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Heutz JW, Looijen AEM, Kuijpers JHSAM, Schreurs MWJ, van der Helm-van Mil AHM, de Jong PHP. The prognostic value of IgA anti-citrullinated protein antibodies and rheumatoid factor in an early arthritis population with a treat-to-target approach. Immunol Res 2024:10.1007/s12026-024-09500-w. [PMID: 38960995 DOI: 10.1007/s12026-024-09500-w] [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: 02/29/2024] [Accepted: 05/27/2024] [Indexed: 07/05/2024]
Abstract
The mucosal origin hypothesis of rheumatoid arthritis has renewed the interest in IgA autoantibodies, but their added value over IgG anti-citrullinated protein antibody (ACPA) and IgM rheumatoid factor (RF) for modern treatment outcomes remains unknown. We aimed to investigate the prognostic value of IgA-ACPA and IgA-RF for treatment outcomes in an early arthritis population. IgA-ACPA/RF isotypes were measured in baseline sera from 480 inflammatory arthritis (IA) patients, who were included in the treatment in the Rotterdam Early Arthritis Cohort trial (tREACH). The tREACH trial was a multicentre, stratified, single-blinded trial with a treat-to-target approach. The prognostic value of IgA-ACPA/RF was determined by evaluating differences in (1) quick-attained (< 6 months after diagnosis) and persistent remission rates, (2) DMARD-free remission and (3) biological use between IA patients with and without IgA-ACPA/RF over 3 years of follow-up. IgA-ACPA was present in 23% of patients and overlapped with IgG-ACPA positivity in 94%. Similarly, IgA-RF overlapped with IgM-RF in 90% of patients. IgA-ACPA positivity was associated with lower DFR rates and more biological use, but this effect was largely mediated by the presence of IgG-ACPA, since this effect disappeared after stratification for IgG-ACPA (HR 0.6, 95%CI 0.2-1.6 for DFR). No differences were observed in 'quick-attained and persistent remission' rates and for IgA-RF. Their seems to be no additional value of IgA-ACPA and IgA-RF for modern, long-term clinical outcomes. The effects of IgA-ACPA seen in our study are largely mediated by the presence of IgG-ACPA. Based on these results, there is no rationale for measuring these isotypes in daily practice.
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Affiliation(s)
- Judith W Heutz
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Agnes E M Looijen
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Marco W J Schreurs
- Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pascal H P de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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2
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Hee JY, Cai B, Thomas R. Liposomal delivery of self-peptide and calcitriol as tolerogenic immunotherapy in rheumatoid arthritis: an exploration using sensory science. Immunol Cell Biol 2024; 102:353-357. [PMID: 38216149 DOI: 10.1111/imcb.12719] [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] [Indexed: 01/14/2024]
Abstract
Immunology research holds significant potential for enhanced inclusivity at the beginning of the science literacy journey, but persistent challenges stem from limited awareness that improvement is needed in this field. At the 2023 Monash Sensory Science Exhibition, we had the opportunity to present several tactile posters, using simple materials, for visually impaired participants to showcase our research on the pathogenesis of rheumatoid arthritis as a result of immune tolerance breakdown and liposome-based tolerogenic immunotherapy. The posters stimulated lively discussions about autoimmune arthritic diseases and our research. With consideration of the diversity of the participants, the efforts of scientists in promoting science literacy for the community can promote a more inclusive environment and engage and inspire a broader audience.
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Affiliation(s)
- Jia Yi Hee
- Frazer Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Benjamin Cai
- Frazer Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Ranjeny Thomas
- Frazer Institute, The University of Queensland, Brisbane, QLD, Australia
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Kjørholt KE, Sundlisæter NP, 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, Kvien TK, Solomon DH, van der Heijde D, Haavardsholm EA, Lillegraven S. Effects of tapering conventional synthetic disease-modifying antirheumatic drugs to drug-free remission versus stable treatment in rheumatoid arthritis (ARCTIC REWIND): 3-year results from an open-label, randomised controlled, non-inferiority trial. THE LANCET. RHEUMATOLOGY 2024; 6:e268-e278. [PMID: 38583450 DOI: 10.1016/s2665-9913(24)00021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Tapering of disease-modifying antirheumatic drugs (DMARDs) to drug-free remission is an attractive treatment goal for patients with rheumatoid arthritis, although long-term effects of tapering and withdrawal remain unclear. We compared 3-year risks of flare between three conventional synthetic DMARD treatment strategies in patients with rheumatoid arthritis in sustained remission. METHODS In this open-label, randomised controlled, non-inferiority trial, we enrolled patients aged 18-80 years with rheumatoid arthritis who had been in sustained remission for at least 1 year on stable conventional synthetic DMARD therapy. Patients from ten hospitals in Norway were randomly assigned (2:1:1) with centre stratification to receive stable conventional synthetic DMARDs, half-dose conventional synthetic DMARDs, or half-dose conventional synthetic DMARDs for 1 year followed by withdrawal of all conventional synthetic DMARDs. The primary endpoint of this part of the study was disease flare over 3 years, analysed as flare-free survival and risk difference in the per-protocol population with a non-inferiority margin of 20%. This trial is registered with ClinicalTrials.gov (NCT01881308) and is completed. FINDINGS Between June 17, 2013, and June 18, 2018, 160 patients were enrolled and randomly assigned to receive stable-dose conventional synthetic DMARDs (n=80), half-dose conventional synthetic DMARDs (n=42), or half-dose conventional synthetic DMARDs tapering to withdrawal (n=38). Four patients did not receive the intervention and 156 patients received the allocated treatment strategy. One patient was excluded due to major protocol violation and 155 patients were included in the per-protocol analysis. 