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Venetsanopoulou AI, Voulgari PV, Drosos AA. Optimizing withdrawal strategies for anti-TNF-α therapies in rheumatoid arthritis. Expert Opin Biol Ther 2024:1-11. [PMID: 39051615 DOI: 10.1080/14712598.2024.2384000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 07/20/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a chronic autoimmune disease that significantly impacts patients' quality of life. While treatment options have expanded over the years, including the introduction of tumor necrosis factor-alpha (TNFα) inhibitors (TNFi), optimizing withdrawal strategies for these agents remains a challenge. AREAS COVERED This review examines the current evidence on TNFi withdrawal strategies in RA, focusing on factors influencing withdrawal decisions such as disease activity monitoring, treatment response, patient characteristics, and biomarkers. A comprehensive literature search was conducted, including randomized controlled trials, observational studies, and expert guidelines. The pathophysiology of RA, current pharmacological agents, and the treat-to-target strategy are discussed to provide a holistic understanding of RA management. EXPERT OPINION Withdrawal strategies could be suitable for certain patients, keeping in mind that several factors influence withdrawal decisions, including treatment response, disease activity and monitoring, and patient characteristics. The decision to withdraw TNFi must balance the benefits against the potential risks of disease flare and long-term treatment-related adverse effects. Combining DMARDs and TNFi early improves outcomes, supporting tapering strategies for cost-effectiveness and flare prevention. Future directions, including precision medicine approaches, patient-centered care models, and health economics analyses, are proposed to further optimize RA management and improve patient outcomes.
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Affiliation(s)
- Aliki I Venetsanopoulou
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
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Gleeson D, Naveed M, Moorhead L, McAteer H, Sewell G, McGuire A, Weinman J, Barker JNWN, Norton S, Chapman SCE, Smith CH, Mahil SK. Acceptability of 'as needed' biologic therapy in psoriasis: insights from a multistakeholder mixed-methods study. Br J Dermatol 2024; 191:243-251. [PMID: 38366988 DOI: 10.1093/bjd/ljae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/02/2024] [Accepted: 02/14/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Biologic therapies have led to increasing numbers of patients with psoriasis who have clear or nearly clear skin. It is current practice to continue biologic therapy indefinitely in these patients, which contributes to a substantial long-term drug and healthcare burden. 'As needed' biologic therapy in psoriasis may address this; however, our understanding of patient and clinician perceptions of this strategy is limited. OBJECTIVES The aim of this mixed-methods study was to gain insight into the perspectives of both patients and clinicians regarding the acceptability of an 'as needed' approach to biologic therapy in psoriasis, including potential barriers and enablers to implementation in routine care. METHODS We first conducted UK-wide online scoping surveys of patients with psoriasis and dermatology clinicians to explore their views on 'as needed' biologic therapy. Using topic guides informed by these survey findings, we then carried out qualitative focus groups with patients and clinicians. Themes were identified using reflexive thematic analysis. RESULTS Of 67 patients and 27 clinicians completing the scoping surveys, 67% (43 of 64 patients) and 78% (21 of 27 clinicians) supported the use of 'as needed' biologic therapy, respectively. Respondents highlighted advantages such as a reduction in healthcare burden and greater ownership of care. Challenges included logistics of 'as needed' drug provision and potential risks of disease flare and drug immunogenicity. Focus groups comprised 15 patients with psoriasis [9 female patients (60%), average disease duration 32 years (range 9-64)] and 9 dermatology clinicians [8 female clinicians (89%), average dermatology experience 20 years (range 8-33)]. Both patients and clinicians felt that an 'as needed' treatment approach will deliver a reduction in treatment burden and present an opportunity for patient-led ownership of care. Both groups highlighted the importance of ensuring ongoing access to medication and discussing the potential impact of psoriasis recurrence. Patient preferences were influenced by their lived experiences, particularly previous difficulties with medication delivery logistics and establishing disease control. Clinician perspectives were informed by personal experience of their patients adapting their own dosing schedules. Clinicians highlighted the importance of targeted patient selection for an 'as needed' approach, ongoing disease monitoring, and prompt reaccess to medications upon psoriasis recurrence. CONCLUSIONS These data indicate that 'as needed' biologic therapy in psoriasis is acceptable for both patients and clinicians. Formal assessment of clinical effectiveness and cost-effectiveness is warranted to enable the real-world potential of this approach to be realized.
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Affiliation(s)
- David Gleeson
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Maneeha Naveed
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Lucy Moorhead
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Helen McAteer
- Psoriasis Association, Northampton, Northamptonshire, UK
| | - Georgia Sewell
- Psoriasis Association, Northampton, Northamptonshire, UK
| | - Arlene McGuire
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John Weinman
- Centre for Adherence Research and Education, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Jonathan N W N Barker
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Sam Norton
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sarah C E Chapman
- Centre for Adherence Research and Education, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Catherine H Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Satveer K Mahil
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Li Y, Xie C, Ding X, Wu Z, Zhang J, Zhu J, Miao L. What are the benefits of therapeutic drug monitoring in the optimization of adalimumab therapy? a systematic review and meta-analysis up to 2022. Front Pharmacol 2024; 15:1376708. [PMID: 39040471 PMCID: PMC11260779 DOI: 10.3389/fphar.2024.1376708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/17/2024] [Indexed: 07/24/2024] Open
Abstract
Aims Persistent uncertainties exist surrounding the therapeutic drug monitoring (TDM) of adalimumab in clinical settings. To address these issues, we conducted a systematic review to assess the current evidence regarding the benefits of TDM for adalimumab. Methods PubMed, EMBASE, and Cochrane Databases were searched from inception to October 2022. The trials regarding to the list three key questions were considered: 1) Could routine proactive TDM assist in improving outcomes in patients receiving adalimumab? 2) Could reactive TDM assist in guiding subsequent treatment strategies for patients with treatment failure to adalimumab? 3) Could TDM assist in informing dose reduction or discontinuation in patients with low disease activity or in remission treated with adalimumab? Two reviewers independently selected the studies and extracted the data. Meta-analysis was performed to calculate the relative risk (RR) and 95% confidence interval (CI). Results A total of 9 studies was included in this review. For proactive TDM, meta-analysis indicated that proactive TDM (n = 163/257, 63.42%) showed no significant superiority over reactive TDM and/or conventional management (n = 336/606, 55.44%) in achieving and/or maintaining clinical remission by random effects model (RR: 1.24, 95% CI 0.98-1.58, I 2 = 73%). There were three studies that supporting the reactive TDM, low drug levels in the absence of anti-drug antibodies (ADA) strongly indicate the need for dose intensification, and infliximab is a feasible choice for patients with low drug levels and ADA positivity. While swapping to another class should be considered in patients with adequate drug levels. In addition, TDM can help clinicians optimize dosing schedules and prevent overtreatment in patients who have achieved low disease activity and sufficient drug concentrations, with no predictive value for successful adalimumab discontinuation. Conclusion Current evidence suggests that proactive TDM is numerically but not statistically significant superiority over reactive TDM and/or conventional management. Reactive TDM can aid in understanding treatment failure and developing subsequent therapy. For patients reaching low disease activity and remission, TDM can help successful dose reduction, while it cannot inform the successful drug discontinuation. However, existing trials are limited, and more well-designed trials are necessary to clarify the role of TDM in adalimumab treatment.
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Affiliation(s)
- Yun Li
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Cheng Xie
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoliang Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ziyang Wu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jingjing Zhang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianguo Zhu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China
- College of Pharmaceutical Sciences, Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
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Lee J, Kumar N, Kabeto M, Galecki A, Chang CH, Singh N, Yung R, Makris UE, Bynum JPW. Prevalence and Factors Associated with De-escalation of Anti-TNFs in Older Adults with Rheumatoid Arthritis: A Medicare Claims-Based Observational Study. Drugs Aging 2024; 41:601-613. [PMID: 38900379 DOI: 10.1007/s40266-024-01125-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE The aim was to evaluate prevalence and factors associated with anti-tumor necrosis factor (anti-TNF) de-escalation in older adults with rheumatoid arthritis (RA). METHODS We identified adults ≥ 66 years of age with RA on anti-TNF therapy within 6 months after RA diagnosis with at least 6-7 months duration of use (proxy for stable use), using 20% Medicare data from 2008-2017. Patient demographic and clinical characteristics, including concomitant use of glucocorticoid (GC), were collected. Anti-TNF use was categorized as either de-escalation (identified by dosing interval increase, dose reduction, or cessation of use) or continuation. We used (1) an observational cohort design with Cox regression to assess patient characteristics associated with de-escalation and (2) a case-control design with propensity score-adjusted logistic regression to assess the association of de-escalation with different clinical conditions and concomitant medication use. RESULTS We identified 5106 Medicare beneficiaries with RA on anti-TNF, 65.5% of whom had de-escalation. De-escalation was more likely with older age (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.01-1.02) or greater comorbidity (HR 1.07, 95% CI 1.05-1.09), but was less likely with low-income subsidy status (HR 0.85, 95% CI 0.78-0.92), adjusting for patient sex and race/ethnicity. Lower odds of de-escalation were associated with serious infection (odds ratio [OR] 0.79, 95% CI 0.66-0.94), new heart failure diagnosis (OR 0.70, 95% CI 0.52-0.95), and long-term GC use (OR 0.84, 95% CI 0.74-0.95), whereas higher odds were associated with concomitant methotrexate use (OR 1.16, 95% CI 1.03-1.31). CONCLUSIONS Anti-TNFs are de-escalated in two-thirds of older adults with RA in usual care. Further study is needed on RA outcomes after anti-TNF de-escalation.
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Affiliation(s)
- Jiha Lee
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Navasuja Kumar
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mohammed Kabeto
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrzej Galecki
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Chiang-Hua Chang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Internal Medicine, University of Washington, Seattle, WA, USA
| | - Raymond Yung
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Una E Makris
- Division of Rheumatic Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- VA North Texas Health Care System, Dallas, TX, USA
| | - Julie P W Bynum
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Bertrand D, Deprez A, Doumen M, De Cock D, Pazmino S, Marchal A, Thelissen M, Joly J, De Meyst E, Neerinckx B, Westhovens R, Verschueren P. Patients' and rheumatologists' perceptions on dose reduction of rituximab in rheumatoid arthritis. Musculoskeletal Care 2024; 22:e1893. [PMID: 38693680 DOI: 10.1002/msc.1893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE The recommended dose of a rituximab course for the treatment of Rheumatoid Arthritis (RA) consists of two infusions of 1000 mg with a 2-week interval. Evidence is growing that a lower dose could be as effective. We aimed to investigate patients' and rheumatologists' perceptions on dose reduction of rituximab. METHODS Patients with RA treated with rituximab, and rheumatologists were invited for a qualitative study via individual semi-structured interviews. Participants were recruited based on purposive sampling to ensure diversity. Interviews were analysed according to the principles of grounded theory and the constant comparative method. RESULTS Sixteen patients and 13 rheumatologists were interviewed. Patients and rheumatologists perceived the benefits of rituximab dose reduction for reasons of safety and societal costs. Furthermore, available evidence for the effectiveness of lower doses was mentioned as an argument in favour, in addition to the possibility to tailor the dose based on the patients' clinical manifestations. However, patients and rheumatologists had concerns about the potential loss of effectiveness and quality of life. Moreover, some rheumatologists felt uncomfortable with dose reduction due to insufficient experience with rituximab in general. Patients and rheumatologists emphasised the importance of shared decision-making, underscoring the pivotal role of physicians in this process by explaining the reasoning behind dose reduction. CONCLUSION Although some concerns on effectiveness were perceived, both patients and rheumatologists saw potential benefits of dose reduction in terms of safety, societal costs, and application of a personalised approach. As a result, most rheumatologists and patients showed a willingness to consider dose reduction strategies.
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Affiliation(s)
- Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
| | - Anke Deprez
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Environment and Health, KU Leuven, Leuven, Belgium
| | - Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
- Rheumatology, UZ Leuven, Leuven, Belgium
| | - Diederik De Cock
- Biostatistics and Medical Informatics Research Group, Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | | | | | - Johan Joly
- Rheumatology, UZ Leuven, Leuven, Belgium
| | - Elias De Meyst
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
- Rheumatology, UZ Leuven, Leuven, Belgium
| | - Barbara Neerinckx
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
- Rheumatology, UZ Leuven, Leuven, Belgium
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
- Rheumatology, UZ Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
- Rheumatology, UZ Leuven, Leuven, Belgium
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Yuan PD, Hu YW, Chen XQ, Chen GY, Pan Y, Lao HY, Liang D. Adalimumab Dose Reduction and Withdrawal in Stable Non-Infectious Pediatric Uveitis: An Open-Label, Prospective, Pilot Study. Ocul Immunol Inflamm 2024:1-8. [PMID: 38652891 DOI: 10.1080/09273948.2024.2343084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
PURPOSES This study investigated the feasibility of adalimumab (ADA) dose reduction and withdrawal strategy in children with stable pediatric non-infectious uveitis (PNIU). METHODS This open-label prospective pilot trial recruited 18 stable PNIU patients (33 eyes) between two and eighteen years old who were treated with standard doses of ADA (20/40 mg every 2 weeks) plus oral methotrexate. The interval of ADA injection was extended to 4 weeks and followed up for 24 weeks. If the uveitis remained stable, ADA was discontinued and followed up for another 24 weeks. ADA was considered successfully stopped if no relapse occurred during this period. The relapse-free survival rate, best corrected visual acuity (BVCA), anterior chamber cell (ACC), vitritis, macular thickness (MT), and serum ADA levels were evaluated. Approval Number: 2021KYPJ201. ClinicalTrials.gov identifier: NCT05155592. RESULTS The relapse-free survival rate was 22.2% (4/18) at 48 weeks. 33.3% (6/18) of patients relapsed when ADA was given every 4 weeks, while 44.5% of patients (8/18) relapsed after ADA was stopped. The four patients successfully withdrawn from ADA were all diagnosed with BD. No statistically significant differences (p > 0.05) were observed in BCVA and MT between baseline and final follow-up. The proportion of ACC and vitritis exhibited an upward trend (p < 0.05) during follow-up. Serum ADA gradually decreased to zero during follow-up in both non-recurrence and recurrence groups. CONCLUSIONS In PNIU children who reached remission for 6 months, ADA dose reduction and withdrawal were associated with a high risk of inflammation recurrence. Timely adjustment of ADA to the last effective dosage frequency can regain control of the inflammation. Detection of ADA serum levels in patients with recurrence may help find the appropriate interval of ADA use.
