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Zink A, Huscher D, Schneider M. [The National Database of the German Arthritis Centres--a 12 year balance]. Z Rheumatol 2006; 65:144, 146-51. [PMID: 16496072 DOI: 10.1007/s00393-006-0042-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The National Database of the German Collaborative Arthritis Centres is the most important source for the evaluation of current health care for German rheumatology patients. Since 1993, all outpatients with inflammatory rheumatic diseases treated in one of 24 arthritis centres have been recorded once a year using a clinical record form and a patient questionnaire. The aim is to gain knowledge on the outcomes and the medical, social and economic consequences of inflammatory rheumatic diseases in the real world, and to monitor continuously the current state and trends in health care. Data from more than 200,000 patients with inflammatory rheumatic diseases from 11 years (1993-2003) are available, making it possible to analyse even very rare diseases with a sufficient numbers of cases. Selected results on the health care situation, practice variation in rheumatology and the burden of illness in various diseases are reported.
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Affiliation(s)
- A Zink
- Forschungsbereich Epidemiologie, Deutsches Rheuma-Forschungszentrum Berlin.
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24
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Chan V, Tett SE. Changes in use of disease-modifying anti-rheumatic drugs in Australia over the period 1992–2004. Pharmacoepidemiol Drug Saf 2006; 15:462-8. [PMID: 16700080 DOI: 10.1002/pds.1256] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Evidence is growing that early use of disease-modifying anti-rheumatic drugs (DMARDs) and combinations of these drugs provide optimal care for people with rheumatoid arthirits. The aim of this study was to describe objectively the pattern of consumption of DMARDs in the Australian community (community-based prescribing, specialist and general practitioner) 1992-2004, and to compare this with prescribing patterns reported in other countries. METHOD Dispensing statistics from the Pharmaceutical Benefit Scheme (PBS-Australia's universal prescription subsidy scheme) were analysed and temporal trends evaluated. Drug consumption was calculated as the number of dispensed defined daily doses (DDD)/1000 inhabitants/day (WHO ATC/DDD classification 2005). RESULTS The consumption of DMARDs in the Australian community increased steadily from 2.6 DDD/1000 inhabitants/day in 1992 to 5.5 DDD/1000 inhabitants/day. Over the period 1992-2004, methotrexate (MTX) was the most commonly used DMARD (from 0.6 to 3.0 DDD/1000 inhabitants/day). Consumption of gold (parenteral and oral) and penicillamine declined during this time. The inclusion of leflunomide on the PBS in 2000 contributed to the increase in DMARD usage. CONCLUSION Use of DMARDs within the Australian community has increased in recent years, coinciding with the change in guidelines for therapy for rheumatoid arthritis (RA) to earlier use of DMARDs and the more common use of combinations. This study used DDD methodology to quantify trends for DMARD consumption and these trends are broadly consistent with international prescribing patterns assessed using different methodologies.
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Affiliation(s)
- Vivien Chan
- School of Pharmacy, The University of Queensland, Brisbane, Qld., Australia
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25
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Schneider M, Ostendorf B, Specker CH. [Early diagnosis of rheumatoid arthritis]. Z Rheumatol 2005; 64:516-23. [PMID: 16328755 DOI: 10.1007/s00393-005-0790-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Accepted: 10/17/2005] [Indexed: 10/25/2022]
Abstract
The therapeutic concept of rheumatoid arthritis changed dramatically during the last years. There is significant evidence for the need of an early treatment with disease modifying drugs, the new therapeutic aim is remission. And then the question is: what is a rheumatoid arthritis and when does it start? There is move into the direction of an early undifferentiated arthritis, which may or may not become a persistent arthritis with or without development of erosions. Diagnostic criteria for rheumatoid arthritis are not exsisting, and this article comes after reviewing the existing instruments to the conclusion there is no need for such criteria. In fact, there is a need for instruments that evaluate the risk of an individual patient for persistence, erosive arthritis, and even better, the severity of the disease, which means a judgement of progression. And then the rheumatologists can set the crossbar for starting a DMARD-therapy.
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Affiliation(s)
- M Schneider
- Klinik für Endokrinologie, Diabetologie und Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225 Düsseldorf.