104 (67%) of 156 patients were women and 52 (33%) were men. 139 patients completed 3-years follow-up without major protocol violation; 68 (87%) of 78 patients in the stable-dose group, 36 (88%) of 41 patients in the half-dose group and 35 (95%) of 37 patients in the half-dose tapering to withdrawal group. During the 3-year study period, 80% (95% CI 69-88%) were flare-free in the stable-dose group, compared with 57% (41-71%) in the half-dose group and 38% (22-53%) in the half-dose tapering to withdrawal group. Compared with stable-dose conventional synthetic DMARDs, the risk difference of flare was 23% (95% CI 6-41%, p=0·010) in the half-dose group and 40% (22-58%, p<0·0001) in the half-dose tapering to withdrawal group, non-inferiority was therefore not shown. Adverse events were reported in 65 (83%) of 78 patients in the stable-dose group, 36 (90%) of 40 patients in the half-dose group, and 36 (97%) of 37 patients in the half-dose tapering to withdrawal group. One death occurred in the stable-dose conventional synthetic DMARD group (sudden death considered unlikely related to the study medication). INTERPRETATION Two conventional synthetic DMARD tapering strategies were associated with significantly lower rates of flare-free survival compared with stable conventional synthetic DMARD treatment, and the data do not support non-inferiority. However, drug-free remission was achiveable for a significant subgroup of patients. This trial provides information on risk and benefits of different treatment strategies important for shared decision making. FUNDING Research Council of Norway and South-Eastern Norway Regional Health Authority.
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Affiliation(s)
- Kaja E Kjørholt
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Nina Paulshus Sundlisæter
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Anna-Birgitte Aga
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Joseph Sexton
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Inge C Olsen
- Clinical Trial Unit, Oslo University Hospital, Oslo, Norway
| | - Hallvard Fremstad
- Department of Rheumatology, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Cristina Spada
- Department of Rheumatology, Rheumatism Hospital AS, Lillehammer, Norway
| | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | | | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, Tromsø, Norway; Institute of Clinical Medicine, Faculty of Health Science, UiT The Arctic University, 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
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Till Uhlig
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tore K Kvien
- 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, Brigham and Women's Hospital, Boston, MA, USA
| | - Désirée van der Heijde
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Espen A Haavardsholm
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Siri Lillegraven
- Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
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van Mulligen E. Tapering conventional synthetic DMARDs towards sustained drug-free remission in rheumatoid arthritis. THE LANCET. RHEUMATOLOGY 2024; 6:e254-e255. [PMID: 38583451 DOI: 10.1016/s2665-9913(24)00038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Elise van Mulligen
- Department of Rheumatology, Leiden University Medical Center, Leiden, 2333 ZA Netherlands; Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands.
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Baker KF, McDonald D, Hulme G, Hussain R, Coxhead J, Swan D, Schulz AR, Mei HE, MacDonald L, Pratt AG, Filby A, Anderson AE, Isaacs JD. Single-cell insights into immune dysregulation in rheumatoid arthritis flare versus drug-free remission. Nat Commun 2024; 15:1063. [PMID: 38316770 PMCID: PMC10844292 DOI: 10.1038/s41467-024-45213-2] [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: 01/22/2023] [Accepted: 01/18/2024] [Indexed: 02/07/2024] Open
Abstract
Immune-mediated inflammatory diseases (IMIDs) are typically characterised by relapsing and remitting flares of inflammation. However, the unpredictability of disease flares impedes their study. Addressing this critical knowledge gap, we use the experimental medicine approach of immunomodulatory drug withdrawal in rheumatoid arthritis (RA) remission to synchronise flare processes allowing detailed characterisation. Exploratory mass cytometry analyses reveal three circulating cellular subsets heralding the onset of arthritis flare - CD45RO+PD1hi CD4+ and CD8+ T cells, and CD27+CD86+CD21- B cells - further characterised by single-cell sequencing. Distinct lymphocyte subsets including cytotoxic and exhausted CD4+ memory T cells, memory CD8+CXCR5+ T cells, and IGHA1+ plasma cells are primed for activation in flare patients. Regulatory memory CD4+ T cells (Treg cells) increase at flare onset, but with dysfunctional regulatory marker expression compared to drug-free remission. Significant clonal expansion is observed in T cells, but not B cells, after drug cessation; this is widespread throughout memory CD8+ T cell subsets but limited to the granzyme-expressing cytotoxic subset within CD4+ memory T cells. Based on our observations, we suggest a model of immune dysregulation for understanding RA flare, with potential for further translational research towards novel avenues for its treatment and prevention.