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Affiliation(s)
- P D Yuan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
- Department of Ophthalmology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Y W Hu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
- Department of Ophthalmology, The Second Affiliated Hospital, Nanchang University, Nanchang, China
| | - X Q Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - G Y Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - Y Pan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - H Y Lao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - D Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
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Kedra J, Dieudé P, Giboin C, Marotte H, Salliot C, Schaeverbeke T, Perdriger A, Soubrier M, Morel J, Constantin A, Dernis E, Royant V, Salmon JH, Pham T, Gottenberg JE, Pertuiset E, Dougados M, Devauchelle-Pensec V, Gaudin P, Cormier G, Goupille P, Mariette X, Berenbaum F, Alcaix D, Rouidi SA, Berthelot JM, Monnier A, Piroth C, Lioté F, Goëb V, Gaujoux-Viala C, Chary-Valckenaere I, Hajage D, Tubach F, Fautrel B. Towards the Lowest Efficacious Dose: Results From a Multicenter Noninferiority Randomized Open-Label Controlled Trial Assessing Tocilizumab or Abatacept Injection Spacing in Rheumatoid Arthritis in Remission. Arthritis Rheumatol 2024; 76:541-552. [PMID: 37942714 DOI: 10.1002/art.42752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE We assess the clinical and structural impact at two years of progressively spacing tocilizumab (TCZ) or abatacept (ABA) injections versus maintenance at full dose in patients with rheumatoid arthritis in sustained remission. METHODS This multicenter open-label noninferiority (NI) randomized clinical trial included patients with established rheumatoid arthritis in sustained remission receiving ABA or TCZ at a stable dose. Patients were randomized to treatment maintenance (M) at full dose (M-arm) or progressive injection spacing (S) driven by the Disease Activity Score in 28 joints every 3 months up to biologics discontinuation (S-arm). The primary end point was the evolution of disease activity according to the Disease Activity Score in 44 joints during the 2-year follow-up analyzed per protocol with a linear mixed-effects model, evaluated by an NI test based on the one-sided 95% confidence interval (95% CI) of the slope difference (NI margin 0.25). Other end points were flare incidence and structural damage progression. RESULTS Overall, 202 of the 233 patients included were considered for per protocol analysis (90 in S-arm and 112 in M-arm). At the end of follow-up, 16.2% of the patients in the S-arm could discontinue their biologic disease-modifying antirheumatic drug, 46.9% tapered the dose and 36.9% returned to a full dose. NI was not demonstrated for the primary outcome, with a slope difference of 0.10 (95% CI 0.10-0.31) between the two arms. NI was not demonstrated for flare incidence (difference 42.6%, 95% CI 30.0-55.1) or rate of structural damage progression at two years (difference 13.9%, 95% CI -6.7 to 34.4). CONCLUSION The Towards the Lowest Efficacious Dose trial failed to demonstrate NI for the proposed ABA or TCZ tapering strategy.
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Affiliation(s)
- Joanna Kedra
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Philippe Dieudé
- Université de Paris Cité, INSERM UMR 1152 and Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Caroline Giboin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Hubert Marotte
- Université Jean Monnet Saint-Étienne, Centre Hospitalier Universitaire de Saint-Etienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Étienne, France
| | | | | | | | - Martin Soubrier
- Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Jacques Morel
- Montpellier University Hospital and University of Montpellier, INSRM, CNRS, Montpellier, France
| | - Arnaud Constantin
- Pierre-Paul Riquet University Hospital, Toulouse III - Paul Sabatier University, and INSERM UMR 1291, Purpan University Hospital, Toulouse, France
| | | | | | - Jean-Hugues Salmon
- University of Reims Champagne-Ardenne, Faculty of Medicine, UR 3797 and Maison Blanche Hospital, Reims University Hospitals, Reims, France
| | - Thao Pham
- Sainte-Marguerite Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | | | | | - Maxime Dougados
- University of Paris, Hôpital Cochin. AP-HP, INSERM U1153, pôle de recherche et d'enseignement supérieur Sorbonne Paris-Cité, Paris, France
| | | | | | | | | | - Xavier Mariette
- Université Paris-Saclay, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Le Kremlin Bicêtre, France
| | - Francis Berenbaum
- Sorbonne University-INSERM Centre De Recherche scientifique Saint-Antoine, AP-HP Saint-Antoine Hospital, Paris, France
| | | | | | | | | | | | - Frédéric Lioté
- Université de Paris and INSERM UMR1132 Bioscar (Centre Viggo Petersen), Hôpital Lariboisière, AP-HP, Paris, France
| | - Vincent Goëb
- University Hospital of Amiens, Université de Picardie Jules Verne, Amiens, France
| | - Cécile Gaujoux-Viala
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, University of Montpellier, INSERM, Centre Hospitalier Universitaire de Nîmes, Montpellier, France
| | | | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno Fautrel
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
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Lillegraven S, Paulshus Sundlisæter N, Aga AB, Sexton J, Olsen IC, Lexberg ÅS, Madland TM, Fremstad H, Høili CA, Bakland G, Spada C, Haukeland H, Hansen IM, Moholt E, Uhlig T, Solomon DH, van der Heijde D, Kvien TK, Haavardsholm EA. Effect of tapered versus stable treatment with tumour necrosis factor inhibitors on disease flares in patients with rheumatoid arthritis in remission: a randomised, open label, non-inferiority trial. Ann Rheum Dis 2023; 82:1394-1403. [PMID: 37607809 PMCID: PMC10579188 DOI: 10.1136/ard-2023-224476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Many patients with rheumatoid arthritis (RA) require treatment with tumour necrosis factor inhibitor (TNFi) to reach remission. It is debated whether tapering of TNFi to discontinuation should be considered in sustained remission. The aim of ARCTIC REWIND TNFi was to assess the effect of tapering TNFi to withdrawal compared with stable treatment on the risk of disease activity flares in patients with RA in remission ≥1 year. METHODS This randomised, open-label, non-inferiority trial was undertaken at nine Norwegian rheumatology departments. Patients with RA in remission ≥12 months on stable TNFi therapy were allocated by computer-based block-randomisation to tapering to discontinuation of TNFi or stable TNFi. Conventional synthetic disease-modifying antirheumatic co-medication was unchanged. The primary endpoint was disease flare during the 12-month study period (non-inferiority margin 20%), assessed in the per-protocol population. RESULTS Between June 2013 and January 2019, 99 patients were enrolled and 92 received the allocated treatment strategy. Eighty-four patients were included in the per-protocol population. In the tapering TNFi group, 27/43 (63%) experienced a flare during 12 months, compared with 2/41 (5%) in the stable TNFi group; risk difference (95% CI) 58% (42% to 74%). The tapering strategy was not non-inferior to continued stable treatment. The number of total/serious adverse events was 49/3 in the tapering group, 57/2 in the stable group. CONCLUSION In patients with RA in remission for more than 1 year while using TNFi, an increase in flare rate was reported in those who tapered TNFi to discontinuation. However, most regained remission after reinstatement of full-dose treatment. TRIAL REGISTRATION NUMBERS EudraCT: 2012-005275-14 and clinicaltrials.gov: NCT01881308.
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Affiliation(s)
- Siri Lillegraven
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Nina Paulshus Sundlisæter
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Anna-Birgitte Aga
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Joseph Sexton
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Inge Christoffer Olsen
- Department of Research Support for Clinical Trials, Oslo University Hospital, Oslo, Norway
| | | | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - Hallvard Fremstad
- Department of Rheumatology, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | | | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, Tromsø, Norway
| | - Cristina Spada
- Department of Rheumatology, Revmatismesykehuset AS, Lillehammer, Norway
| | - Hilde Haukeland
- Department of Rheumatology, Martina Hansens Hospital, Sandvika, Norway
| | | | - Ellen Moholt
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Till Uhlig
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Daniel H Solomon
- Division of Rheumatology, Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Désirée van der Heijde
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tore K Kvien
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen A Haavardsholm
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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9
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van Esveld L, Cox JM, Kuijper TM, Bosch TM, Weel-Koenders AE. Cost-utility analysis of tapering strategies of biologicals in rheumatoid arthritis patients in the Netherlands. Ann Rheum Dis 2023; 82:1296-1306. [PMID: 37423648 DOI: 10.1136/ard-2023-224190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Current guidelines recommend tapering biological disease-modifying antirheumatoid drugs (bDMARDs) in rheumatoid arthritis (RA) if the disease is under control. However, guidelines on tapering are lacking. Assessing cost-effectiveness of different tapering strategies might provide broader input for creating guidelines on how to taper bDMARDs in patients with RA. The aim of this study is to evaluate the long-term cost-effectiveness from a societal perspective of bDMARD tapering strategies in Dutch patients with RA, namely 50% dose reduction (tapering), discontinuation and a 50% dose reduction followed by discontinuation (de-escalation). METHODS Using a societal perspective, a Markov model with a life-time horizon of 30 years was used to simulate 3-monthly transitions between Disease Activity 28 (DAS28)-defined health states of remission (<2.6), low disease activity (2.63.2). Transition probabilities were estimated through literature search and random effects pooling. Incremental costs, incremental quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits for each tapering strategy were compared with continuation. Deterministic, probabilistic sensitivity analyses and multiple scenario analyses were performed. RESULTS After 30 years, the ICERs were €115 157/QALY lost, €74 226/QALY lost and €67 137/QALY lost for tapering, de-escalation and discontinuation, respectively; mainly driven by bDMARD cost savings and a 72.8% probability of a loss in quality of life. This corresponds to a 76.1%, 64.3% and 60.1% probability of tapering, de-escalation and discontinuation being cost-effective, provided a willingness-to-accept threshold of €50 000/QALY lost. CONCLUSIONS Based on these analyses, the 50% tapering approach saved the highest cost per QALY lost.
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Affiliation(s)
| | - Juul M Cox
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Tessa M Bosch
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
| | - Angelique Eam Weel-Koenders
- Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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10
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Uhrenholt L, Christensen R, Dreyer L, Hauge EM, Schlemmer A, Loft AG, Rasch M, Horn HC, Gade KH, Østgård RD, Taylor PC, Duch K, Kristensen S. Disease activity-guided tapering of biologics in patients with inflammatory arthritis: a pragmatic, randomized, open-label, equivalence trial. Scand J Rheumatol 2023; 52:481-492. [PMID: 36745114 DOI: 10.1080/03009742.2023.2164979] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/02/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate whether disease activity-guided tapering of biologics compared to continuation as usual care enables a substantial dose reduction while disease activity remains equivalent. METHOD In this pragmatic, randomized, open-label, equivalence trial, adults with rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis in low disease activity on stable-dose biologics for ≥ 12 months were randomized 2:1 into either the tapering group, i.e. disease activity-guided prolongation of the biologic dosing interval until flare or withdrawal, or the control group, i.e. maintaince of baseline biologics with a possible small interval increase at the patients request. The co-primary outcome in the intention-to-treat population was met if superiority in ≥ 50% biologic reduction at 18 months was demonstrated and disease activity was equivalent (equivalence margins ± 0.5). RESULTS Ninety-five patients were randomized to tapering and 47 to control, of whom 37% (35/95) versus 2% (1/47) achieved ≥ 50% biologic reduction at 18 months. The risk difference was statistically significant [35%, 95% confidence interval (CI) 24%-45%], while disease activity remained equivalent [mean difference 0.05, 95% CI -0.12-0.29]. A statistically significant flare risk was observed [tapering 41% (39/95) vs control 21% (10/47), risk difference 20%, 95% CI 4%-35%]; but, only 1% (1/95) and 6% (3/47) had persistent flare and needed to switch to another biological drug. CONCLUSIONS Disease activity-guided tapering of biologics in patients with inflammatory arthritis enabled one-third to achieve ≥ 50% biologic reduction, while disease activity between groups remained equivalent. Flares were more frequent in the tapering group but were managed with rescue therapy.
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Affiliation(s)
- L Uhrenholt
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - R Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - L Dreyer
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - E-M Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - A Schlemmer
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Randers Regional Hospital, Randers, Denmark
| | - A G Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mnb Rasch
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - H C Horn
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - K H Gade
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - R D Østgård
- Department of Rheumatology, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - P C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - K Duch
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - S Kristensen
- Center of Rheumatic Research Aalborg (CERRA), Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Montecchi-Palmer M, Wu M, Rolando M, Lau C, Perez Quinones VL, Dana R. Possible Strategies to Mitigate Placebo or Vehicle Response in Dry Eye Disease Trials: A Narrative Review. Ophthalmol Ther 2023; 12:1827-1849. [PMID: 37208548 PMCID: PMC10287883 DOI: 10.1007/s40123-023-00720-1] [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: 02/13/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Many candidate drugs for dry eye disease (DED) have been assessed over the years in pursuit of demonstrating efficacy in both signs and symptoms. However, patients with DED have very limited treatment options for management of both signs and symptoms of DED. There are several potential reasons behind this including the placebo or vehicle response, which is a frequent issue observed in DED trials. A high magnitude of vehicle response interferes with the estimation of a drug's treatment effect and may lead to failure of a clinical trial. To address these concerns, Tear Film and Ocular Surface Society International Dry Eye Workshop II taskforce has recommended a few study design strategies to minimize vehicle response observed in DED trials. This review briefly describes the factors that lead to placebo/vehicle response in DED trials and focuses on the aspects of clinical trial design that can be improved to mitigate vehicle response. In addition, it presents the observations from a recent ECF843 phase 2b study, wherein the study design approach consisted of a vehicle run-in phase, withdrawal phase, and masked treatment transition, and led to consistent data for DED signs and symptoms and reduced vehicle response post randomization.