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26
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Jäckel WH, Mau W, Zink A, Beyer W, Droste U, Engel M, Genth E. Routineberichterstattung zur medizinischen Rehabilitation bei muskuloskelettalen Krankheiten. Z Rheumatol 2005; 64:345-50. [PMID: 15965820 DOI: 10.1007/s00393-005-0626-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2003] [Accepted: 04/08/2004] [Indexed: 10/25/2022]
Abstract
The commission "Rehabilitation" of the German Society of Rheumatology compiled a data set for a routine report of the rehabilitation system for muskuloskeletal diseases. More than 250 rehabilitation hospitals offer inpatient rehabilitation for patients with musculoskeletal diseases. The prevalence of inpatient rehabilitation decreased due to new legislative rules in 1997, increased again thereafter but has not reached the former level. The prevalence of inpatient rehabilitation during the preceding year in patients with inflammatory rheumatic diseases treated by rheumatologists amounts to 12% with higher figures in men than in women and lower figures in the area of the former German Democratic Republic. The prevalence of outpatient rehabilitation increased during the last few years but, currently, does not exceed 5% of the entire rehabilitation procedures.
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Affiliation(s)
- W H Jäckel
- Universitätsklinikum Freiburg, Abteilung Qualitätsmanagement und Sozialmedizin, Breisacherstr. 62, Haus 4, 79106 Freiburg im Breisgau, Germany
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27
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Zink A, Fischer-Betz R, Thiele K, Listing J, Huscher D, Gromnica-Ihle E, Specker C, Schneider M. Health care and burden of illness in systemic lupus erythematosus compared to rheumatoid arthritis: results from the National Database of the German Collaborative Arthritis Centres. Lupus 2005; 13:529-36. [PMID: 15352425 DOI: 10.1191/0961203304lu1054oa] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
During the past 20 years, outcome studies in the rheumatic diseases have, on the one hand, given increasing evidence of the unfavourable long-term prognosis of rheumatoid arthritis (RA) and on the other hand determined continuous improvement of prognosis in systemic lupus erythematosus (SLE). The aim of the study was to investigate how this translates into the current spectrum of patients with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) seen by rheumatologists in Germany and to compare aspects of the burden of disease, disease outcomes and treatment between these two important rheumatic diseases using a large clinical database. Current health care was analysed with data from the German rheumatological database of 10 068 patients with RA and 1248 patients with SLE seen by rheumatologists in 2001. In addition, of a total of 3546 patients with SLE and 24 969 patients with RA seen at the German Collaborative Arthritis Centres between 1994 and 2001, 3465 cases of SLE were matched by age, sex, disease duration and referral status with a corresponding RA case. There were considerable differences in treatment of patients before referral to a rheumatologist and in rheumatologic care. In 2001, patients with SLE were treated by their rheumatologists mainly with antimalarials (AM, 37%), azathioprine (29%) and nonselective NSAIDs (16%). Of them, 61% received at least one immunosuppressive drug (including AM) plus glucocorticoids. In RA, methotrexate was the predominant medication (63%), and 56% received at least one immunosuppressive drug plus glucocorticoids. Matched pairs analysis showed that SLE patients with a short disease duration were almost equally burdened by pain, functional limitations and reduced health status as RA patients. After a disease duration of >10 years, however, patients with RA showed poorer outcomes than those with SLE: RA patients reported significantly more often severe pain (30% in RA versus 17% in SLE) and poor global health status (52 versus 38%), and their disease activity as well as severity was rated higher by the rheumatologists. In conclusion, comparing large groups of RA and SLE patients we found a similar burden in early but not in late disease. Taking into account limitations as to the generalizability of the results (recruitment in rheumatologic care, cross-sectional data, underestimation of SLE-specific outcomes), the discrepancy between the high increase in disease-related negative outcomes with longer disease duration in RA but not in SLE indicates a better long-term prognosis in SLE concerning the items observed. The great disparity in treatment intensity between rheumatologists and nonrheumatologists shows that the involvement of a specialist is needed equally in both diseases.
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Affiliation(s)
- A Zink
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany.
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28
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Abstract
Rheumatoid arthritis (RA) registers and databases serve as data storage for longitudinal observational studies. This article describes selected computerized RA databases from the United States and Europe and focuses on their novel observations concerning long-term outcomes of RA.
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Affiliation(s)
- Tuulikki Sokka
- Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University, 203 Oxford House, Nashville, TN 37232-4500, USA.