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Affiliation(s)
- Kenneth F Baker
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
- Musculoskeletal Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - David McDonald
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Gillian Hulme
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Rafiqul Hussain
- Genomics Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathan Coxhead
- Genomics Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - David Swan
- School of Medicine, University of Sunderland, Sunderland, UK
| | - Axel R Schulz
- Deutsches Rheuma-Forschungszentrum Berlin, A Leibniz Institute, Berlin, Germany
| | - Henrik E Mei
- Deutsches Rheuma-Forschungszentrum Berlin, A Leibniz Institute, Berlin, Germany
| | - Lucy MacDonald
- School of Infection and Immunity, Glasgow University, Glasgow, UK
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Filby
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Amy E Anderson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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6
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Brown P, Pratt AG, Hyrich KL. Therapeutic advances in rheumatoid arthritis. BMJ 2024; 384:e070856. [PMID: 38233032 DOI: 10.1136/bmj-2022-070856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Rheumatoid arthritis (RA) is one of the most common immune mediated inflammatory diseases. People with rheumatoid arthritis present with pain, swelling, and stiffness that typically affects symmetrically distributed small and large joints. Without effective treatment, significant joint damage, disability, and work loss develop, owing to chronic inflammation of the joint lining (synovium). Over the past 25 years, the management of this condition has been revolutionized, resulting in substantially higher levels of disease remission and better long term outcomes. This improvement reflects a paradigm shift towards early and aggressive pharmacological intervention coupled with a proliferation in treatment choice, in turn related to enhanced pathobiological understanding and the advent of new drugs for rheumatoid arthritis. Following an overview of these developments from a historical perspective, and with a general audience in mind, this review focuses on newer, targeted treatments in an ever evolving landscape. The review highlights ongoing areas of debate and unmet need, including the proportion of patients with persistent, difficult-to-treat disease, despite recent advances. Also discussed are personalized, strategic approaches to individual patients, the role for imaging in clinical decision making, and the goal of sustained, drug free remission and disease prevention in the future.
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Affiliation(s)
- Philip Brown
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- National Institute for Health and Care Research Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne Hospitals and Cumbria, Northumberland; and Tyne and Wear NHS Foundation Trusts, Newcastle upon Tyne, UK
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- National Institute for Health and Care Research Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne Hospitals and Cumbria, Northumberland; and Tyne and Wear NHS Foundation Trusts, Newcastle upon Tyne, UK
| | - Kimme L Hyrich
- Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
- National Institute for Health and Care Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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7
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Konzett V, Kerschbaumer A, Smolen JS, Kristianslund EK, Provan SA, Kvien TK, Aletaha D. Definition of rheumatoid arthritis flare based on SDAI and CDAI. Ann Rheum Dis 2024; 83:169-176. [PMID: 37890977 DOI: 10.1136/ard-2023-224742] [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: 07/18/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVE To develop and validate definitions for disease flares in rheumatoid arthritis (RA) based on the quantitative Simplified and Clinical Disease Activity Indices (SDAI, CDAI). METHODS We analysed RA treatment courses from the Norwegian disease-modifying antirheumatic drug registry (NOR-DMARD) and the Vienna RA cohort. In a receiver operating curve analysis, we determined flare definitions for absolute changes in SDAI and CDAI based on a semiquantitative patient anchor. NOR-DMARD was sampled into an 80%-training cohort for cut point derivation and a 20%-test cohort for internal validation. The definitions were then externally validated in the independent Vienna RA cohort and tested regarding their performance on longitudinal, content, face, and construct validity. RESULTS We analysed 4256 treatment courses from NOR-DMARD and 2557 from the Vienna RA cohort. The preliminary definitions for absolute changes in SDAI and CDAI for flare are an increase of 4.7 and 4.5, respectively. The definitions performed well in the test and external validation cohorts, and showed clinical face and construct validity, as flares significantly impact both functional ( ∆ Health Assessment Questionnaire flare vs no-flare +0.43; p<0.001) and structural ( ∆ modified Sharp Score 43% higher after flare; p<0.001) disease outcomes, and reflect consistent worsening across all disease core sets, both patient reported and objective. CONCLUSION We here provide novel definitions for flare in RA based on SDAI and CDAI, validated in two large independent real-world cohorts. In times of highly effective medications for RA, and consideration of their tapering, these definitions will be useful for guiding decision making in clinical practice and designing clinical trials.
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Affiliation(s)
- Victoria Konzett
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Andreas Kerschbaumer
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Josef S Smolen
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Eirik Klami Kristianslund
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Sella A Provan
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Tore K Kvien
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Daniel Aletaha
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
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den Hollander NK, Verstappen M, van Dijk BT, van der Helm-van Mil AHM, van Steenbergen HW. Disentangling heterogeneity in contemporary undifferentiated arthritis - A large cohort study using latent class analysis. Semin Arthritis Rheum 2023; 63:152251. [PMID: 37607441 PMCID: PMC7615885 DOI: 10.1016/j.semarthrit.2023.152251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/03/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Undifferentiated arthritis(UA) is clinically heterogeneous and differs in outcomes ranging from spontaneous resolution to RA-development. Therefore, we hypothesized that subgroups exist within UA and we aimed to identify homogeneous groups based on clinical features, and thereafter to relate these groups to the outcomes spontaneous resolution and RA-development. These outcomes can only be studied in UA-patients in which DMARD-treatment does not influence the natural disease course; these cohorts are scarce. METHODS We studied autoantibody-negative UA-patients (not fulfilling 1987/2010 RA-criteria, no alternate diagnosis), included in the Leiden Early Arthritis Clinic between 1993 and 2006, when early DMARD-treatment in UA was infrequent. Latent class analysis was used to identify subgroups based on combinations of clinical features. Within these subgroups, test-characteristics were assessed for spontaneous resolution of arthritis and RA-development within 1 year. RESULTS 310 consecutive UA-patients were studied. Five classes were identified: location and number of swollen joints were most distinguishing. Classes were characterized by: 1) polyarthritis, often symmetric; 2) oligoarthritis, frequently with subacute onset; 3) wrist-monoarthritis, often with subacute onset, increased BMI and without morning stiffness; 4) small-joint monoarthritis, often without increased acute phase reactants, and 5) large-joint monoarthritis, often with subacute onset. Studying the classes in relation to the outcomes revealed that patients without spontaneous resolution (thus having persistent disease) were nearly absent in the classes characterized by monoarthritis (specificity >90%). Additionally, patients who developed RA were infrequent in monoarthritis classes (sensitivity <7%). CONCLUSION Using a data-driven unsupervised approach, five subgroups within contemporary UA were identified. These have differences in the natural course of disease.