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Affiliation(s)
| | - Min Wu
- Ocular Surface Disease, Novartis Pharmaceuticals Corporation, East Hanover, USA
| | | | - Charis Lau
- Ocular Surface Disease, Novartis Pharmaceuticals Corporation, East Hanover, USA
| | - Victor L Perez Quinones
- Foster Center for Ocular Immunology, Duke Eye Center, Duke University School of Medicine, Durham, NC, USA
| | - Reza Dana
- Harvard Medical School, Boston, MA, USA
- Massachusetts Eye and Ear, Boston, MA, USA
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van Linschoten RCA, Jansen FM, Pauwels RWM, Smits LJT, Atsma F, Kievit W, de Jong DJ, de Vries AC, Boekema PJ, West RL, Bodelier AGL, Gisbertz IAM, Wolfhagen FHJ, Römkens TEH, Lutgens MWMD, van Bodegraven AA, Oldenburg B, Pierik MJ, Russel MGVM, de Boer NK, Mallant-Hent RC, Ter Borg PCJ, van der Meulen-de Jong AE, Jansen JM, Jansen SV, Tan ACITL, van der Woude CJ, Hoentjen F. Increased versus conventional adalimumab dose interval for patients with Crohn's disease in stable remission (LADI): a pragmatic, open-label, non-inferiority, randomised controlled trial. Lancet Gastroenterol Hepatol 2023; 8:343-355. [PMID: 36736339 DOI: 10.1016/s2468-1253(22)00434-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite its effectiveness in treating Crohn's disease, adalimumab is associated with an increased risk of infections and high health-care costs. We aimed to assess clinical outcomes of increased adalimumab dose intervals versus conventional dosing in patients with Crohn's disease in stable remission. METHODS The LADI study was a pragmatic, open-label, multicentre, non-inferiority, parallel, randomised controlled trial, done in six academic hospitals and 14 general hospitals in the Netherlands. Adults (aged ≥18 years) diagnosed with luminal Crohn's disease (with or without concomitant perianal disease) were eligible when in steroid-free clinical and biochemical remission (defined as Harvey-Bradshaw Index [HBI] score <5, faecal calprotectin <150 μg/g, and C-reactive protein <10 mg/L) for at least 9 months on a stable dose of 40 mg subcutaneous adalimumab every 2 weeks. Patients were randomly assigned (2:1) to the intervention group or control group by the coordinating investigator using a secure web-based system with variable block randomisation (block sizes of 6, 9, and 12). Randomisation was stratified on concomitant use of thiopurines and methotrexate. Patients and health-care providers were not masked to group assignment. Patients allocated to the intervention group increased adalimumab dose intervals to 40 mg every 3 weeks at baseline and further to every 4 weeks if they remained in clinical and biochemical remission at week 24. Patients in the control group continued their 2-weekly dose interval. The primary outcome was the cumulative incidence of persistent flares at week 48 defined as the presence of at least two of the following criteria: HBI score of 5 or more, C-reactive protein 10 mg/L or more, and faecal calprotectin more than 250 μg/g for more than 8 weeks and a concurrent decrease in the adalimumab dose interval or start of escape medication. The non-inferiority margin was 15% on a risk difference scale. All analyses were done in the intention-to-treat and per-protocol populations. This trial was registered at ClinicalTrials.gov, NCT03172377, and is not recruiting. FINDINGS Between May 3, 2017, and July 6, 2020, 174 patients were randomly assigned to the intervention group (n=113) or the control group (n=61). Four patients from the intervention group and one patient from the control group were excluded from the analysis for not meeting inclusion criteria. 85 (50%) of 169 participants were female and 84 (50%) were male. At week 48, the cumulative incidence of persistent flares in the intervention group (three [3%] of 109) was non-inferior compared with the control group (zero; pooled adjusted risk difference 1·86% [90% CI -0·35 to 4·07). Seven serious adverse events occurred, all in the intervention group, of which two (both patients with intestinal obstruction) were possibly related to the intervention. Per 100 person-years, 168·35 total adverse events, 59·99 infection-related adverse events, and 42·57 gastrointestinal adverse events occurred in the intervention group versus 134·67, 75·03, and 5·77 in the control group, respectively. INTERPRETATION The individual benefit of increasing adalimumab dose intervals versus the risk of disease recurrence is a trade-off that should take patient preferences regarding medication and the risk of a flare into account. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Reinier C A van Linschoten
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Fenna M Jansen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Renske W M Pauwels
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Lisa J T Smits
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Femke Atsma
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Wietske Kievit
- Radboud institute for Health Science, Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Paul J Boekema
- Department of Gastroenterology and Hepatology, Maxima Medical Center, Eindhoven, Netherlands
| | - Rachel L West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | | | - Ingrid A M Gisbertz
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Uden, Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Maurice W M D Lutgens
- Department of Gastroenterology and Hepatology, Elisabeth Twee Steden Ziekenhuis, Tilburg, Netherlands
| | - Adriaan A van Bodegraven
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Center, Sittard-Geleen/Heerlen, Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, Netherlands
| | - Marieke J Pierik
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Maurice G V M Russel
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Twente, Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Pieter C J Ter Borg
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Netherlands
| | - Sita V Jansen
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, Netherlands
| | - Adrianus C I T L Tan
- Department of Gastroenterology and Hepatology, CWZ Hospital, Nijmegen, Netherlands
| | | | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands; Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Kaban N, Harman H. Paradigm guiding to tapering or discontinuation of biologic and targeted synthetic disease-modifying antirheumatic drugs in the treatment of patients with rheumatoid arthritis: Results from a local prospective study. Int J Rheum Dis 2023; 26:689-698. [PMID: 36807751 DOI: 10.1111/1756-185x.14616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/26/2022] [Accepted: 02/02/2023] [Indexed: 02/20/2023]
Abstract
OBJECTIVE We prospectively conduct the current study to figure out predicting factors whether biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) can be discontinued or tapered in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS The study population encompassed 126 consecutive RA patients on b/tsDMARDs for at least 1 year. Remission was defined as a Disease Activity Score of 28 joints (DAS28) - erythrocyte sedimentation rate <2.6. The b/tsDMARD dosing interval was increased in patients in remission for at least 6 months. In patients in whom the b/tsDMARD dosing interval could be increased by 100% for at least 6 months, the b/tsDMARD was stopped at the end of this period. Disease relapse was defined as deterioration from remission to moderate or high disease activity. RESULTS The mean duration of b/tsDMARD treatment for all patients was 2.54 ± 1.55 years. Logistic regression analysis did not identify any independent predictor of treatment discontinuation. Independent predictors for tapering in b/tsDMARD treatment are no switch to another therapy and lower baseline DAS28 scores (respectively, P = .029, .024). Time to relapse after tapering was shorter in patients requiring corticosteroids when the 2 groups were compared with the log-rank test (2.83 vs 10.8 months; P = .05). CONCLUSION It seems a reasonable approach to consider b/tsDMARD tapering in patients with remission period of >3.5 months, lower baseline DAS28 scores and without requiring corticosteroid use. Unfortunately, no predictor has been found to predict b/tsDMARD discontinuation.
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Affiliation(s)
- Nedim Kaban
- Department of Rheumatology, Çanakkale Mehmet Akif Ersoy State Hospital, Çanakkale, Turkey
| | - Halil Harman
- Department of Rheumatology, University of Health Sciences, İstanbul Physical Medicine and Rehabilitation Education and Research Hospital, İstanbul, Turkey
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Grede N, Kuss K, Staudt I, Donner-Banzhoff N, Viniol A. Mapping the methodological diversity of published drug discontinuation studies-a scoping review of study topics, objectives, and designs. Trials 2023; 24:58. [PMID: 36703178 PMCID: PMC9878942 DOI: 10.1186/s13063-023-07105-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Trials evaluating drug discontinuation (drug discontinuation trials, DDTs) show a broad methodological spectrum. There are several specific methodological aspects in drug discontinuation trials (e.g., determination of research question; configuration of intervention; definition of outcomes). To verify this specifies, we did a scoping review about the study designs of drug discontinuation trials. METHODS A systematic literature search in Medline (PubMed), The Cochrane Library, EMBASE, CINAHL, Web of Science, and PsycINFO was performed. In a two-step selection process, we identified DDTs, which evaluate the discontinuation of one or more long-term medication as the investigated intervention, by two independent reviewers. Besides bibliographic data, we extracted several parameters to describe the used study design of the included DDTs: motivation for DDT, initially treatment aim of the discontinued medication, study design, methods of discontinuation, follow-up times, number of study participants, and outcome parameter. RESULTS Out of 12,132 records, we included 581 DDTs. The most common motivation for doing a DDT were expected side effects (48.8%), the motivation of proving the efficacy of medication (21.6%), or doubts on the expected benefit of the used medication (13.8%). The majority of the discontinued medication was initially prescribed to improve the prognosis of a chronic disease (60.4%) or to relieve symptoms (31%). The study designs of the trials showed a broad methodological spectrum. The minority of the drug discontinuation trials were randomized controlled trials (34%). CONCLUSION The results of this scoping review illustrates the need for an evidence-based methodological standard for planning and conducting drug discontinuation trials.
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Affiliation(s)
- Nina Grede
- grid.10253.350000 0004 1936 9756Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-Von-Frisch Str. 4, 35043 Marburg, Germany
| | - Katrin Kuss
- grid.10253.350000 0004 1936 9756Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-Von-Frisch Str. 4, 35043 Marburg, Germany
| | - Ina Staudt
- grid.10253.350000 0004 1936 9756Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-Von-Frisch Str. 4, 35043 Marburg, Germany
| | - Norbert Donner-Banzhoff
- grid.10253.350000 0004 1936 9756Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-Von-Frisch Str. 4, 35043 Marburg, Germany
| | - Annika Viniol
- grid.10253.350000 0004 1936 9756Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-Von-Frisch Str. 4, 35043 Marburg, Germany
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Labinsky H, Ukalovic D, Hartmann F, Runft V, Wichmann A, Jakubcik J, Gambel K, Otani K, Morf H, Taubmann J, Fagni F, Kleyer A, Simon D, Schett G, Reichert M, Knitza J. An AI-Powered Clinical Decision Support System to Predict Flares in Rheumatoid Arthritis: A Pilot Study. Diagnostics (Basel) 2023; 13:diagnostics13010148. [PMID: 36611439 PMCID: PMC9818406 DOI: 10.3390/diagnostics13010148] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/11/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Treat-to-target (T2T) is a main therapeutic strategy in rheumatology; however, patients and rheumatologists currently have little support in making the best treatment decision. Clinical decision support systems (CDSSs) could offer this support. The aim of this study was to investigate the accuracy, effectiveness, usability, and acceptance of such a CDSS-Rheuma Care Manager (RCM)-including an artificial intelligence (AI)-powered flare risk prediction tool to support the management of rheumatoid arthritis (RA). Longitudinal clinical routine data of RA patients were used to develop and test the RCM. Based on ten real-world patient vignettes, five physicians were asked to assess patients' flare risk, provide a treatment decision, and assess their decision confidence without and with access to the RCM for predicting flare risk. RCM usability and acceptance were assessed using the system usability scale (SUS) and net promoter score (NPS). The flare prediction tool reached a sensitivity of 72%, a specificity of 76%, and an AUROC of 0.80. Perceived flare risk and treatment decisions varied largely between physicians. Having access to the flare risk prediction feature numerically increased decision confidence (3.5/5 to 3.7/5), reduced deviations between physicians and the prediction tool (20% to 12% for half dosage flare prediction), and resulted in more treatment reductions (42% to 50% vs. 20%). RCM usability (SUS) was rated as good (82/100) and was well accepted (mean NPS score 7/10). CDSS usage could support physicians by decreasing assessment deviations and increasing treatment decision confidence.
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Affiliation(s)
- Hannah Labinsky
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | | | - Fabian Hartmann
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | | | | | | | - Kira Gambel
- Siemens Healthineers, 91502 Erlangen, Germany
| | | | - Harriet Morf
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Jule Taubmann
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Filippo Fagni
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Arnd Kleyer
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - David Simon
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | | | - Johannes Knitza
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Correspondence:
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Gieling J, van den Bemt B, Hoppenreijs E, Schatorjé E. Discontinuation of biologic DMARDs in non-systemic JIA patients: a scoping review of relapse rates and associated factors. Pediatr Rheumatol Online J 2022; 20:109. [PMID: 36471348 PMCID: PMC9721079 DOI: 10.1186/s12969-022-00769-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/08/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Biologic disease-modifying antirheumatic drugs (bDMARDs) have changed the treatment of juvenile idiopathic arthritis (JIA) patients notably, as bDMARDs enable substantially more patients to achieve remission. When sustained remission is achieved, tapering or even discontinuation of the bDMARD is advocated, to reduce side effects and costs. However, when and how to discontinue bDMARD therapy and what happens afterwards, is less known. OBJECTIVES With this scoping review we aim to collect available data in current literature on relapse rate, time to relapse (TTR) and possible flare associated variables (such as time spent in remission and method of discontinuation) after discontinuing bDMARDs in non-systemic JIA patients. METHODS We performed a literature search until July 2022 using the Pubmed database. All original studies reporting on bDMARD discontinuation in non-systemic JIA patients were eligible. Data on patient- and study characteristics, the applied discontinuation strategy, relapse rates and time to relapse were extracted in a standardized template. RESULTS Of the 680 records screened, 28 articles were included in this review with 456 non-systemic JIA patients who tapered and/or stopped bDMARD therapy. Relapse rate after discontinuation of bDMARDs, either abruptly or following tapering, were 40-48%, 36.8-45.0% and 60-78% at 6, 8 and 12 months respectively. Total relapse rate ranged from 26.3% to 100%, with mean time to relapse (TTR) of 2 to 8.4 months, median TTR 3 to 10 months. All studies stated a good response after restart of therapy after flare. JIA subtype, type of bDMARD, concomitant methotrexate use, treatment duration, tapering method, age, sex, and time in remission could not conclusively be related to relapse rate or TTR. However, some studies reported a positive correlation between flare and antinuclear antibodies positivity, younger age at disease onset, male sex, disease duration and delayed remission, which were not confirmed in other studies. CONCLUSION Flares seem to be common after bDMARD discontinuation, but little is known about which factors influence these flares in JIA patients. Follow up after discontinuation with careful registration of patient variables, information about tapering methods and flare rates are required to better guide tapering and/or stopping of bDMARDs in JIA patients in the future.
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Affiliation(s)
- Job Gieling
- Department of Pediatric Rheumatology, Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Bart van den Bemt
- grid.10417.330000 0004 0444 9382Departments of Pharmacy, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esther Hoppenreijs
- grid.10417.330000 0004 0444 9382Department of Pediatric Rheumatology, Pediatrics, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ellen Schatorjé
- grid.10417.330000 0004 0444 9382Department of Pediatric Rheumatology, Pediatrics, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
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17
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Spekhorst LS, Bakker D, Drylewicz J, Rispens T, Loeff F, Boesjes CM, Thijs J, Romeijn GLE, Loman L, Schuttelaar ML, van Wijk F, de Graaf M, de Bruin-Weller MS. Patient-centered dupilumab dosing regimen leads to successful dose reduction in persistently controlled atopic dermatitis. Allergy 2022; 77:3398-3407. [PMID: 35837880 DOI: 10.1111/all.15439] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/14/2022] [Accepted: 06/19/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND At present, no real-world studies are available on different dupilumab dosing regimens in controlled atopic dermatitis (AD). The aim of this study was to clinically evaluate a patient-centered dupilumab dosing regimen in patients with controlled AD and to relate this to serum drug levels and serum biomarkers. METHODS Ninety adult AD patients from the prospective BioDay registry were included based on their dupilumab administration interval according to a predefined patient-centered dosing regimen. Group A (n = 30) did not fulfill the criteria for interval prolongation and continued using the standard dupilumab dosage (300 mg/2 weeks), group B (n = 30) prolonged dupilumab interval with 50% (300 mg/4 weeks), and group C (n = 30) prolonged dupilumab interval with 66%-75% (300 mg/6-8 weeks). AD severity score, patient-reported outcomes, serum dupilumab levels, and serum biomarkers were analyzed over time. RESULTS Disease severity scores did not significantly change over time during the tapering period in any of the groups. In groups B and C, the Numeric Rating Scale (NRS)-pruritus temporarily significantly increased after interval prolongation but remained low (median NRS-pruritus≤4). Median dupilumab levels remained stable in group A (standard dosage), but significantly decreased in groups B and C (24.1 mg/L (IQR = 17.1-45.6); 12.5 mg/L (IQR = 1.7-22.3)) compared with the levels during the standard dosage (88.2 mg/L [IQR = 67.1-123.0, p < .001]). Disease severity biomarker levels (CCL17/CCL18) remained low in all study groups during the whole observation period. CONCLUSIONS This study showed that dose reduction was successful in a subgroup of patients with controlled AD by using a patient-centered dosing regimen. These patients showed stable low disease activity and low severity biomarkers over time.