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29
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Schädlich PK, Zeidler H, Zink A, Gromnica-Ihle E, Schneider M, Straub C, Brecht JG, Huppertz E. Modelling cost effectiveness and cost utility of sequential DMARD therapy including leflunomide for rheumatoid arthritis in Germany: II. The contribution of leflunomide to efficiency. PHARMACOECONOMICS 2005; 23:395-420. [PMID: 15853438 DOI: 10.2165/00019053-200523040-00008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To estimate the 3-year incremental cost effectiveness and cost utility of introducing leflunomide into sequential therapy, consisting of the most frequently used disease-modifying antirheumatic drugs (DMARDs), for patients with rheumatoid arthritis in specialised, i.e. rheumatological, care in Germany. DESIGN AND SETTING The analysis was conducted from the societal perspective in Germany using an existing 3-year simulation model, which was adapted to the German healthcare system after secondary analysis of relevant publications and data. DMARD sequences including leflunomide were compared with those excluding leflunomide. Costs comprised direct costs incurred by treatment and indirect costs incurred by loss of productivity (sick leave and premature retirement) of rheumatoid arthritis patients. Effectiveness parameters were given by response years gained (RYGs) according to the American College of Rheumatology (ACR) criteria for 20%, 50% and 70% improvement (ACR20/50/70RYGs) and by QALYs gained (QALYGs). Costs, effects and QALYs were discounted by 5% per annum. In the base-case analysis, average values of costs, response years and QALYs were applied. Costs were in 1998-2001 values (euro 1 approximately equal to $US 0.91, average of the period from the year 2000 through 2001). MAIN OUTCOME MEASURES AND RESULTS After 3 years, adding leflunomide was less costly and more effective than the strategy excluding leflunomide when total (direct and indirect) costs were considered. There were savings of euro 271,777 and 8.1, 4.3, 5.1 and 4.9 ACR20RYGs, ACR50RYGs, ACR70RYGs and QALYGs per 100 patients, respectively, obtained through adding leflunomide. Focusing on direct costs, adding leflunomide was more costly and more effective compared with excluding leflunomide, with an incremental cost effectiveness of euro 5004 per ACR20RYG, euro 9535 per ACR50RYG, euro 7996 per ACR70RYG, and an incremental cost utility of euro8301 per QALYG, after 3 years. The robustness of the results was shown in comprehensive sensitivity analyses. In the analysis of extremes, different combinations of the limits of cost, effectiveness and utility parameters were investigated. Adding leflunomide to sequential DMARD therapy remained dominant in 79% of the possible cases, i.e. was less costly and more effective than the strategy excluding leflunomide. Focusing on direct costs, adding leflunomide became dominant in 29% and remained more costly and more effective in 50% of possible cases. CONCLUSIONS Our analysis suggests, with its underlying data and assumptions, that having leflunomide as an additional option in a DMARD treatment sequence extends the time patients benefit from DMARD therapy at reasonable additional direct costs. Adding leflunomide may even be cost saving when total (direct and indirect) costs are considered. As data on DMARD effectiveness were extracted from the results of clinical trials, real-world data from observational studies would be needed to corroborate the findings of the present analysis.
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Affiliation(s)
- Peter K Schädlich
- InForMed GmbH - Outcomes Research and Health Economics, Bureau Itzehoe, Conrad-Roentgen-Strasse 58C, D-25524 Itzehoe, Ingolstadt, Germany.
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Thiele K, Buttgereit F, Huscher D, Zink A. Current use of glucocorticoids in patients with rheumatoid arthritis in Germany. ACTA ACUST UNITED AC 2005; 53:740-7. [PMID: 16208641 DOI: 10.1002/art.21467] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe the current use of glucocorticoids in German patients with rheumatoid arthritis (RA). METHODS We analyzed clinical and patient-derived data from 10,068 outpatients with RA from the national database of the German Collaborative Arthritis Centres for the year 2001 collected by more than 80 rheumatologists in hospitals and private practices. RESULTS Systemic glucocorticoid therapy was prescribed for 60% of all patients with RA in rheumatologic care. The proportion of patients receiving systemic glucocorticoids in addition to disease-modifying antirheumatic drug (DMARD) therapy ranged from 53% to 81% of the patients for the various DMARDs. Glucocorticoid therapy was administered more often in combination with tumor necrosis factor inhibitors (81%), cyclosporin A (80%), or leflunomide (77%) than with more traditional DMARDs such as methotrexate (63%) or sulfasalazine (55%). Regarding the prevention and treatment of osteoporosis, 63% of patients taking systemic glucocorticoids were also receiving some type of osteoporosis therapy, as opposed to only 26% of those not taking glucocorticoids. CONCLUSION Glucocorticoids play a pivotal role in the management of RA. This is reflected in the extensive use of low-dose glucocorticoids by German rheumatologists. Even if highly effective DMARDs are prescribed, they are accompanied by glucocorticoids, at least in the initial phase. High-dose glucocorticoids are prescribed for only a small proportion of the patients. There is increasing awareness of the risk of osteoporosis in long-term glucocorticoid treatment, demonstrated by the fact that osteoporosis medication is prescribed for a large proportion of patients taking glucocorticoids.