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Affiliation(s)
- N K den Hollander
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands.
| | - M Verstappen
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - B T van Dijk
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - A H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands; Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - H W van Steenbergen
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
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9
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Chen SF, Yeh FC, Chen CY, Chang HY. Tailored therapeutic decision of rheumatoid arthritis using proteomic strategies: how to start and when to stop? Clin Proteomics 2023; 20:22. [PMID: 37301840 DOI: 10.1186/s12014-023-09411-2] [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: 10/17/2022] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Unpredictable treatment responses have been an obstacle for the successful management of rheumatoid arthritis. Although numerous serum proteins have been proposed, there is a lack of integrative survey to compare their relevance in predicting treatment outcomes in rheumatoid arthritis. Also, little is known about their applications in various treatment stages, such as dose modification, drug switching or withdrawal. Here we present an in-depth exploration of the potential usefulness of serum proteins in clinical decision-making and unveil the spectrum of immunopathology underlying responders to different drugs. Patients with robust autoimmunity and inflammation are more responsive to biological treatments and prone to relapse during treatment de-escalation. Moreover, the concentration changes of serum proteins at the beginning of the treatments possibly assist early recognition of treatment responders. With a better understanding of the relationship between the serum proteome and treatment responses, personalized medicine in rheumatoid arthritis will be more achievable in the near future.
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Affiliation(s)
- Shuo-Fu Chen
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fu-Chiang Yeh
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Yun Chen
- Department of Biomedical Sciences and Engineering, Institute of Biomedical Engineering and Nanomedicine, National Central University, Taoyuan, Taiwan
- Institute of Biomedical Engineering and Nanomedicine, National Health Research Institutes, Miaoli, Taiwan
| | - Hui-Yin Chang
- Department of Biomedical Sciences and Engineering, Institute of Systems Biology and Bioinformatics, National Central University, No. 300, Zhongda Rd., Zhongli District, Taoyuan, 320317, Taiwan.
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Valero M, Sánchez-Piedra C, Freire M, Colazo M, Busquets N, Meriño-Ibarra E, Rodríguez-Lozano C, Manrique S, Campos C, Sánchez-Alonso F, Castrejón I. Factors associated with discontinuation of biologics in patients with inflammatory arthritis in remission: data from the BIOBADASER registry. Arthritis Res Ther 2023; 25:86. [PMID: 37217997 PMCID: PMC10201751 DOI: 10.1186/s13075-023-03045-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/31/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND The objectives of this study were to assess the discontinuation of biologic therapy in patients who achieve remission and identify predictors of discontinuation of biologics in patients with inflammatory arthritis in remission. METHODS An observational retrospective study from the BIOBADASER registry comprising adult patients diagnosed with rheumatoid arthritis (RA), ankylosing spondylitis (AS), or psoriatic arthritis (PsA) and receiving 1 or 2 biological disease-modifying drugs (bDMARDs) between October 1999 and April 2021. Patients were followed yearly after initiation of therapy or until discontinuation of treatment. Reasons for discontinuation were collected. Patients who discontinued bDMARDs because of remission as defined by the attending clinician were studied. Predictors of discontinuation were explored using multivariable regression models. RESULTS The study population comprised 3,366 patients taking 1 or 2 bDMARDs. Biologics were discontinued owing to remission by 80 patients (2.4%): 30 with RA (1.7%), 18 with AS (2.4%), and 32 with PsA (3.9%). The factors associated with a higher probability of discontinuation on remission were shorter disease duration (OR: 0.95; 95% CI: 0.91-0.99), no concomitant use of classic DMARDs (OR: 0.56; 95% CI: 0.34-0.92), and shorter usage of the previous bDMARD (before the decision to discontinue biological therapy) (OR: 1.01; 95% CI: 1.01-1.02); in contrast, smoking status (OR: 2.48; 95% CI: 1.21-5.08) was associated with a lower probability. In patients with RA, positive ACPA was associated with a lower probability of discontinuation (OR: 0.11; 95% CI: 0.02-0.53). CONCLUSIONS Discontinuation of bDMARDs in patients who achieve remission is uncommon in routine clinical care. Smoking and positive ACPA in RA patients were associated with a lower probability of treatment discontinuation because of clinical remission.