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Affiliation(s)
- Lotte S Spekhorst
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daphne Bakker
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Julia Drylewicz
- Division Laboratories, Pharmacy and Biomedical Genetics, Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Floris Loeff
- Sanquin Diagnostic Services, Sanquin, Amsterdam, The Netherlands
| | - Celeste M Boesjes
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith Thijs
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geertruida L E Romeijn
- Department of Dermatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Laura Loman
- Department of Dermatology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Femke van Wijk
- Division Laboratories, Pharmacy and Biomedical Genetics, Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marlies de Graaf
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolein S de Bruin-Weller
- Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, The Netherlands
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Birkner B, Rech J, Edelmann E, Verheyen F, Schett G, Stargardt T. Patient-individual tapering of DMARDs in rheumatoid arthritis patients in a real-world setting. Rheumatology (Oxford) 2022; 62:1476-1484. [PMID: 35980267 DOI: 10.1093/rheumatology/keac472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 07/17/2022] [Accepted: 07/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We aim to provide real-world evidence on the effectiveness of patient-individual tapering of DMARDs for patients with rheumatoid arthritis (RA) in daily clinical practice using medical records and claims data. METHODS We utilize data obtained through a controlled prospective cohort study in Germany conducted from July 2018 to March 2021. Participants consist of RA patients in sustained remission (>6 months) who were eligible for tapering at enrolment. Patients treated with individual tapering based on shared decision making (n = 200) are compared with patients without any dose-reduction (n = 237). The risk of loss of remission and the risk of flare is assessed with risk-adjusted Kaplan-Meier estimators and Cox-Regressions. We evaluate differences in costs one year before and after baseline based on claims data for the subgroup of patients insured at one major sickness fund in Germany (n = 76). RESULTS The risk of flare (HR 0.88 95%-CI: 0.59-1.30) or loss of remission (HR 1.04 95%-CI: 0.73, 1.49) was not statistically different between the individual tapering group and the continuation group. Minor increases of disease activity and decreases of quality of life were observed 12 months after baseline, again with no statistically significant difference. Drug costs decreased by 1,017€in the individual tapering group while increased by 1,151€in the continuation group (p< 0.01). CONCLUSION Individual tapering of DMARDs does not increase the average risk of experiencing flares or loss of remission. Encouraging rheumatologists and patients to apply tapering in shared decision may be a feasible approach to allow individualisation of treatment in RA.
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Affiliation(s)
- Benjamin Birkner
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
| | - Jürgen Rech
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Tom Stargardt
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
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19
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Messelink MA, van der Leeuw MS, den Broeder AA, Tekstra J, van der Goes MC, Heijstek MW, Lafeber F, Welsing PMJ. Prediction Aided Tapering In rheumatoid arthritis patients treated with biOlogicals (PATIO): protocol for a randomized controlled trial. Trials 2022; 23:494. [PMID: 35710576 PMCID: PMC9202120 DOI: 10.1186/s13063-022-06471-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Biological disease-modifying anti-rheumatic drugs (bDMARDs) are effective in the treatment of rheumatoid arthritis (RA) but are expensive and increase the risk of infection. Therefore, in patients with a stable low level of disease activity or remission, tapering bDMARDs should be considered. Although tapering does not seem to affect long-term disease control, (short-lived) flares are frequent during the tapering process. We have previously developed and externally validated a dynamic flare prediction model for use as a decision aid during stepwise tapering of bDMARDs to reduce the risk of a flare during this process. METHODS In this investigator-initiated, multicenter, open-label, randomized (1:1) controlled trial, we will assess the effect of incorporating flare risk predictions into a bDMARD tapering strategy. One hundred sixty RA patients treated with a bDMARD with stable low disease activity will be recruited. In the control group, the bDMARD will be tapered according to "disease activity guided dose optimization" (DGDO). In the intervention group, the bDMARD will be tapered according to a strategy that combines DGDO with the dynamic flare prediction model, where the next bDMARD tapering step is not taken in case of a high risk of flare. Patients will be randomized 1:1 to the control or intervention group. The primary outcome is the number of flares per patient (DAS28-CRP increase > 1.2, or DAS28-CRP increase > 0.6 with a current DAS28-CRP ≥ 2.9) during the 18-month follow-up period. Secondary outcomes include the number of patients with a major flare (flare duration ≥ 12 weeks), bDMARD dose reduction, adverse events, disease activity (DAS28-CRP) and patient-reported outcomes such as quality of life and functional disability. Health Care Utilization and Work Productivity will also be assessed. DISCUSSION This will be the first clinical trial to evaluate the benefit of applying a dynamic flare prediction model as a decision aid during bDMARD tapering. Reducing the risk of flaring during tapering may enhance the safety and (cost)effectiveness of bDMARD treatment. Furthermore, this study pioneers the field of implementing predictive algorithms in clinical practice. TRIAL REGISTRATION Dutch Trial Register number NL9798, registered 18 October 2021, https://www.trialregister.nl/trial/9798 . The study has received ethical review board approval (number NL74537.041.20).
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Affiliation(s)
- Marianne A Messelink
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3508, GA, Utrecht, The Netherlands.
| | - Matthijs S van der Leeuw
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3508, GA, Utrecht, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574, NA, Ubbergen, The Netherlands
| | - Janneke Tekstra
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3508, GA, Utrecht, The Netherlands
| | - Marlies C van der Goes
- Department of Rheumatology, Meander Medical Center, Maatweg 3, 3813, TZ, Amersfoort, The Netherlands
| | - Marloes W Heijstek
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3508, GA, Utrecht, The Netherlands
| | - Floris Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3508, GA, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3508, GA, Utrecht, The Netherlands
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20
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Michielsens CA, den Broeder N, van den Hoogen FH, Mahler EA, Teerenstra S, van der Heijde D, Verhoef LM, den Broeder AA. Treat-to-target dose reduction and withdrawal strategy of TNF inhibitors in psoriatic arthritis and axial spondyloarthritis: a randomised controlled non-inferiority trial. Ann Rheum Dis 2022; 81:1392-1399. [PMID: 35701155 DOI: 10.1136/annrheumdis-2022-222260] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/30/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Tumour necrosis factor inhibitors (TNFi) are effective in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), but are associated with a small (0.6%) increase in serious infection risk, patient burden due to need for self-injection and high costs. Treat-to-target (T2T) tapering might ameliorate these drawbacks, but high-quality evidence on T2T tapering strategies is lacking in PsA and axSpA. METHODS We performed a pragmatic open-label, monocentre, randomised controlled non-inferiority (NI) trial on T2T tapering of TNFi. Patients with PsA and axSpA using a TNFi with ≥6 months stable low disease activity (LDA) were included. Patients were randomised 2:1 to disease activity-guided T2T with or without tapering until withdrawal and followed-up to 12 months. Primary endpoint was the difference in proportion of patients having LDA at 12 months between groups, compared with a prespecified NI margin of 20%, estimated using a Bayesian prior. RESULTS 122 patients (64 PsA and 58 axSpA) were randomised to a T2T strategy with (N=81) or without tapering (N=41). The proportion of patients in LDA at 12 months was 69% for the tapering and 73% for the no-tapering group: adjusted difference 5% (Bayesian 95% credible interval: -10% to 19%) which confirms NI considering the NI margin of 20%. The mean percentage of daily defined dose was 53% for the tapering and 91% for the no-tapering group at month 12. CONCLUSIONS A T2T TNFi strategy with tapering attempt is non-inferior to a T2T strategy without tapering with regard to the proportion of patients still in LDA at 12 months, and results in a substantial reduction of TNFi use. TRIAL REGISTRATION NUMBER NL 6771.
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Affiliation(s)
- Celia Aj Michielsens
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands .,Department of Rheumatic Diseases, Radboudumc Radboud Institute for Health Sciences, Nijmegen, Gelderland, The Netherlands
| | - Nathan den Broeder
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands.,Department of Rheumatic Diseases, Radboudumc Radboud Institute for Health Sciences, Nijmegen, Gelderland, The Netherlands
| | | | - Elien Am Mahler
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands
| | - Steven Teerenstra
- Radboud Institute for Health Sciences, Department for Health Evidence, group Biostatistics, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | | | - Lise M Verhoef
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands
| | - Alfons A den Broeder
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands.,Department of Rheumatic Diseases, Radboudumc Radboud Institute for Health Sciences, Nijmegen, Gelderland, The Netherlands
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21
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van der Leeuw MS, Messelink MA, Tekstra J, Medina O, van Laar JM, Haitjema S, Lafeber F, Veris-van Dieren JJ, van der Goes MC, den Broeder AA, Welsing PMJ. Using real-world data to dynamically predict flares during tapering of biological DMARDs in rheumatoid arthritis: development, validation, and potential impact of prediction-aided decisions. Arthritis Res Ther 2022; 24:74. [PMID: 35321739 PMCID: PMC8941811 DOI: 10.1186/s13075-022-02751-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/27/2022] [Indexed: 11/22/2022] Open
Abstract
Background Biological disease-modifying antirheumatic drugs (bDMARDs) are effective in the treatment of rheumatoid arthritis. However, as bDMARDs may also lead to adverse events and are expensive, tapering them is of great clinical interest. Tapering according to disease activity-guided dose optimization (DGDO) does not seem to affect long term remission rates, but flares are frequent during this process. Our objective was to develop a model for the prediction of flares during bDMARD tapering using data from routine care and to evaluate its potential clinical impact. Methods We used a joint latent class model to repeatedly predict the probability of a flare occurring within the next 3 months. The model was developed using longitudinal data on disease activity (DAS28) and other routine care data from two clinics. Predictive accuracy was assessed in cross-validation and external validation was performed with data from the DRESS (Dose REduction Strategy of Subcutaneous tumor necrosis factor inhibitors) trial. Additionally, we simulated the reduction in number of flares and bDMARD dose when implementing the model as a decision aid during bDMARD tapering in the DRESS trial. Results Data from 279 bDMARD courses were used for model development. The final model included two latent DAS28-trajectories, bDMARD type and dose, disease duration, and seropositivity. The area under the curve of the final model was 0.76 (0.69–0.83) in cross-validation and 0.68 (0.62–0.73) in external validation. In simulation of prediction-aided decisions, the mean number of flares over 18 months decreased from 1.21 (0.99–1.43) to 0.75 (0.54–0.96). The reduction in he bDMARD dose was mostly maintained, increasing from 54 to 64% of full dose. Conclusions We developed a dynamic flare prediction model, exclusively based on data typically available in routine care. Our results show that using this model to aid decisions during bDMARD tapering may significantly reduce the number of flares while maintaining most of the bDMARD dose reduction. Trial registration The clinical impact of the prediction model is currently under investigation in the PATIO randomized controlled trial (Dutch Trial Register number NL9798). Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02751-8.
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Affiliation(s)
- Matthijs S van der Leeuw
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marianne A Messelink
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Janneke Tekstra
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ojay Medina
- Department of Digital Health, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jaap M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Saskia Haitjema
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Floris Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Marlies C van der Goes
- Department of Rheumatology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA , Ubbergen, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Araujo CSR, Medeiros-Ribeiro AC, Saad CGS, Bonfiglioli KR, Domiciano DS, Shimabuco AY, Silva MSR, Yuki EFN, Pasoto SG, Pedrosa T, Kupa LDVK, Zou G, Pereira RMR, Silva CA, Aikawa NE, Bonfa E. Two-week methotrexate discontinuation in patients with rheumatoid arthritis vaccinated with inactivated SARS-CoV-2 vaccine: a randomised clinical trial. Ann Rheum Dis 2022; 81:889-897. [PMID: 35193873 DOI: 10.1136/annrheumdis-2021-221916] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the effect on immunogenicity and safety of 2-week methotrexate (MTX) discontinuation after each dose of the Sinovac-CoronaVac vaccine versus MTX maintenance in patients with rheumatoid arthritis (RA). METHODS This was a single-centre, prospective, randomised, investigator-blinded, intervention study (NCT04754698, CoronavRheum) including adult patients with RA (stable Clinical Disease Activity Index (CDAI) ≤10, prednisone ≤7.5 mg/day) randomised (1:1) to withdraw MTX (MTX-hold) for 2 weeks after each vaccine dose or maintain MTX (MTX-maintain), evaluated at day 0 (D0), D28 and D69. Coprimary outcomes were anti-SARS-CoV-2 S1/S2 IgG seroconversion (SC) and neutralising antibody (NAb) positivity at D69. Secondary outcomes were geometric mean titres (GMT) and flare rates. For immunogenicity analyses, we excluded patients with baseline positive IgG/NAb, and for safety reasons those who flared at D28 (CDAI >10) and did not withdraw MTX twice. RESULTS Randomisation included 138 patients with 9 exclusions (5 COVID-19, 4 protocol violations). Safety evaluation included 60 patients in the MTX-hold and 69 patients in the MTX-maintain group. Further exclusions included 27 patients (13 (21.7%) vs 14 (20.3%), p=0.848) with positive baseline IgG/NAb and 10 patients (21.3%) in MTX-hold with CDAI >10 at D28. At D69, the MTX-hold group (n=37) had a higher rate of SC than the MTX-maintain group (n=55) (29 (78.4%) vs 30 (54.5%), p=0.019), with parallel augmentation in GMT (34.2 (25.2-46.4) vs 16.8 (11.9-23.6), p=0.006). No differences were observed for NAb positivity (23 (62.2%) vs 27 (49.1%), p=0.217). At D28 flare, the rates were comparable in both groups (CDAI, p=0.122; Disease Activity Score in 28 joints with C reactive protein, p=0.576), whereas CDAI >10 was more frequent in MTX-hold at D69 (p=0.024). CONCLUSION We provided novel data that 2-week MTX withdrawal after each dose of the Sinovac-CoronaVac vaccine improves anti-SARS-CoV-2 IgG response. The increased flare rates after the second MTX withdrawal may be attributed to the short-term interval between vaccine doses. This strategy requires close surveillance and shared decision making due to the possibility of flares.