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31
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Wassenberg S, Rau R, Steinfeld P, Zeidler H. Very low-dose prednisolone in early rheumatoid arthritis retards radiographic progression over two years: A multicenter, double-blind, placebo-controlled trial. ACTA ACUST UNITED AC 2005; 52:3371-80. [PMID: 16255011 DOI: 10.1002/art.21421] [Citation(s) in RCA: 180] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the effect of 5 mg/day prednisolone on disease progression in patients with early rheumatoid arthritis (RA) receiving standardized disease-modifying antirheumatic drug (DMARD) therapy. METHODS Patients with active RA of <2 years' duration were randomly assigned in a double-blinded manner to receive prednisolone or placebo while starting concomitant DMARD therapy (gold sodium thiomalate or methotrexate). Hand and foot radiographs were taken at baseline and at 6, 12, and 24 months and were evaluated according to the Ratingen score and the total modified Sharp/van der Heijde score (SHS). RESULTS Of 192 included patients, 166 were available for the intent-to-treat analysis (ITT). Seventy-six patients completed the study per protocol (PP). Radiographic progression (increase in the Ratingen score) was significantly less with prednisolone than with placebo. The difference in the progression rate between the groups was greatest in the first 6 months. At 24 months in the ITT population, the least squares (LS) mean difference was 3.14 (95% confidence interval [95% CI] 0.94, 5.34), P = 0.006. The results were confirmed by the total SHS in the ITT population (LS mean difference 7.20 [95% CI 0.93, 13.47], P = 0.022) and with the PP population. Clinical and functional outcomes tended to be better and the rate of remissions was higher in the prednisolone group. Side effects were observed more frequently in the prednisolone group than in the control group: weight gain (4 versus 0 patients), hypertension (6 versus 2 patients), glaucoma (3 versus 0 patients), Cushing's syndrome (5 versus 0 patients), gastric distress (9 versus 4 patients), and gastric ulcers (only with concomitant nonsteroidal antiinflammatory drug therapy; 3 versus 0 patients). No new lumbar fractures were found in either group. CONCLUSION The very low daily dose of 5 mg prednisolone given over 2 years in combination with background DMARD therapy substantially decreased radiographic progression in early RA at low risk.