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Affiliation(s)
- Marta Valero
- Servicio de Reumatología, Hospital Universitario Ramón Y CajalInstituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Viejo Km: 9,100, 28034, Madrid, Spain.
| | - Carlos Sánchez-Piedra
- Health Technology Assessment Agency of Carlos III Institute of Health (ISCIII), Madrid, Spain
| | - Mercedes Freire
- Department of Rheumatology, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - María Colazo
- Department of Rheumatology, Hospital Universitario de Burgos, Burgos, Spain
| | - Noemí Busquets
- Department of Rheumatology, Hospital General de Granollers, Granollers, Barcelona, Spain
| | - Erardo Meriño-Ibarra
- Department of Rheumatology, Hospital Universitario Miguel Servet, Saragossa, Spain
| | - Carlos Rodríguez-Lozano
- Department of Rheumatology, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Sara Manrique
- Department of Rheumatology, Hospital Universitario Regional de Málaga (Hospital Carlos Haya), Málaga, Spain
| | - Cristina Campos
- Department of Rheumatology, Hospital General Universitario de Valencia, Valencia, Spain
| | | | - Isabel Castrejón
- Department of Rheumatology, Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, Madrid, Spain
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Lillegraven S, Paulshus Sundlisæter N, Aga AB, Sexton J, Solomon DH, van der Heijde D, Haavardsholm EA. Discontinuation of Conventional Synthetic Disease-Modifying Antirheumatic Drugs in Patients With Rheumatoid Arthritis and Excellent Disease Control. JAMA 2023; 329:1024-1026. [PMID: 36976288 PMCID: PMC10051094 DOI: 10.1001/jama.2023.0492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/13/2023] [Indexed: 03/29/2023]
Abstract
This open-label randomized clinical trial assessed the 12-month risk of disease activity flares after discontinuation of conventional synthetic DMARDs (csDMARDs) compared with continuing half-dose csDMARDs in adult Norwegian patients with rheumatoid arthritis and excellent disease control.
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Affiliation(s)
- Siri Lillegraven
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Nina Paulshus Sundlisæter
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Anna-Birgitte Aga
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Joseph Sexton
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Daniel H. Solomon
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Espen A. Haavardsholm
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
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12
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D'Onofrio B, van der Helm-van Mil A, W J Huizinga T, van Mulligen E. Inducibility or predestination? Queries and concepts around drug-free remission in rheumatoid arthritis. Expert Rev Clin Immunol 2023; 19:217-225. [PMID: 36511619 DOI: 10.1080/1744666x.2023.2157814] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Drug-free remission (DFR) and its maintenance have been defined as the most desirable outcome for rheumatoid arthritis (RA) patients. DFR is linked to resolution of arthritis-related symptoms and restoration of normal functioning. However, there is currently no consensus if an optimal strategy, upon the initiation of treatment to the proper drugs withdrawal, is enough to induce it, or whether it is a predetermined condition related to patients' intrinsic characteristics. AREAS COVERED This review focuses on two key concepts around DFR. First, we analyze patients' intrinsic factors that may increase the chance of DFR, regardless of therapeutic choices. Second, we discuss on the evidence that it can be induced thanks to adequate, extrinsic disease management. Finally, we provide a glimpse into consequences of drugs discontinuation. EXPERT OPINION The early initiation of DMARD and the subsequent strict monitoring and drug adjustments are of primary importance to allow patients to achieve DFR, irrespective of initial treatment strategy. Once remission is obtained and maintained, it is possible to gradually taper and discontinue drugs with no dramatic consequences on the disease course. Among those who stop medication, ACPA-negative patients more often maintain the remission. Thus, DFR might depend on a combination of intrinsic and extrinsic factors.
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Affiliation(s)
- Bernardo D'Onofrio
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Elise van Mulligen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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13
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García IE, Abud-Mendoza C. Correspondence on 'Tapering towards DMARD-free remission in rheumatoid arthritis'. Ann Rheum Dis 2023; 82:e9. [PMID: 33158882 DOI: 10.1136/annrheumdis-2020-219239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/08/2020] [Accepted: 10/11/2020] [Indexed: 02/03/2023]
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14
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Verstappen M, Matthijssen XME, Connolly SE, Maldonado MA, Huizinga TWJ, van der Helm-van Mil AHM. ACPA-negative and ACPA-positive RA patients achieving disease resolution demonstrate distinct patterns of MRI-detected joint-inflammation. Rheumatology (Oxford) 2022; 62:124-134. [PMID: 35583256 PMCID: PMC9788814 DOI: 10.1093/rheumatology/keac294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/07/2022] [Accepted: 05/07/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Although sustained DMARD-free remission (SDFR; sustained absence of clinical-synovitis after DMARD-discontinuation) is increasingly achievable in RA, prevalence differs between ACPA-negative (40%) and ACPA-positive RA (5-10%). Additionally, early DAS remission (DAS4months<1.6) is associated with achieving SDFR in ACPA-negative, but not in ACPA-positive RA. Based on these differences, we hypothesized that longitudinal patterns of local tissue inflammation (synovitis/tenosynovitis/osteitis) also differ between ACPA-negative and ACPA-positive RA patients achieving SDFR. With the ultimate aim being to increase understanding of disease resolution in RA, we studied MRI-detected joint inflammation over time in relation to SDFR development in ACPA-positive RA and ACPA-negative RA. METHODS A total of 198 RA patients (94 ACPA-negative, 104 ACPA-positive) underwent repeated MRIs (0/4/12/24 months) and were followed on SDFR development. The course of MRI-detected total inflammation, and synovitis/tenosynovitis/osteitis individually were compared between RA patients who did and did not achieve SDFR, using Poisson mixed models. In total, 174 ACPA-positive RA patients from the AVERT-1 were studied as ACPA-positive validation population. RESULTS In ACPA-negative RA, baseline MRI-detected inflammation levels of patients achieving SDFR were similar to patients without SDFR but declined 2.0 times stronger in the first year of DMARD treatment [IRR 0.50 (95% CI; 0.32, 0.77); P < 0.01]. This stronger decline was seen in tenosynovitis/synovitis/osteitis. In contrast, ACPA-positive RA-patients achieving SDFR, had already lower inflammation levels (especially synovitis/osteitis) at disease presentation [IRR 0.45 (95% CI; 0.24, 0.86); P = 0.02] compared with patients without SDFR, and remained lower during subsequent follow-up (P = 0.02). Similar results were found in the ACPA-positive validation population. CONCLUSION Compared with RA patients without disease resolution, ACPA-positive RA patients achieving SDFR have less severe joint inflammation from diagnosis onwards, while ACPA-negative RA patients present with similar inflammation levels but demonstrate a stronger decline in the first year of DMARD therapy. These different trajectories suggest different mechanisms underlying resolution of RA chronicity in both RA subsets.