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Affiliation(s)
| | | | - Carla G S Saad
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Karina Rossi Bonfiglioli
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Diogo Souza Domiciano
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Andrea Yukie Shimabuco
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | | | | | - Sandra Gofinet Pasoto
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Tatiana Pedrosa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | | | - Gioanna Zou
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Rosa M R Pereira
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Clóvis Artur Silva
- Pediatric Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Nádia Emi Aikawa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
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23
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Ulijn E, den Broeder AA, Boers N, Gotthardt M, Bouman CAM, Landewé R, den Broeder N, van Herwaarden N. Extra-articular findings with FDG-PET/CT in rheumatoid arthritis patients: more harm than benefit. Rheumatol Adv Pract 2022; 6:rkac014. [PMID: 35311064 PMCID: PMC8924972 DOI: 10.1093/rap/rkac014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/15/2022] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT
Objective
Whole-body Positron Emission Tomography with CT-scanning using fluorine-18 fluorodeoxyglucose (18F-FDG) is occasionally used in rheumatoid arthritis (RA) patients to detect arthritis. FDG-PET/CT might also detect malignancies, but the amount of incidental findings and the number of relevant malignant disease that could be missed are currently unknown. We aimed to study the malignancy screening performance of whole-body FDG-PET/CT in longstanding RA patients with low disease activity.
Methods
FDG-PET/CT-scanning was done in the intervention arm of the Dose REduction Strategy of Subcutaneous TNF-inhibitors (DRESS) study, a randomized controlled trial on dose-tapering of biological Disease Modifying Anti-Rheumatic Drugs (bDMARDs). The reference standard was clinical diagnosis of malignancy during the 3 year follow-up of the study. Prevalence of extra-articular abnormalities, follow-up, and treatments were summarized post-hoc.
Results
121 scans were made in 79 patients. Extra-articular abnormalities were found in 59/121 (49%) scans, resulting in additional diagnostic procedures in 21/79 (26.6%) patients. Nine patients (7.4%) were suspected of malignancy, none turned out to be malignant. Six clinical malignancies that developed during follow-up were all negative on baseline FDG-PET/CT.
Conclusion
Whole-body FDG-PET/CT-scanning used in RA patients for imaging of arthritis results in frequent incidental extra-articular findings, while some who apparently had normal scans also developed malignancies.
Trial registration
Netherlands Trial Register, www.trialregister.nl, NL6771
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Affiliation(s)
- Evy Ulijn
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Martin Gotthardt
- Radiology Nuclear Medicine, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Chantal A M Bouman
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Landewé
- Department of Rheumatology and Clinical immunology, Amsterdam Medical Center, Amsterdam, the Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Noortje van Herwaarden
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
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24
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Hirose T, Kawaguchi I, Murata T, Atsumi T. Cost-Effectiveness Analysis of Etanercept 25 mg Maintenance Therapy After Treatment with Etanercept 50 mg for Moderate Rheumatoid Arthritis in the PRESERVE Trial in Japan. Value Health Reg Issues 2021; 28:105-111. [PMID: 34923285 DOI: 10.1016/j.vhri.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/23/2021] [Accepted: 06/10/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To use Markov modeling to estimate the cost-effectiveness of treatment with etanercept 25 mg once weekly plus methotrexate (MTX) in Japanese patients with rheumatoid arthritis who had achieved remission or low disease activity with etanercept 50 mg once weekly plus MTX. METHODS Effectiveness data were estimated based on results from a clinical trial (PRESERVE) in patients with rheumatoid arthritis who had achieved remission or low disease activity and who were then randomized to receive etanercept 25 mg plus MTX or placebo plus MTX. A Markov model was established and included flare rates of 21% and 62% in the etanercept 25 mg and placebo groups, respectively. EQ-5D was calculated using an ordinary least-squares model that included the health assessment questionnaire disability index and pain visual analog scale. Worsening of the health assessment questionnaire score over 1 year was estimated to be 0.047 for patients with flare, and when associated with radiographic progression it was estimated to increase by 0.006 and 0.025 in the etanercept 25 mg and placebo groups, respectively. A cycle length of 1 year was applied to calculate the cumulative cost and effectiveness for a 10-year time span. RESULTS Compared with the placebo group, the quality-adjusted life-years for the etanercept 25 mg group was increased by 0.841. The incremental cost-effectiveness ratio was ¥6 173 772. CONCLUSION These results suggest that maintenance treatment with etanercept 25 mg is cost-effective.
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Affiliation(s)
- Tomohiro Hirose
- Immunology & Inflammation Medical Affairs, Pfizer Innovative Health, Pfizer Japan, Tokyo, Japan; Atopy (Allergy) Research Center, Juntendo University School of Medicine, Tokyo, Japan.
| | - Isao Kawaguchi
- Immunology & Inflammation Medical Affairs, Pfizer Innovative Health, Pfizer Japan, Tokyo, Japan
| | | | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Hokkaido University Hospital, Sapporo, Japan
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25
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Defining the Optimal Strategies for Achieving Drug-Free Remission in Rheumatoid Arthritis: A Narrative Review. Healthcare (Basel) 2021; 9:healthcare9121726. [PMID: 34946453 PMCID: PMC8701994 DOI: 10.3390/healthcare9121726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Background: It is now accepted that the optimum treatment goal for rheumatoid arthritis (RA) is sustained remission, as this has been shown to be associated with the best patient outcomes. There is little guidance on how to manage patients once remission is achieved; however, it is recommended that patients can taper therapy, with a view to discontinuing and achieving drug-free remission if treatment goals are maintained. This narrative review aims to present the current literature on drug-free remission in rheumatoid arthritis, with a view to identifying which strategies are best for disease-modifying anti-rheumatic drug (DMARD) tapering and to highlight areas of unmet clinical need. Methods: We performed a narrative review of the literature, which included research articles, meta-analyses and review papers. The key search terms included were rheumatoid arthritis, remission, drug-free remission, b-DMARDS/biologics, cs-DMARDS and tapering. The databases that were searched included PubMed and Google Scholar. For each article, the reference section of the paper was reviewed to find additional relevant articles. Results: It has been demonstrated that DFR is possible in a proportion of RA patients achieving clinically defined remission (both on cs and b-DMARDS). Immunological, imaging and clinical associations with/predictors of DFR have all been identified, including the presence of autoantibodies, absence of Power Doppler (PD) signal on ultrasound (US), lower disease activity according to composite scores of disease activity and lower patient-reported outcome scores (PROs) at treatment cessation. Conclusions: DFR in RA may be an achievable goal in certain patients. This carries importance in reducing medication-induced side-effects and potential toxicity, the burden of taking treatment if not required and cost effectiveness, specifically for biologic therapy. Prospective studies of objective biomarkers will help facilitate the prediction of successful treatment discontinuation.
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26
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Uhrenholt L, Christensen R, Dinesen WKH, Liboriussen CH, Andersen SS, Dreyer L, Schlemmer A, Hauge EM, Skrubbeltrang C, Taylor PC, Kristensen S. Risk of flare after tapering or withdrawal of b-/tsDMARDs in patients with RA or axSpA: A systematic review and meta-analysis. Rheumatology (Oxford) 2021; 61:3107-3122. [PMID: 34864896 DOI: 10.1093/rheumatology/keab902] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate flare risk when tapering or withdrawing biological or targeted synthetic disease-modifying antirheumatic drugs (b-/tsDMARDs) compared to continuation in patients with inflammatory arthritis (IA) in sustained remission or low disease activity. METHODS Articles were identified in Cochrane Library, PubMed, EMBASE and Web of Science. Eligible trials were randomised, controlled trials comparing tapering and/or withdrawal of b- and/or tsDMARDs with standard dose in IA. Random-effects meta-analysis was performed with risk ratio (RR), or Peto's Odds Ratio (POR) for sparse events, and 95% confidence intervals (95%CI). RESULTS The meta-analysis comprised 22 trials: 11 assessed tapering and 7 addressed withdrawal (4 assessed both). Only trials with a rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) population were identified. An increased flare risk was demonstrated when b-/tsDMARD tapering was compared to continuation, RR = 1.45 (95%CI: 1.19 to 1.77, I2 = 42.5%), and potentially increased for persistent flare, POR = 1.56 (95%CI: 0.97 to 2.52, I2 = 0%). Comparing tumour necrosis factor inhibitor (TNFi) withdrawal to continuation, a highly increased flare risk (RR = 2.28, 95%CI: 1.78 to 2.93, I2 = 78%) and increased odds of persistent flare (POR = 3.41, 95%CI: 1.91 to 6.09, I2 = 49%) was observed. No clear difference in flare risk between RA or axSpA was observed. CONCLUSION A high risk for flare and persistent flare was demonstrated for TNFi withdrawal whereas an increased risk for flare but not for persistent flare was observed for b-/tsDMARD tapering. Thus, tapering seems to be the more favourable approach. REGISTRATION PROSPERO (CRD42019136905).
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Affiliation(s)
- Line Uhrenholt
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Section for Biostatistics and Evidence-Based Research, Bispebjerg and Frederiksberg Hospital, The Parker Institute, Copenhagen, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, Bispebjerg and Frederiksberg Hospital, The Parker Institute, Copenhagen, Denmark.,Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | | | - Stine S Andersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lene Dreyer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Annette Schlemmer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Rheumatology, Randers Regional Hospital, Randers, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Conni Skrubbeltrang
- Department of Medical Library, Aalborg University Hospital, Aalborg, Denmark
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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27
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Bouman CAM, van Herwaarden N, Blanken AB, Van der Laken CJ, Gotthardt M, Oyen WJG, den Broeder AA, van der Maas A, van den Ende CH. 18F-FDG PET-CT scanning in rheumatoid arthritis patients tapering TNFi: reliability, validity and predictive value. Rheumatology (Oxford) 2021; 61:SI6-SI13. [PMID: 34791068 DOI: 10.1093/rheumatology/keab842] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/03/2021] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To investigate the reliability and validity of 18F-FDG PET-CT scanning (FDG-PET) in rheumatoid arthritis (RA) patients with low disease activity tapering tumor necrosis factor inhibitors (TNFi) and its' predictive value for successful tapering or discontinuation. METHODS Patients in the tapering arm of the DRESS study, a randomized controlled trial on TNFi tapering in RA, underwent FDG-PET before tapering (baseline) and after maximal tapering. 48 joints per scan were scored: 1) visually (FDG-avid joint (FAJ) y/n), 2) quantitatively (maximal and mean standardized uptake values (SUVmax and SUVmean)). Interobserver agreement was calculated in 10 patients at baseline. Quantitative and visual FDG-PET scores were investigated for: 1) (multilevel) association with clinical parameters both on joint and patient level and 2) predictive value at baseline and change between baseline and maximal tapering (delta) for successful tapering and discontinuation at 18 months. RESULTS 79 patients underwent FDG-PET. For performance of identification of FAJs on PET, Cohen's kappa was 0.49 (0.35-0.63). For SUVmax and SUVmean, ICCs were 0.80 (0.77-0.83) and 0.96 (0.9-1.0), respectively. On joint level, swelling was significantly associated with SUVmax and SUVmean (B coefficients with 95%CI 1.0 (0.73-1.35) and 0.2 (0.08-0.32) respectively). On patient level only correlation with acute phase reactants was found. FDG-PET scores were not predictive for successful tapering or discontinuation. CONCLUSIONS Quantitative FDG-PET arthritis scoring in RA patients with low disease activity is reliable and has some construct validity. However, no predictive values were found for FDG-PET parameters for successful tapering and/or discontinuation of TNFi.
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Affiliation(s)
- Chantal A M Bouman
- Department of Rheumatology, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Noortje van Herwaarden
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Farmacology-Toxicology, Radboudumc, Nijmegen, The Netherlands
| | - Annelies B Blanken
- Department of Rheumatology, AmsterdamUMC-location VU Medical Center, Amsterdam, The Netherlands.,Department of Rheumatology, Reade, Amsterdam, The Netherlands
| | - Conny J Van der Laken
- Department of Rheumatology, AmsterdamUMC-location VU Medical Center, Amsterdam, The Netherlands
| | - Martin Gotthardt
- Department of Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Wim J G Oyen
- Department of Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands.,Department of Nuclear Medicin, Humanitas University and Clinical and Research Center, Milan, Italy.,Department of Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Cornelia H van den Ende
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
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28
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Michielsens CAJ, den Broeder N, Mulder MLM, van den Hoogen FHJ, Verhoef LM, den Broeder AA. Tumour necrosis factor inhibitor dose adaptation in psoriatic arthritis and axial spondyloarthritis (TAPAS): a retrospective cohort study. Rheumatology (Oxford) 2021; 61:2307-2315. [PMID: 34599803 PMCID: PMC9157113 DOI: 10.1093/rheumatology/keab741] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/20/2021] [Indexed: 02/07/2023] Open
Abstract
Objectives We investigated the effect of disease activity-guided dose optimization (DAGDO) of TNF inhibitor (TNFi) on disease activity and TNFi dose in PsA and axial spondyloarthritis (axSpA) patients with low disease activity (LDA). Methods A retrospective cohort study was conducted in PsA and axSpA patients doing well on TNFi and eligible for TNFi DAGDO. Three different treatment periods were defined: (i) full dose continuation period, (ii) TNFi DAGDO period, and (iii) period with stable TNFi dose after DAGDO. A mixed-model analysis was used to estimate mean Disease Activity Score 28-joint count CRP (DAS28-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) during these periods, and a mean percentage of the daily defined dose (%DDD) was calculated as secondary outcome. Results Three hundred and twenty-four patients (153 PsA and 171 axSpA) were included, with a mean of 6.5 DAS28-CRP and 6.4 BASDAI measurements and a median follow-up duration of 46 and 44 months, respectively. A corrected difference of 0.06 (95% CI: −0.09, 0.21) in mean DAS28-CRP was found for the TNFi DAGDO period and 0.03 (95% CI: −0.14, 0.20) for the period with stable TNFi dose, compared with full dose continuation period. Differences for BASDAI were 0.03 (95% CI: −0.21, 0.27) and 0.05 (95% CI: −0.24, 0.34), respectively. The mean %DDD for the three treatment periods was for PsA 108%, 62% and 78%, and for axSpA 108%, 62% and 72%, respectively. Conclusion DAGDO of TNFi reduces drug exposure and has no negative effects on disease activity in PsA and axSpA patients compared with full dose continuation.
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Affiliation(s)
- Celia A J Michielsens
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands
| | - Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
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29
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Bertrand D, Stouten V, De Cock D, Pazmino S, Doumen M, de Wergifosse I, Joly J, Badot V, Corluy L, Hoffman I, Taelman V, De Knop K, Geens E, Langenaken C, Lenaerts JL, Lenaerts J, Walschot M, Mannaerts J, Westhovens R, Verschueren P. Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial. Scand J Rheumatol 2021; 51:470-480. [PMID: 34514929 DOI: 10.1080/03009742.2021.1955467] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice.Method: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months.Results: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit.Conclusions: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.