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Schädlich PK, Zeidler H, Zink A, Gromnica-Ihle E, Schneider M, Straub C, Brecht JG, Huppertz E. Modelling cost effectiveness and cost utility of sequential DMARD therapy including leflunomide in rheumatoid arthritis in Germany: I. Selected DMARDs and patient-related costs. PHARMACOECONOMICS 2005; 23:377-93. [PMID: 15853437 DOI: 10.2165/00019053-200523040-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To quantify direct costs of medication and cost of illness (according to functional capacity) for patients with rheumatoid arthritis (RA) in Germany, allowing further use in a health economic evaluation of sequential therapy with disease-modifying antirheumatic drugs (DMARDs) in specialised, i.e. rheumatological, care in Germany. DESIGN AND SETTING The analysis was conducted from the societal perspective in Germany using a modelling approach, which was based on secondary analysis of existing data and on data from a sample of 583 patients from the German rheumatological database of 1998. Functional capacity was defined by the Hannover Functional Ability Questionnaire (HFAQ) scores. Costs were calculated from resources utilised and patients' work capacity. Direct costs consisted of outpatient medical services, inpatient treatment, long-term care and rehabilitation treatment. Indirect costs incurred by sick leave and premature retirement were quantified according to the human-capital approach. MAIN OUTCOME MEASURES AND RESULTS Average total direct costs (year 1998-2001 values) per patient per year for continuous treatment with the selected DMARDs comprising costs for drugs, monitoring and treatment of adverse drug reactions (ADRs) were highest for intramuscular gold (sodium aurothiomalate) [euro 2106 (euro 1 approximately equal to $US 0.91; average of the period from 2000 through 2001)] followed by leflunomide (euro 2010), azathioprine (euro 1878), sulfasalazine (euro 1190), oral methotrexate (euro 708), and lowest for the antimalarials chloroquine/hydroxychloroquine (euro 684). There were additional yearly costs for RA-related non-DMARD medication of euro 554 per patient, including management of ADRs. Mean cost of illness (year 1998 values) excluding medication cost amounted to euro 17,868 per RA patient per year. Annual costs increased with increasing disability, i.e. decreasing functional capacity, of RA patients from euro 6029 per patient with more than 94% of functional capacity to euro 28,509 per patient with <20% of functional capacity. In general, there was a predominance of indirect costs in each of the categories of functional capacity, ranging between 74% and 87% of total (direct and indirect) annual costs per RA patient. Annual direct costs increased from euro 811 to euro 7438 per patient with increasing disability. Inpatient treatment was the predominant component of direct costs. Patients in the worst category (<20%) of function experienced hospital costs that were 6.5 times higher than those of patients in the best category (>94%). CONCLUSIONS On the basis of the data presented it can be concluded that the results of this investigation are typical for patients in rheumatological care in Germany and can therefore be used in a health economic analysis of different DMARD sequences aimed at changing disease progression over time.
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Affiliation(s)
- Peter K Schädlich
- InForMed GmbH - Outcomes Research and Health Economics, Bureau Itzehoe, Conrad-Roentgen-Strasse 58C, D-25524 Itzehoe, Ingolstadt, Germany.
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Buttgereit F, Straub RH, Wehling M, Burmester GR. Glucocorticoids in the treatment of rheumatic diseases: an update on the mechanisms of action. ACTA ACUST UNITED AC 2004; 50:3408-17. [PMID: 15529366 DOI: 10.1002/art.20583] [Citation(s) in RCA: 216] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Schumannstrasse 20/21, 10117 Berlin, Germany.
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Ruof J, Hülsemann JL, Mittendorf T, von der Schulenburg JM, Zeidler H, Merkesdal S. Konzeptionelle und methodische Grundlagen von Krankheitskostenerhebungen in der Rheumatologie. Z Rheumatol 2004; 63:372-9. [PMID: 15517297 DOI: 10.1007/s00393-004-0657-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Accepted: 08/25/2004] [Indexed: 10/26/2022]
Abstract
Cost-of-illness studies in rheumatic conditions show an enormous variability in reported costs. Reasons are-among others-a lack of standardization with regards to relevant cost domains and the utilization of various insufficiently validated costing sources. A flow scheme is presented which may serve as a systematic basis for a valid costing analysis. The scheme includes: i) Selection of relevant cost domains. A comprehensive matrix of cost domains may be used as a framework. According to the specific aims of any costing study individual domains might be selected. ii) An adequate level of detail has to be determined taking into account factors such as the validity of the data collection and the feasibility. iii) Appropriate objective (i. e. usage of administrative data) or subjective (i. e. patient-derived) data sources have to be identified under consideration of respective strengths and weaknesses. While administrative sources provide a valid access to costing data accessibility and feasibility are important advantages of patient-derived costing procedures. iv) During data collection the potential bias due to protocol-driven costs and the differentiation of disease-related from other health care costs should be considered. v) The data analysis should support a transparent presentation of the costing data both in physical and monetary units. In summary, no 'gold standard' has been established for costing studies yet. However, valid costing approaches might follow the flow scheme presented in this analysis.