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Affiliation(s)
- Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | | | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, The Netherlands
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15
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Harnden K, Di Matteo A, Mankia K. When and how should we use imaging in individuals at risk of rheumatoid arthritis? Front Med (Lausanne) 2022; 9:1058510. [PMID: 36507546 PMCID: PMC9726914 DOI: 10.3389/fmed.2022.1058510] [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: 09/30/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
In recent years rheumatologists have begun to shift focus from early rheumatoid arthritis (RA) to studying individuals at risk of developing the disease. It is now possible to use blood, clinical and imaging biomarkers to identify those at risk of progression before the onset of clinical synovitis. The use of imaging, in particular ultrasound (US) and magnetic resonance imaging (MRI), has become much more widespread in individuals at-risk of RA. Numerous studies have demonstrated that imaging can help us understand RA pathogenesis as well as identifying individuals at high risk of progression. In addition, imaging techniques are becoming more sophisticated with newer imaging modalities such as high-resolution peripheral quantitative computed tomography (HR-pQRCT), nuclear imaging and whole body-MRI (WB-MRI) starting to emerge. Imaging studies in at risk individuals are heterogeneous in nature due to the different at-risk populations, imaging modalities and protocols used. This review will explore the available imaging modalities and the rationale for their use in the main populations at risk of RA.
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16
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Verstappen M, van der Helm-van Mil AHM. Sustained DMARD-free remission in rheumatoid arthritis - about concepts and moving towards practice. Joint Bone Spine 2022; 89:105418. [PMID: 35636705 PMCID: PMC7615888 DOI: 10.1016/j.jbspin.2022.105418] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
Abstract
Sustained DMARD-free remission (SDFR) is the best possible outcome in RA. It is characterized by sustained absence of clinical arthritis, which is accompanied by resolution of symptoms and restoration of normal physical functioning. Therefore it's the best proxy for cure in RA. The mechanisms underlying SDFR-development are yet unidentified. Hypothetically, there are two possible scenarios. The first hypothesis is based on the concept of regaining immune-tolerance, which implies that RA-patients are similar at diagnosis and that disease-processes during the disease-course shift into a favorable direction, resulting in regaining a state in which arthritis is persistently absent. This could imply that SDFR is theoretically achievable for all RA-patients. The alternative hypothesis is that RA-patients who achieve SDFR are intrinsically different from those who cannot. This would imply that DMARD-cessation could be restricted to a subgroup of RA-patients. Since the 1990s, DMARD-discontinuation and SDFR have been increasingly studied as long-term-outcome in RA. In this review, we describe hitherto results of clinical, genetic, serological, histological and imaging studies and looked for arguments for the first or second hypothesis in both auto-antibody-positive and auto-antibody-negative RA. In auto-antibody-negative RA, SDFR is presumably restricted to a subgroup of patients with high serological-markers of inflammation at diagnosis and a rapid and sustained decrease in inflammation after treatment-start. Identifying these RA-patients could be helpful in realizing personalized-medicine. In auto-antibody-positive RA, only few patients achieve SDFR and no definite conclusions can be drawn, but data could suggest that SDFR-patients might be a subgroup with relatively low inflammation from disease-presentation onwards.