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Affiliation(s)
- D Bertrand
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - V Stouten
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - D De Cock
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - S Pazmino
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - M Doumen
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | | | - J Joly
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - V Badot
- Rheumatology, CHU Brugmann, Brussels, Belgium
| | - L Corluy
- Rheumatology, AZ Herentals, Herentals, Belgium
| | - I Hoffman
- Rheumatology, GZA Sint-Augustinus Antwerpen, Antwerpen, Belgium
| | - V Taelman
- Rheumatology, Heilig Hart Ziekenhuis Leuven, Leuven, Belgium
| | - K De Knop
- Rheumatology, GZA Sint-Augustinus Antwerpen, Antwerpen, Belgium
| | - E Geens
- Rheumatology, ZNA Jan Palfijn Antwerpen, Antwerpen, Belgium
| | | | | | - J Lenaerts
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | | | - J Mannaerts
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - R Westhovens
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - P Verschueren
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Leuven, Belgium
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Fraenkel L, Bathon JM, England BR, St.Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2021; 73:924-939. [PMID: 34101387 PMCID: PMC9273041 DOI: 10.1002/acr.24596] [Citation(s) in RCA: 360] [Impact Index Per Article: 120.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.
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Affiliation(s)
- Liana Fraenkel
- Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut
| | - Joan M. Bathon
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - Bryant R. England
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care System, Omaha, Nebraska
| | | | | | | | | | - Mark Genovese
- Stanford University Medical Center, Palo Alto, California
| | - Kent Kwas Huston
- The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri
| | - Gail Kerr
- Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC
| | - Joel Kremer
- Albany Medical College and The Center for Rheumatology, Albany, New York
| | | | | | - Jasvinder A. Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Benjamin J. Smith
- State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | - Jeffrey A. Sparks
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jennifer L. Barton
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | | | | | | | - Sindhu R. Johnson
- Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lara Kahale
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Reza Mirza
- University of Toronto, Toronto, Ontario, Canada
| | - Pascale Schwab
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | | | | | | | | | - Elie A. Akl
- American University of Beirut, Beirut, Lebanon
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Fraenkel L, Bathon JM, England BR, St Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2021; 73:1108-1123. [PMID: 34101376 DOI: 10.1002/art.41752] [Citation(s) in RCA: 310] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/15/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.
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Affiliation(s)
- Liana Fraenkel
- Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut, United States
| | - Joan M Bathon
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, United States
| | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska, United States
| | | | | | | | | | - Mark Genovese
- Stanford University Medical Center, Palo Alto, California, United States
| | - Kent Kwas Huston
- The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri, United States
| | - Gail Kerr
- Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC, United States
| | - Joel Kremer
- Albany Medical College and The Center for Rheumatology, Albany, New York, United States
| | | | - Linda A Russell
- Hospital for Special Surgery, New York, New York, United States
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, United States
| | - Benjamin J Smith
- Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | - Michael E Weinblatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | - Joshua F Baker
- Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Jennifer L Barton
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon, United States
| | - Laura Cappelli
- Johns Hopkins Medicine, Baltimore, Maryland, United States
| | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lara Kahale
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Reza Mirza
- University of Toronto, Toronto, Ontario, Canada
| | - Pascale Schwab
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon, United States
| | | | - Marat Turgunbaev
- American College of Rheumatology, Atlanta, Georgia, United States
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia, United States
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
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Thomas M, Fraenkel L, Boonen A, Bansback N, Buchbinder R, Marshall D, Proulx L, Voshaar M, Richards P, Richards DP, Hiligsmann M, Guillemin F, Shea B, Tugwell P, Hazlewood G. Patient preferences to value health outcomes in rheumatology clinical trials: Report from the OMERACT special interest group ✰. Semin Arthritis Rheum 2021; 51:919-924. [PMID: 34134892 DOI: 10.1016/j.semarthrit.2021.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To inform a research plan for future studies by obtaining stakeholder input on the application of preference-based methods to clinical trial design. METHODS We conducted a virtual OMERACT session to encourage stakeholder engagement. We developed materials for the session to facilitate discussion based on identified case examples and feedback sessions. RESULTS Participants prioritized incorporating patient preferences in all aspects of trial design with an emphasis on outcome selection. Participants highlighted the need for careful consideration around preference heterogeneity and equity factors. CONCLUSION Including patient preferences in trial design was considered a priority requiring further exploration to develop comprehensive guidance.
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Affiliation(s)
- Megan Thomas
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Liana Fraenkel
- Yale University School of Medicine, Section of Rheumatology, CT, USA
| | - Annelies Boonen
- Department of Internal Medicine, Maastricht University Medical Center, Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Nick Bansback
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University and Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia
| | | | - Laurie Proulx
- Patient research partner, Canadian Arthritis Patient Alliance, Ottawa, Canada
| | - Marieke Voshaar
- Patient research partner, Radboud University, Department of Pharmacy, Nijmegen, the Netherlands
| | - Pamela Richards
- Patient research partner, University Hospitals, Bristol NHS Trust, Bristol, UK
| | - Dawn P Richards
- Patient research partner, Canadian Arthritis Patient Alliance, Ottawa, Canada; Patient research partner, Five02 Labs Inc., Toronto, Canada
| | - Mickael Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | | | - Beverly Shea
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Glen Hazlewood
- Department of Community Health Sciences, University of Calgary, Calgary, Canada; Department of Medicine, University of Calgary, Calgary, Canada.
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Lillegraven S, Paulshus Sundlisæter N, Aga AB, Sexton J, Olsen IC, Fremstad H, Spada C, Madland TM, Høili CA, Bakland G, Lexberg Å, Hansen IJW, Hansen IM, Haukeland H, Ljoså MKA, Moholt E, Uhlig T, Solomon DH, van der Heijde D, Kvien TK, Haavardsholm EA. Effect of Half-Dose vs Stable-Dose Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Disease Flares in Patients With Rheumatoid Arthritis in Remission: The ARCTIC REWIND Randomized Clinical Trial. JAMA 2021; 325:1755-1764. [PMID: 33944875 PMCID: PMC8097499 DOI: 10.1001/jama.2021.4542] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Sustained remission has become an achievable goal for patients with rheumatoid arthritis (RA) receiving conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), but how to best treat patients in clinical remission remains unclear. OBJECTIVE To assess the effect of tapering of csDMARDs, compared with continuing csDMARDs without tapering, on the risk of flares in patients with RA in sustained remission. DESIGN, SETTING, AND PARTICIPANTS ARCTIC REWIND was a multicenter, randomized, parallel, open-label noninferiority study conducted in 10 Norwegian hospital-based rheumatology practices. A total of 160 patients with RA in remission for 12 months who were receiving stable csDMARD therapy were enrolled between June 2013 and June 2018, and the final visit occurred in June 2019. INTERVENTIONS Patients were randomly assigned to half-dose csDMARDs (n = 80) or stable-dose csDMARDs (n = 80). MAIN OUTCOMES AND MEASURES The primary end point was the proportion of patients with a disease flare between baseline and the 12-month follow-up, defined as a combination of Disease Activity Score (DAS) greater than 1.6 (threshold for RA remission), an increase in DAS score of 0.6 units or more, and at least 2 swollen joints. A disease flare could also be recorded if both the patient and investigator agreed that a clinically significant flare had occurred. A risk difference of 20% was defined as the noninferiority margin. RESULTS Of 160 enrolled patients (mean [SD] age, 55.1 [11.9] years; 66% female), 156 received the allocated therapy, of which 155 without any major protocol violations were included in the primary analysis population (77 receiving half-dose and 78 receiving stable-dose csDMARDs). Flare occurred in 19 patients (25%) in the half-dose csDMARD group compared with 5 (6%) in the stable-dose csDMARD group (risk difference, 18% [95% CI, 7%-29%]). Adverse events occurred in 34 patients (44%) in the half-dose group and 42 (54%) in the stable-dose group, none leading to study discontinuation. No deaths occurred. CONCLUSIONS AND RELEVANCE Among patients with RA in remission taking csDMARD therapy, treatment with half-dose vs stable-dose csDMARDs did not demonstrate noninferiority for the percentage of patients with disease flares over 12 months, and there were significantly fewer flares in the stable-dose group. These findings do not support treatment with half-dose therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01881308.
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Affiliation(s)
- Siri Lillegraven
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Anna-Birgitte Aga
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Joseph Sexton
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Inge C. Olsen
- Clinical Trial Unit, Oslo University Hospital, Oslo, Norway
| | - Hallvard Fremstad
- Department of Rheumatology, Ålesund Hospital, Helse Møre og Romsdal HF, Ålesund, Norway
| | | | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | | | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, Tromsø, Norway
| | - Åse Lexberg
- Department of Rheumatology, Drammen Hospital, Vestre Viken HF, Drammen, Norway
| | | | - Inger Myrnes Hansen
- Department of Rheumatology, Helgelandssykehuset Mo i Rana, Mo i Rana, Norway
| | - Hilde Haukeland
- Department of Rheumatology, Martina Hansens Hospital, Bærum, Norway
| | | | - Ellen Moholt
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Till Uhlig
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Daniel H. Solomon
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Désirée van der Heijde
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Tore K. Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen A. Haavardsholm
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Choi SJ. Biologic therapies for the treatment of rheumatoid arthritis. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.2.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects the synovial joints. If left untreated, persistent synovial inflammation can lead to cartilage and bone destruction, ultimately causing significant longterm disability and mortality. However, since the late 1990s, the combined use of methotrexate, a synthetic diseasemodifying antirheumatic drug (DMARD), and a biological DMARD has revolutionized the treatment of RA. As of 2021, the Korea Food and Drug Administration has approved seven biological DMARDs for RA treatment: four tumor necrosis factor-alpha inhibitors (infliximab, etanercept, adalimumab, and golimumab) and three non-tumor necrosis factor biological products (abatacept, rituximab, and tocilizumab). Although the use of biological products has allowed significant advances in the treatment of RA, there are certain drawbacks, such as high cost, increased infection risk, and the necessity for parenteral route product administration. Therefore, discontinuation of biological DMARD use without a resulting disease flare is the next treatment goal and a desirable result from the standpoint of risk reduction and cost-effectiveness, especially for patients with clinical remission. It is still unclear which biological product is the best. Clinicians must, therefore, personalize the sequence and strategy of treatment by considering patient characteristics, disease activity, comorbidity, and economic condition
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Ramos-Petersen L, Nester CJ, Reinoso-Cobo A, Nieto-Gil P, Ortega-Avila AB, Gijon-Nogueron G. A Systematic Review to Identify the Effects of Biologics in the Feet of Patients with Rheumatoid Arthritis. MEDICINA (KAUNAS, LITHUANIA) 2020; 57:23. [PMID: 33383830 PMCID: PMC7824565 DOI: 10.3390/medicina57010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/18/2020] [Accepted: 12/26/2020] [Indexed: 01/04/2023]
Abstract
Background and objective: Ninety percent of patients with rheumatoid arthritis (RA) feel foot pain during the disease process. Pharmacological treatment of RA has a systematic effect on the body and includes: Nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs (DMARDs) and biologics. The objective of our review was to examine the impact of biologics on patients with RA 'foot. Methods and material: A systematic review of randomized control trials and observational studies that evaluated the efficacy of biologics against other pharmacological treatment, and included a foot outcome measure. The search covered MEDLINE Ovid, Pubmed, CINAHL, Cochrane Library, Evidence Search, and Web of Science. Risk of bias was evaluated using Cochrane guidance and the Newcastle Ottawa Scale adapted version. Results: A total of eight studies fully met the inclusion criteria: Three randomized control trials, and five observational studies were the basis of our review. A total sample of 1856 RA patients with RA treatment participated. The use of biologics was not associated as a risk factor for post-operative surgical site infection or delayed wound healing. The benefits of biologics, in terms of the disease evolution, were assessed using X-ray. Conclusion: Evidence suggests that the use of biologics is not a risk factor for post-operative surgical site infection or delayed wound healing. The use of biologics presents benefits in terms of the disease evolution assessed through X-ray.
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Affiliation(s)
- Laura Ramos-Petersen
- Department Podiatry, Universidad Católica San Antonio de Murcia, 30107 Murcia, Spain;
| | | | - Andres Reinoso-Cobo
- Department Podiatry, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Malaga, Spain; (A.R.-C.); (G.G.-N.)
| | - Pilar Nieto-Gil
- Department of Nursing and Podiatry, University of Valencia, 46010 Valencia, Spain;
| | - Ana Belen Ortega-Avila
- Department Podiatry, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Malaga, Spain; (A.R.-C.); (G.G.-N.)
- Instituto de Investigación Biomedica de Malaga (IBIMA), 29071 Malaga, Spain
| | - Gabriel Gijon-Nogueron
- Department Podiatry, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Malaga, Spain; (A.R.-C.); (G.G.-N.)
- Instituto de Investigación Biomedica de Malaga (IBIMA), 29071 Malaga, Spain
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Reduction of biologics in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatol Int 2020; 40:1949-1959. [PMID: 32710197 DOI: 10.1007/s00296-020-04651-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
The effects of dose reduction or spacing of all types of biologics in rheumatoid arthritis has not been consistently assessed in systematic reviews. We aimed to assess the effects of biologics reduction compared with dose maintenance in patients with rheumatoid arthritis in low disease activity or remission. We performed a systematic review with meta-analysis according to a previously registered protocol (PROSPERO registration: CRD42017069080); and searched MEDLINE, Embase, Scopus, Cochrane Library and trial registers up to July, 2020. Two researchers selected, extracted and assessed the risk of bias of controlled trials that randomized patients to reduction/spacing or dose maintenance of biologics. Low disease activity, disability and other clinically important outcomes were summarized in random effect meta-analyses. We rated the certainty of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation approach. We included ten studies (n = 1331 patients), which assessed reduction or spacing of abatacept, adalimumab, certolizumab pegol, etanercept, or tocilizumab. Risk of bias was high in over half of trials, mainly due to lack of blinding. No statistically significant difference was found in low disease activity (RR = 0.90; 95% CI 0.78-1.04; I2 = 60%, very low certainty), and other outcomes. Subgroup analysis of blinded studies led to homogeneous results, which remained heterogeneous in open-label studies. Reduction or spacing biologics did not affect disease activity and other important outcome. Changes in the doses regimen should consider patient preferences, considering the low certainty of evidence.