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Affiliation(s)
- J Ruof
- Abteilung für Rheumatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
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Schneider M, Lelgemann M, Baerwald C, Braun J, Hammer M, Kern P, Krause A, Alten R, Faubel U, Hammer M, Lakomek J, Liman W, Pauly T, Schnabel A. Nutzen der station�ren Therapie in der Versorgung von Patienten mit Rheumatoider Arthritis. Z Rheumatol 2004; 63:402-13. [PMID: 15517301 DOI: 10.1007/s00393-004-0613-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2003] [Accepted: 12/03/2003] [Indexed: 10/26/2022]
Abstract
Our aim was to analyze the existing body of evidence about inpatient care of patients suffering from rheumatoid arthritis (RA). The report was induced by the executive board of the German Society of Rheumatology which assigned the "Oliver-Sangha committee" to dissect and point out the tasks of inpatient care during the next few years. A systemic search of the literature was performed covering the years 1966 to 2001. A total of 16 studies were selected and thoroughly appraised in a systematic way. Four randomized controlled trials addressing the question could be identified. All of them included only patients in a clinical condition allowing outpatient care as well. Two studies indicate some advantage of inpatient care in comparison to outpatient treatment. Two studies, both equivalence studies from design, reveal that RA patients do not generally experience additional benefit from hospitalization. Consideration of two additional cohort studies demonstrates the increased need of inpatient care in RA patients. None of the studies was derived from the German health care system. Emergency cases were not the subject of any of these trials. General statements about the value of inpatient care of RA patients can not be drawn from the analyzed studies. The committee makes suggestions for future investigations that may help to answer this important question considering the special circumstances of the German health care system.
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Affiliation(s)
- M Schneider
- Klinik für Nephrologie und Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany.
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González-Alvaro I, Hernández-García C, Villaverde García V, Vargas E, Ortiz AM. [Variations in the drug treatment of rheumatoid arthritis in Spain]. Med Clin (Barc) 2002; 118:771-6. [PMID: 12049692 DOI: 10.1016/s0025-7753(02)72526-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Variations in the use of healthcare resources can result in differences in the outcome of rheumatoid arthritis (RA). The emAR study was developed to determine variations in the management of socio-sanitary resources, including drugs use, in patients with this disorder. PATIENTS AND METHOD The clinical records of 1,379 patients, randomly selected among all RA patients attended in Spanish hospitals, were reviewed. Information about prescription of disease modifying anti-rheumatic drugs (DMARD), non-steroidal anti-inflammatory drugs (NSAID), corticosteroids, analgesics, gastric protectors and drugs for osteoporosis was collected. In addition, socio-demographic- and disease-related information, as well as data from hospitals, medical units and responsible physicians were also obtained in each patient. RESULTS There was a high level of DMARD and NSAID prescription that was associated with patient or disease characteristics. Treatment with corticosteroids, as well as with the remaining drugs, showed a substantial regional variability, which may be related to physician-associated variables as well as to patient- and disease-associated characteristics. CONCLUSIONS Variability in the management of therapeutic resources in RA patients mainly depends on the characteristics of the patient or the disease. There is also a variation that is influenced by physician's characteristics; in some cases, the available scientific evidence may not support this variability.
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Garrood T, Scott DL. Combination therapy with disease modifying anti-rheumatic drugs in rheumatoid arthritis. BioDrugs 2002; 15:543-61. [PMID: 11543695 DOI: 10.2165/00063030-200115080-00006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
There is increasing interest in using combinations of two or more disease modifying anti-rheumatic drugs to treat rheumatoid arthritis. The use of such combinations is increasing in routine clinical practice. We have identified 18 well-conducted, randomised controlled trials of the use of combinations of disease modifying drugs, and a number of open studies that provide helpful supportive information. The 18 trials involved 2221 patients. Two trials reported strongly positive results, six reported moderately positive results and ten gave largely negative results. The combination of methotrexate, sulfasalazine and hydroxychloroquine appears to be effective with an acceptable level of adverse effects. There is also evidence that the combination of methotrexate and cyclosporin is advantageous. With both combinations, there appears to be further advantages from using corticosteroids in addition to the combination, although the evidence for this is incomplete. The use of other combinations is of less value, and in particular combinations involving parenteral gold, penicillamine and azathioprine are best avoided. Finally, there is growing evidence from randomised trials that the combination of anti-tumour necrosis factor (TNF) therapy with methotrexate is effective and well tolerated. We have identified four randomised controlled trials of the use of combinations of anti-TNF with methotrexate that all reported results favouring this combination. There is insufficient evidence to support the use of other combinations involving immunotherapies at the present time.
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Affiliation(s)
- T Garrood
- Clinical and Academic Rheumatology, GKT School of Medicine, Kings College Hospital (Dulwich), East Dulwich Grove, London, UK
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