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Affiliation(s)
- Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands; Department of Rheumatology, Erasmus Medical Centre, Rotterdam, The Netherlands
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17
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den Hollander NK, Verstappen M, Sidhu N, van Mulligen E, Reijnierse M, van der Helm-van Mil AHM. Hand and foot MRI in contemporary undifferentiated arthritis: in which patients is MRI valuable to detect rheumatoid arthritis early? A large prospective study. Rheumatology (Oxford) 2022; 61:3963-3973. [PMID: 35022703 PMCID: PMC9536782 DOI: 10.1093/rheumatology/keac017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/28/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Identifying patients that will develop RA among those presenting with undifferentiated arthritis (UA) remains a clinical dilemma. Although MRI is helpful according to EULAR recommendations, this has only been determined in UA patients not fulfilling 1987 RA criteria, while some of these patients are currently considered as RA because they fulfil the 2010 criteria. Therefore, we studied the predictive value of MRI for progression to RA in the current UA population, i.e. not fulfilling RA classification criteria (either 1987 or 2010 criteria) and not having an alternate diagnosis. Additionally, the value of MRI was studied in patients with a clinical diagnosis of UA, regardless of the classification criteria. METHODS Two UA populations were studied: criteria-based UA as described above (n = 405) and expert-opinion-based UA (n = 564), i.e. UA indicated by treating rheumatologists. These patients were retrieved from a large cohort of consecutively included early arthritis patients that underwent contrast-enhanced MRI scans of hand and foot at baseline. MRIs were scored for osteitis, synovitis and tenosynovitis. Patients were followed for RA development during the course of 1 year. Test characteristics of MRI were determined separately for subgroups based on joint involvement and autoantibody status. RESULTS Among criteria-based UA patients (n = 405), 21% developed RA. MRI-detected synovitis and MRI-detected tenosynovitis were predictive for progression to RA. MRI-detected tenosynovitis was independently associated with RA progression (odds ratio (OR) 2.79; 95% CI 1.40, 5.58), especially within ACPA-negative UA patients (OR 2.91; 95% CI 1.42, 5.96). Prior risks of RA development for UA patients with mono-, oligo- and polyarthritis were 3%, 19% and 46%, respectively. MRI results changed this risk most within the oligoarthritis subgroup: positive predictive value was 27% and negative predictive value 93%. Similar results were found in expert-opinion-based UA (n = 564). CONCLUSION This large cohort study showed that MRI is most valuable in ACPA-negative UA patients with oligoarthritis; a negative MRI could aid in preventing overtreatment.
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Affiliation(s)
| | | | - Navkiran Sidhu
- Department of Rheumatology, Leiden University Medical Center, Leiden
| | | | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden
- Department of Rheumatology, Erasmus Medical Center, Rotterdam
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18
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van Mulligen E, de Jong PHP. Response to: ‘Tapering antirheumatic drugs in a resource-poor setting: real-world evidence’ by Haroon et al. Ann Rheum Dis 2022; 81:e209. [DOI: 10.1136/annrheumdis-2020-218731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 11/03/2022]
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19
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Contreras-Yáñez I, Guaracha-Basáñez GA, Cuevas-Montoya M, de Jesús Hernández-Bautista J, Pascual-Ramos V. Early persistence on therapy impacts drug-free remission: a case-control study in a cohort of Hispanic patients with recent-onset rheumatoid arthritis. Arthritis Res Ther 2022; 24:193. [PMID: 35962421 PMCID: PMC9373313 DOI: 10.1186/s13075-022-02884-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022] Open
Abstract
Background Medication adherence is suboptimal in rheumatoid arthritis (RA) patients and impacts outcomes. DMARD-free remission (DFR) is a sustainable and achievable outcome in a minority of RA patients. Different factors have been associated with DFR, although persistence in therapy (PT), a component of the adherence construct, has never been examined. The study’s primary aim was to investigate the impact of PT’s characteristics on DFR in a cohort of Hispanic patients with recent-onset RA. Methods A single data abstractor reviewed the charts from 209 early (symptoms duration ≤ 1 year) RA patients. All the patients had prospective assessments of disease activity and PT and at least 1 year of follow-up, which was required for the DFR definition. DFR was defined when patients achieved ≥ 1 year of continuous Disease Activity Score-28 joints evaluated ≤ 2.6, without DMARDs and corticosteroids. PT was defined based on pre-specified criteria and recorded through an interview from 2004 to 2008 and thereafter through a questionnaire. Cases (patients who achieved ≥ 1 DFR status) were paired with controls (patients who never achieved DFR during their entire follow-up) according to ten relevant variables (1:2). Cox regression analysis estimated hazard ratios (HRs) for DFR according to two characteristics of PT: the % of the patient follow-up PT and early PT (first 2 years of patients’ follow-up). Results In March 2022, the population had 112 (55–181) patient/years follow-up. There were 23 patients (11%) with DFR after 74 months (44–122) of follow-up, and the DFR status was maintained during 48 months (18–82). Early PT was associated with DFR, while the % of the patient follow-up PT was not: HR = 3.84 [1.13–13.07] when the model was adjusted for cumulative N of DMARDs/patient and 3.16 [1.14–8.77] when also adjusted for baseline SF-36 physical component score. A lower N of cumulative DMARDs/patient was also retained in the models. Receiving operating curve to define the best cutoff of patient follow-up being PT to predict DFR was 21 months: sensitivity of 0.739, specificity of 0.717, and area under the curve of 0.682 (0.544–0.821). Conclusions DFR status might be added to the benefits of adhering to prescribed treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02884-w.
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Affiliation(s)
- Irazú Contreras-Yáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Vasco de Quiroga 15, colonia Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Guillermo Arturo Guaracha-Basáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Vasco de Quiroga 15, colonia Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,Emergency Medicine Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Vasco de Quiroga 15, colonia Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Maximiliano Cuevas-Montoya
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Vasco de Quiroga 15, colonia Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - José de Jesús Hernández-Bautista
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Vasco de Quiroga 15, colonia Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Virginia Pascual-Ramos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Vasco de Quiroga 15, colonia Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico.