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Naniwa T, Iwagaitsu S, Kajiura M. Successful cessation of tumor necrosis factor inhibitor treatment in rheumatoid arthritis patients and potential predictors for early flare: An observational study in routine clinical care. Mod Rheumatol 2020; 30:948-958. [DOI: 10.1080/14397595.2019.1702253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Taio Naniwa
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, and Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Takeuchi Orthopedics & Internal Medicine, Chita, Japan
| | - Shiho Iwagaitsu
- Department of Nephrology and Rheumatology, Aichi Medical University School of Medicine, Nagakute, Japan
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van Mulligen E, Weel AE, Hazes JM, van der Helm-van Mil A, de Jong PHP. Tapering towards DMARD-free remission in established rheumatoid arthritis: 2-year results of the TARA trial. Ann Rheum Dis 2020; 79:1174-1181. [PMID: 32482645 PMCID: PMC7456559 DOI: 10.1136/annrheumdis-2020-217485] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To evaluate the 2-year clinical effectiveness of two gradual tapering strategies. The first strategy consisted of tapering the conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) first (i.e., methotrexate in ~90%), followed by the tumour necrosis factor inhibitor (TNF-inhibitor), the second strategy consisted of tapering the TNF-inhibitor first, followed by the csDMARD. METHODS This multicentre single-blinded randomised controlled trial included patients with rheumatoid arthritis (RA) with well-controlled disease for ≥3 consecutive months, defined as a Disease Activity Score (DAS) measured in 44 joints ≤2.4 and a swollen joint count ≤1, which was achieved with a csDMARD and a TNF-inhibitor. Eligible patients were randomised into gradual tapering the csDMARD followed by the TNF-inhibitor, or vice versa. The primary outcome was the number of disease flares. Secondary outcomes were DMARD-free remission (DFR), DAS, functional ability (Health Assessment Questionnaire Disability Index (HAQ-DI)) and radiographic progression. RESULTS 189 patients were randomly assigned to tapering their csDMARD (n=94) or TNF-inhibitor (n=95) first. The cumulative flare rate after 24 months was, respectively, 61% (95% CI 50% to 71%) and 62% (95% CI 52% to 72%). The patients who tapered their csDMARD first were more often able to go through the entire tapering protocol and reached DFR more often than the group that tapered the TNF-inhibitor first (32% vs 20% (p=0.12) and 21% vs 10% (p=0.07), respectively). Mean DAS and HAQ-DI over time, and radiographic progression did not differ between groups (p=0.45, p=0.17, p=0.8, respectively). CONCLUSION The order of tapering did not affect flare rates, DAS or HAQ-DI. DFR was achievable in 15% of patients with established RA, slightly more frequent in patients that first tapered csDMARDs. Because of similar effects from a clinical viewpoint, financial arguments may influence the decision to taper TNF-inhibitors first.
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Affiliation(s)
| | - Angelique E Weel
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Rheumatology, Maasstad Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus Universiteit Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - J M Hazes
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Annette van der Helm-van Mil
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
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Dose tapering of biologic agents in patients with rheumatoid arthritis-results from a cohort study in Germany. Clin Rheumatol 2020; 40:887-893. [PMID: 32822057 DOI: 10.1007/s10067-020-05316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/19/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the association of demographic and clinical factors with the clinical decision of tapering biologic disease modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) in daily practice. METHODS All RA patients receiving bDMARDs were documented by 14 rheumatologists when presenting in 9 specialized private practices. Statistical analyses employed multivariable logistic models for dose reduction with the covariates age, gender, disease duration until bDMARD start, smoking status, disease activity, comorbidity, functional capacity, radiographic damage, concomitant methotrexate (MTX) treatment, rheumatoid factor positivity, and glucocorticoid use. In the multivariable model (MVM), missing values were imputed. RESULTS Data of 586 RA patients on bDMARD treatment were available, 171 of which (29%) received a reduced dose. The highest rates of patients with dose reduction were seen for rituximab (67%) and infliximab (50%). The degree of dose reduction was most prominent for rituximab (57%). In the MVM, 6/11 covariates were significantly associated with dose reduction: age (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.05; P = 0.002), time between disease onset and bDMARD start (OR 1.03, 95% CI 1.01-1.06; P = 0.015), DAS 28 < 2.6 (OR 1.55, 95% CI 1.01-2.37; P = 0.045), MTX therapy (OR 1.52, 95% CI 1.03-2.25; P = 0.036), comorbidity (OR 1.20, 95% CI 1.01-1.42; P = 0.036), and glucocorticoid dose (OR 0.82, 95% CI 0.76-0.89; P < 0.001). CONCLUSION DAS 28 remission, concomitant MTX, and lower glucocorticoid doses were positively associated with dose tapering of bDMARDs in RA patients. While this could be expected, the reason for the association with age, comorbidity, and the time between disease onset and bDMARD start is less clear. Key points • In rheumatology practice, tapering of biologic disease modifying antirheumatic drugs is feasible in nearly 30% of patients with rheumatoid arthritis. • The degree of dose reduction may exceed 50% of the recommended dose. • In a multivariable model, concomitant methotrexate is positively associated with dose tapering of biologic disease modifying antirheumatic drugs.
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Michaud K, Pope J, van de Laar M, Curtis JR, Kannowski C, Mitchell S, Bell J, Workman J, Paik J, Cardoso A, Taylor PC. Systematic Literature Review of Residual Symptoms and an Unmet Need in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2020; 73:1606-1616. [PMID: 32619340 PMCID: PMC8596735 DOI: 10.1002/acr.24369] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 06/25/2020] [Indexed: 12/11/2022]
Abstract
Objective To evaluate the nature and burden of residual disease in rheumatoid arthritis (RA) in patients who meet treatment targets. Second, for those who did not meet targets, to evaluate how much is due to patient symptoms. Methods Prospective and retrospective studies were searched in Medline, Embase, and Cochrane Library in the English language from January 1, 2008 to April 18, 2018; conference abstracts (from January 2016 to April 2018) and reference lists of relevant studies were also screened. Results Of 8,339 records identified, 55 were included in the review; 53 were unique studies, including 10 randomized controlled trials. Of these, 48 reported on patients who achieved low disease activity (LDA) or remission. Studies varied in population, treatment goals, and outcome reporting. The proportions of patients with residual symptoms in these studies varied by the definitions used for LDA or remission and were more often reported in patients with LDA than those in remission. The most commonly reported outcome measures were functional disability (n = 34 studies), tender or swollen joints (n = 18), pain (n = 17), patient global assessment (n = 15), and fatigue (n = 14). However, few studies reported the percentage of patients achieving a specific threshold, which could then be used to easily define the presence of residual symptoms. Conclusion Residual symptoms are present in some patients despite their achieving LDA or remission, highlighting an unmet need, especially with respect to improving pain, fatigue, and function. Standardized reporting in future observational studies would facilitate better understanding of this issue in defined RA populations.
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Affiliation(s)
- Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Janet Pope
- University of Western Ontario, London, Ontario, Canada
| | | | | | | | | | | | | | - Jim Paik
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - Peter C Taylor
- Botnar Research Centre, University of Oxford, Oxford, UK
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Abstract
Non-adherence in non-inferiority trials can affect treatment effect estimates and often increases the chance of claiming non-inferiority under the standard intention-to-treat analysis. This article discusses the implications of different patterns of non-adherence in non-inferiority trials and offers practical recommendations for trial design, alternative analysis strategies, and outcome reporting to reduce bias in treatment estimates and improve transparency in reporting.
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Affiliation(s)
- Yin Mo
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, National University of Singapore, Singapore
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Cherry Lim
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - James A Watson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Ben S Cooper
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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Ma MHY, Defranoux N, Li W, Sasso EH, Ibrahim F, Scott DL, Cope AP. A multi-biomarker disease activity score can predict sustained remission in rheumatoid arthritis. Arthritis Res Ther 2020; 22:158. [PMID: 32580789 PMCID: PMC7313155 DOI: 10.1186/s13075-020-02240-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/09/2020] [Indexed: 01/10/2023] Open
Abstract
Background Reliable assessment of remission is important for the optimal management of rheumatoid arthritis (RA) patients. In this study, we used the multi-biomarker disease activity (MBDA) test to explore the role of biomarkers in predicting point remission and sustained remission. Methods RA patients on > 6 months stable therapy in stable low disease activity (DAS28-ESR ≤ 3.2) were assessed every 3 months for 1 year. Baseline, intermittent (IR) and sustained (SR) remission were defined by DAS28-ESR, DAS28-CRP, simple disease activity index (SDAI), clinical disease activity index (CDAI) and ACR/EULAR Boolean criteria. Patients not fulfilling any remission criteria at baseline were classified as ‘low disease activity state’ (LDAS). Patients not fulfilling any remission criteria over 1 year were classified as ‘persistent disease activity’ (PDA). MBDA score was measured at baseline/3/6 months. The baseline MBDA score, the 6-month time-integrated MBDA score and MBDA biomarkers were used for analyses. The area under the receiver operating characteristic curve (AUROC) assessed the ability of the MBDA score to discriminate between remission and non-remission. Biomarkers were analysed at baseline using the Mann-Whitney test and over time using the Jonckheere-Terpstra trend test. Results Of 148 patients, 27% were in the LDAS, 65% DAS28-ESR remission, 51% DAS28-CRP remission, 40% SDAI remission, 43% CDAI remission and 25% ACR/EULAR Boolean remission at baseline. Over 1 year, 9% of patients were classified as PDA. IR and SR were achieved in 42%/47% by DAS28-ESR, 46%/29% by DAS28-CRP, 45%/20% by SDAI, 44%/21% by CDAI and 35%/9% by ACR/EULAR Boolean criteria, respectively. By all remission criteria, baseline MBDA score discriminated baseline remission (AUROCs 0.68–0.75) and IR/SR (AUROCs 0.65–0.74). The 6-month time-integrated MBDA score discriminated IR/SR (AUROCs 0.65–0.79). Baseline MBDA score and concentrations of IL-6, leptin, SAA and CRP were significantly lower in all baseline remission criteria groups vs LDAS. They and the 6-month time-integrated values were lower among patients who achieved IR/SR vs PDA over 1 year. Conclusions This study demonstrated that the MBDA score and its biomarkers IL-6, leptin, SAA and CRP differentiated between small differences in disease activity (i.e. between low disease activity and remission states). They were also predictors of remission over 1 year.
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Affiliation(s)
- M H Y Ma
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road., London, SE5 9RJ, UK. .,Level 10, Tower Block, Division of Rheumatology, University Medicine Cluster, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore.
| | - N Defranoux
- Crescendo Bioscience, Inc., South San Francisco, CA, USA.,Present Address: Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA
| | - W Li
- Crescendo Bioscience, Inc., South San Francisco, CA, USA.,MyoKardia, Inc., Brisbane, CA, USA
| | - E H Sasso
- Crescendo Bioscience, Inc., South San Francisco, CA, USA
| | - F Ibrahim
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road., London, SE5 9RJ, UK
| | - D L Scott
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road., London, SE5 9RJ, UK
| | - A P Cope
- Academic Department of Rheumatology, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road., London, SE5 9RJ, UK.,Department of Rheumatology, Guy's and St Thomas' UK National Health Service (NHS) Foundation Trust, London, UK
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Schlager L, Loiskandl M, Aletaha D, Radner H. Predictors of successful discontinuation of biologic and targeted synthetic DMARDs in patients with rheumatoid arthritis in remission or low disease activity: a systematic literature review. Rheumatology (Oxford) 2020; 59:324-334. [PMID: 31325305 DOI: 10.1093/rheumatology/kez278] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/29/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To systematically review possible predictors of successful discontinuation of biologic or targeted synthetic DMARDs (b/tsDMARDs) in RA patients in remission or low disease activity. METHODS MEDLINE database and Cochrane Library were scanned for studies that discontinued b/tsDMARDs in remission/low disease activity and searched for predictors of successful discontinuation. Additionally, EULAR and ACR meeting abstracts were hand searched. RESULTS Thirty-four studies with a total of 5724 patients were included. Predictors of successful b/tsDMARD discontinuation were (number of studies): low disease activity (n = 13), better physical function (n = 6), low or absence of rheumatoid factor (n = 5) or ACPA (n = 3), low levels of CRP (n = 3) or ESR (n = 3), shorter disease duration (n = 3), low signals of disease activity by ultrasound (n = 3). Only one study with high risk of bias was identified on tsDMARD discontinuation. CONCLUSION Several predictors of successful bDMARD discontinuation were identified. Although studies are heterogeneous, these predictors may inform clinical decision making in patients who are considered for a potential bDMARD discontinuation.
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Affiliation(s)
- Lukas Schlager
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Michaela Loiskandl
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - Helga Radner
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
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Mankia K, Di Matteo A, Emery P. Prevention and cure: The major unmet needs in the management of rheumatoid arthritis. J Autoimmun 2020; 110:102399. [DOI: 10.1016/j.jaut.2019.102399] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 01/01/2023]
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Smits LJT, Pauwels RWM, Kievit W, de Jong DJ, de Vries AC, Hoentjen F, van der Woude CJ. Lengthening adalimumab dosing interval in quiescent Crohn's disease patients: protocol for the pragmatic randomised non-inferiority LADI study. BMJ Open 2020; 10:e035326. [PMID: 32461297 PMCID: PMC7259868 DOI: 10.1136/bmjopen-2019-035326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Adalimumab is effective for maintenance of remission in patients with Crohn's disease (CD) at a dose of 40 mg subcutaneously every 2 weeks. However, adalimumab is associated with (long-term) adverse events and is costly. The aim of this study is to demonstrate non-inferiority and cost-effectiveness of disease activity guided adalimumab interval lengthening compared to standard dosing of every other week (EOW). METHODS AND ANALYSIS The Lengthening Adalimumab Dosing Interval (LADI) study is a pragmatic, multicentre, open label, randomised controlled non-inferiority trial. Non-inferiority is reached if the difference in cumulative incidence of persistent (>8 weeks) flares does not exceed the non-inferiority margin of 15%. 174 CD patients on adalimumab maintenance therapy in long-term (>9 months) clinical and biochemical remission will be included (C-reactive protein (CRP) <10 mg/L, faecal calprotectin (FC) <150 µg/g, Harvey-Bradshaw Index (HBI) <5). Patients will be randomised 2:1 into the intervention (adalimumab interval lengthening) or control group (adalimumab EOW). The intervention group will lengthen the adalimumab administration interval to every 3 weeks, and after 24 weeks to every 4 weeks. Clinical and biochemical disease activity will be monitored every 12 weeks by physician global assessment, HBI, CRP and FC. In case of disease flare, dosing will be increased. A flare is defined as two of three of the following criteria; FC>250 µg/g, CRP≥10 mg/l, HBI≥5. Secondary outcomes include cumulative incidence of transient flares, adverse events, predictors for successful dose reduction and cost-effectiveness. ETHICS AND DISSEMINATION The study is approved by the Medical Ethics Committee Arnhem-Nijmegen, the Netherlands (registration number NL58948.091.16). Results will be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBERS EudraCT registry (2016-003321-42); Clinicaltrials.gov registry (NCT03172377); Dutch trial registry (NTRID6417).
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Affiliation(s)
- L J T Smits
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - R W M Pauwels
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - W Kievit
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - D J de Jong
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - A C de Vries
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - F Hoentjen
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - C J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Emery P, Burmester GR, Naredo E, Sinigaglia L, Lagunes I, Koenigsbauer F, Conaghan PG. Adalimumab dose tapering in patients with rheumatoid arthritis who are in long-standing clinical remission: results of the phase IV PREDICTRA study. Ann Rheum Dis 2020; 79:1023-1030. [PMID: 32404343 PMCID: PMC7392484 DOI: 10.1136/annrheumdis-2020-217246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To investigate the association between baseline disease activity and the occurrence of flares after adalimumab tapering or withdrawal in patients with rheumatoid arthritis (RA) in sustained remission. METHODS The PREDICTRA phase IV, randomised, double-blind (DB) study (ImPact of Residual Inflammation Detected via Imaging TEchniques, Drug Levels, and Patient Characteristics on the Outcome of Dose TaperIng of Adalimumab in Clinical Remission Rheumatoid ArThritis (RA) Patients) enrolled patients with RA receiving adalimumab 40 mg every other week who were in sustained remission ≥6 months. After a 4-week, open-label lead-in (OL-LI) period, patients were randomised 5:1 to DB adalimumab taper (every 3 weeks) or withdrawal (placebo) for 36 weeks. The primary endpoint was the association between DB baseline hand and wrist MRI-detected inflammation with flare occurrence. RESULTS Of 146 patients treated during the OL-LI period, 122 were randomised to taper (n=102) or withdrawal (n=20) arms. Patients had a mean 12.9 years of active disease and had received adalimumab for a mean of 5.4 years (mean 2.2 years in sustained remission). Overall, 37 (36%) and 9 (45%) patients experienced a flare in the taper and withdrawal arms, respectively (time to flare, 18.0 and 13.3 weeks). None of the DB baseline disease characteristics or adalimumab concentration was associated with flare occurrence after adalimumab tapering. Approximately half of the patients who flared regained clinical remission after 16 weeks of open-label rescue adalimumab. The safety profile was consistent with previous studies. CONCLUSIONS Approximately one-third of patients who tapered adalimumab versus half who withdrew adalimumab experienced a flare within 36 weeks. Time to flare was numerically longer in the taper versus withdrawal arm. Baseline MRI inflammation was not associated with flare occurrence. TRIAL REGISTRATION NUMBER NCT02198651, EudraCT 2014-001114-26.
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Affiliation(s)
- Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK .,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin, Berlin, Germany
| | - Esperanza Naredo
- Department of Rheumatology, Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Luigi Sinigaglia
- Department of Rheumatology and Medical Sciences, Centro Specialistico Ortopedico Traumatologico Pini-CTO, Milan, Italy
| | - Ivan Lagunes
- Global Medical Affairs Rheumatology, AbbVie Inc, North Chicago, Illinois, USA
| | | | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
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Vinson D, Molet-Benhamou L, Degboé Y, den Broeder A, Ibrahim F, Pontes C, Westhovens R, Závada J, Pham T, Barnetche T, Constantin A, Ruyssen-Witrand A. Impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and adverse events of special interest in patients with rheumatoid arthritis or spondyloarthritis: a systematic analysis of the literature and meta-analysis. Arthritis Res Ther 2020; 22:97. [PMID: 32349791 PMCID: PMC7191828 DOI: 10.1186/s13075-020-02188-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/17/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To systematically review the impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and severe adverse events (SAEs) in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) in remission or low disease activity (LDA) state. MATERIALS AND METHODS A meta-analysis based on a systematic review of PubMed, Embase, Cochrane, until August 2019, as well as relevant databases of international conferences, was used to evaluate the risk difference (RD) at 95% confidence interval (95% CI) of incidence density of serious infections, SAEs, malignancies, cardiovascular adverse events (CV AEs), or deaths after tapering (dose reduction or spacing) compared to continuation of targeted therapies. RESULTS Of the 1957 studies initially identified, 13 controlled trials (9 RA and 4 SpA trials) were included in the meta-analysis. 1174 patient-years were studied in the tapering group (TG) versus 1086 in the usual care group (UC). There were 1.7/100 patient-year (p-y) serious infections in TG versus 2.6/100 p-y in UC (RD (95% CI) 0.01 (0.00 to 0.02), p = 0.13) and 7.4/100 p-y SAEs in TG versus 6.7/100 p-y in UC (RD 0.00 (- 0.02 to 0.02), p = 0.82). The risk of malignancies, CV AEs, or deaths did not differ between the tapering and the usual care groups. Subgroup analysis (RA and SpA) detected no significant differences between the two groups. CONCLUSION We could not show significant impact of tapering bDMARD or JAKi over continuation concerning the risk of serious infections, SAEs, malignancies, CV AEs, or deaths in RA and SpA patients in remission or LDA state.
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Affiliation(s)
- D Vinson
- Rheumatology Department, CHU Sainte Marguerite, 270 Boulevard de Sainte-Marguerite, 13009, Marseille, France.
| | | | - Y Degboé
- INSERM U1043, CPTP, Toulouse, France
| | - A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, 6500 GM, Nijmegen, The Netherlands
| | - F Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, Cutcombe Road, London, SE5 9RJ, UK
| | - C Pontes
- Department of Pharmacology, Therapeutics and Toxicology, Unitat docent Parc Taulí-Medical School-Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - R Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, Rheumatology University Hospitals Leuven, KULeuven, Leuven, Belgium
| | - J Závada
- First Faculty of Medicine, Institute of Rheumatology and Department of Rheumatology, Charles University, Na Slupi 4, Prague, Czech Republic
| | - T Pham
- Rheumatology Department, CHU Sainte Marguerite, 270 Boulevard de Sainte-Marguerite, 13009, Marseille, France
| | - T Barnetche
- Rheumatology Department, Pellegrin Hospital, Bordeaux, France
| | - A Constantin
- Rheumatology Department, Hôpital Purpan, Toulouse, France
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Dierckx S, Sokolova T, Lauwerys BR, Avramovska A, de Bellefon LM, Toukap AN, Stoenoiu M, Houssiau FA, Durez P. Tapering of biological antirheumatic drugs in rheumatoid arthritis patients is achievable and cost-effective in daily clinical practice: data from the Brussels UCLouvain RA Cohort. Arthritis Res Ther 2020; 22:96. [PMID: 32345367 PMCID: PMC7189594 DOI: 10.1186/s13075-020-02165-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/27/2020] [Indexed: 02/01/2023] Open
Abstract
Background/purpose Studies have demonstrated that rheumatoid arthritis (RA) patients who achieve low disease activity or remission are able to taper biological disease-modifying antirheumatic drugs (bDMARDs). The aim of this study was to evaluate the proportion of patients in whom bDMARDs can be tapered in daily practice and to analyse the characteristics of these patients. Other objectives were to analyse which bDMARDs are more suitable for dose reduction and the cost savings. Results Data from 332 eligible RA patients from our Brussels UCLouvain cohort were retrospectively analysed; 140 patients (42.1%) received a tapered regimen, and 192 received stable doses of bDMARDs. The age at diagnosis (43.1 vs 38.7 years, p = 0.04), health assessment questionnaire (HAQ) score (1.3 vs 1.5, p = 0.048), RF positivity rate (83.3 vs 72.9%, p = 0.04) and disease duration at the time of bDMARD introduction (9.7 vs 12.1 years, p = 0.034) were significantly different between the reduced-dose and stable-dose groups. Interestingly, relatively more patients receiving a tapered dose were treated with a combination of bDMARDs and methotrexate (MTX) (86.7% vs 73.8%, p = 0.005). In our cohort, anti-TNF agents were the most commonly prescribed medications (68%). Only 15 patients experienced a flare during follow-up. Adalimumab, etanercept and rituximab were the most common bDMARDs in the reduced-dose group and were associated with the most important reductions in annual cost. Conclusion In daily practice, tapering bDMARDs in RA patients who have achieved low disease activity or remission is an achievable goal in a large proportion of patients, thereby reducing potential side effects and annual drug-associated costs. The combination of bDMARDs with MTX could improve the success of dose reduction attempts. Trial registration This retrospective non-interventional study was retrospectively registered with local ethics approval.
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Affiliation(s)
- Stéphanie Dierckx
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Tatiana Sokolova
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Bernard R Lauwerys
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Aleksandra Avramovska
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Laurent Meric de Bellefon
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Adrien Nzeusseu Toukap
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Maria Stoenoiu
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Frédéric A Houssiau
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Patrick Durez
- Rheumatology, Cliniques universitaires Saint-Luc - Université catholique de Louvain - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium.
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Berkhout LC, l'Ami MJ, Ruwaard J, Hart MH, Heer POD, Bloem K, Nurmohamed MT, van Vollenhoven RF, Boers M, Alvarez DF, Smith CH, Wolbink GJ, Rispens T. Dynamics of circulating TNF during adalimumab treatment using a drug-tolerant TNF assay. Sci Transl Med 2020; 11:11/477/eaat3356. [PMID: 30700574 DOI: 10.1126/scitranslmed.aat3356] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 09/08/2018] [Accepted: 12/19/2018] [Indexed: 12/24/2022]
Abstract
Patients with rheumatoid arthritis (RA) can be successfully treated with tumor necrosis factor (TNF) inhibitors, including the monoclonal antibody adalimumab. Once in remission, a proportion of patients can successfully discontinue treatment, indicating that blocking TNF is no longer required for disease control. To explore the dynamics of circulating TNF during adalimumab treatment, we developed a competition enzyme-linked immunosorbent assay that can quantify TNF in the presence of large amounts of TNF inhibitor, i.e., a "drug-tolerant" assay. In 193 consecutive adalimumab-treated patients with RA, we demonstrated that circulating TNF increased in average of >50-fold upon treatment and reached a stable concentration in time for most patients. A similar increase in TNF was found in 30 healthy volunteers after one dose of adalimumab. This implies that TNF in circulation during anti-TNF treatment is not primarily associated with disease activity. During treatment, TNF was in complex with adalimumab and could be recovered as inactive 3:1 adalimumab-TNF complexes. No quantitative association was found between TNF and adalimumab concentrations. Low TNF concentrations at week 4 were associated with a higher frequency of antidrug antibodies (ADAs) at subsequent time points, less frequent methotrexate use at baseline, and less frequent remission after 52 weeks. Also in healthy volunteers, early low TNF concentrations are associated with ADAs. In conclusion, longitudinal TNF concentrations are mostly stable during adalimumab treatment and may therefore not predict successful treatment discontinuation. However, early low TNF is strongly associated with ADA formation and may be used as timely predictor of nonresponse toward adalimumab treatment.
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Affiliation(s)
- Lea C Berkhout
- Department of Immunopathology, Sanquin Research, 1066 CX Amsterdam, Netherlands, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Merel J l'Ami
- Amsterdam Rheumatology and immunology Center, Reade, 1056 AB Amsterdam, Netherlands
| | - Jill Ruwaard
- Amsterdam Rheumatology and immunology Center, Reade, 1056 AB Amsterdam, Netherlands
| | - Margreet H Hart
- Department of Immunopathology, Sanquin Research, 1066 CX Amsterdam, Netherlands, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Pleuni Ooijevaar-de Heer
- Department of Immunopathology, Sanquin Research, 1066 CX Amsterdam, Netherlands, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Karien Bloem
- Department of Immunopathology, Sanquin Research, 1066 CX Amsterdam, Netherlands, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology and immunology Center, Reade, 1056 AB Amsterdam, Netherlands.,Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, VU University Medical Center, 1081 HV Amsterdam, Netherlands
| | - Ronald F van Vollenhoven
- Amsterdam Rheumatology and immunology Center, Reade, 1056 AB Amsterdam, Netherlands.,Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, VU University Medical Center, 1081 HV Amsterdam, Netherlands.,Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Academic Medical Center, 1105 AZ Amsterdam, Netherlands
| | - Maarten Boers
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, VU University Medical Center, 1081 HV Amsterdam, Netherlands.,Department of Epidemiology and Biostatistics, VU University Medical Center, 1081 HV Amsterdam, Netherlands
| | | | - Catherine H Smith
- St. John's Institute of Dermatology, Division of Genetics and Molecular Medicine, Kings College London, SE1 9RT London, UK
| | - Gerrit J Wolbink
- Department of Immunopathology, Sanquin Research, 1066 CX Amsterdam, Netherlands, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Rheumatology and immunology Center, Reade, 1056 AB Amsterdam, Netherlands
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research, 1066 CX Amsterdam, Netherlands, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
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Michielsens CAJ, Boers N, den Broeder N, Wenink MH, van der Maas A, Mahler EAM, Mulder MLM, van der Heijde D, van den Hoogen FHJ, Verhoef LM, den Broeder AA. Dose reduction and withdrawal strategy for TNF-inhibitors in psoriatic arthritis and axial spondyloarthritis: design of a pragmatic open-label, randomised, non-inferiority trial. Trials 2020; 21:90. [PMID: 31941544 PMCID: PMC6964104 DOI: 10.1186/s13063-019-4000-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Tumour necrosis factor inhibitors (TNFi) are effective in the treatment of patients with spondyloarthritis (SpA), including psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA). However, these drugs come with some disadvantages such as adverse events, practical burden for patients and high costs. Dose optimisation of TNFi after patients have reached low disease activity (LDA) has been shown feasible and safe in rheumatoid arthritis (RA). However, data on TNFi dose optimisation in PsA and axSpA are scarce, especially pragmatic, randomised strategy studies. METHODS We developed an investigator-driven, pragmatic, open-label, randomised, controlled, non-inferiority trial (DRESS-PS) to compare the effects of a disease activity-guided treat-to-target strategy with or without a tapering attempt in patients with SpA (PsA and axSpA combined), ≥ 16 years of age, who are being treated with TNFi, and have had at least 6 months of low disease activity. The primary outcome is the percentage of patients in LDA after 12 months of follow up. Patients are assessed at baseline, 3, 6, 9, and 12 months of follow up. Bayesian power analyses with a weakened prior based on a similar study performed in RA resulted in a sample size of 95 patients in total. DISCUSSION More knowledge on disease activity-guided treatment algorithms would contribute to better treatment choices and cost savings and potentially decrease the risk of side effects. In this article we elucidate some of our design choices on TNFi dose optimisation and its clinical and methodological consequences. TRIAL REGISTRATION Dutch Trial Register, NL6771. Registered on 27 November 2018 (CMO NL66181.091.18, 23 October 2018).
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Affiliation(s)
- Celia A J Michielsens
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands. .,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Mark H Wenink
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Elien A M Mahler
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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