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20
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Kumar V, Kushwaha V, Gandhi Y, Mishra SK, Charde V, Jagtap C, Babu G, Singh A, Singh R, Srikanth N. A validated high-performance thin-layer chromatography method for the simultaneous quantification of 6-gingerol, guggulsterone E and guggulsterone Z in coded formulation AYUSH SG-5 prepared for rheumatoid arthritis. JPC-J PLANAR CHROMAT 2022. [DOI: 10.1007/s00764-022-00153-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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21
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Ahmad HA, Baker JF, Conaghan PG, Emery P, Huizinga TWJ, Elbez Y, Banerjee S, Østergaard M. Prediction of flare following remission and treatment withdrawal in early rheumatoid arthritis: post hoc analysis of a phase IIIb trial with abatacept. Arthritis Res Ther 2022; 24:47. [PMID: 35172859 PMCID: PMC8848810 DOI: 10.1186/s13075-022-02735-8] [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: 07/06/2021] [Accepted: 12/27/2021] [Indexed: 11/26/2022] Open
Abstract
Background Drug-free remission is a desirable goal in rheumatoid arthritis (RA) for both patients and clinicians. The aim of this post hoc analysis was to investigate whether clinical and magnetic resonance imaging (MRI) variables in patients with early RA who achieved remission with methotrexate and/or abatacept at 12 months could predict disease flare following treatment withdrawal. Methods In the AVERT study of abatacept in early RA, patients with low disease activity at month 12 entered a 12-month period with all treatment discontinued (withdrawal, WD). This post hoc analysis assessed predictors of disease flare at WD+6months (mo) and WD+12mo of patients with Disease Activity Score in 28 joints (DAS28)-defined remission (DAS28[C-reactive protein (CRP)] <2.6) at withdrawal using univariate and multivariable regression models. Predictors investigated included the Health Assessment Questionnaire–Disability Index (HAQ-DI), pain, Patient Global Assessment; MRI synovitis, erosion, bone edema, and combined (synovitis + bone edema) inflammation scores. Results Remission was achieved by 172 patients; 100 (58%) and 113 (66%) patients had experienced a flare at WD+6mo and WD+12mo, respectively. In univariate analyses, higher HAQ-DI and MRI synovitis, erosion, bone edema, and combined inflammation scores at WD were identified as potential predictors of flare (P ≤ 0.01). In multivariable analysis, high scores at WD for HAQ-DI and MRI erosion were confirmed as independent predictors of flare at WD+6mo and WD+12mo (P < 0.01). Conclusion In patients with early RA achieving clinical remission, patient function (HAQ-DI), and MRI measures of bone damage (erosion) predicted disease flare 6 and 12 months after treatment withdrawal. These variables may help identify patients with early RA in clinical remission as candidates for successful treatment withdrawal. Trial registration ClinicalTrials.gov, NCT01142726 (date of registration: June 11, 2010) Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02735-8.
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Affiliation(s)
| | - Joshua F Baker
- Philadelphia Veteran's Administration Medical Center and the University of Pennsylvania, Philadelphia, PA, USA
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds, UK
| | | | | | | | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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22
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Mongin D, Lauper K, Finckh A, Frisell T, Courvoisier DS. Accounting for missing data caused by drug cessation in observational comparative effectiveness research: a simulation study. Ann Rheum Dis 2022; 81:729-736. [PMID: 35027398 PMCID: PMC8995805 DOI: 10.1136/annrheumdis-2021-221477] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022]
Abstract
Objectives To assess the performance of statistical methods used to compare the effectiveness between drugs in an observational setting in the presence of attrition. Methods In this simulation study, we compared the estimations of low disease activity (LDA) at 1 year produced by complete case analysis (CC), last observation carried forward (LOCF), LUNDEX, non-responder imputation (NRI), inverse probability weighting (IPW) and multiple imputations of the outcome. All methods were adjusted for confounders. The reasons to stop the treatments were included in the multiple imputation method (confounder-adjusted response rate with attrition correction, CARRAC) and were either included (IPW2) or not (IPW1) in the IPW method. A realistic simulation data set was generated from a real-world data collection. The amount of missing data caused by attrition and its dependence on the ‘true’ value of the data missing were varied to assess the robustness of each method to these changes. Results LUNDEX and NRI strongly underestimated the absolute LDA difference between two treatments, and their estimates were highly sensitive to the amount of attrition. IPW1 and CC overestimated the absolute LDA difference between the two treatments and the overestimation increased with increasing attrition or when missingness depended on disease activity at 1 year. IPW2 and CARRAC produced unbiased estimations, but IPW2 had a greater sensitivity to the missing pattern of data and the amount of attrition than CARRAC. Conclusions Only multiple imputation and IPW2, which considered both confounding and treatment cessation reasons, produced accurate comparative effectiveness estimates.
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Affiliation(s)
- Denis Mongin
- Department of Medicine, University of Geneva, Geneva, Switzerland
| | - Kim Lauper
- Department of Medicine, University of Geneva, Geneva, Switzerland.,Division of Rheumatology, Beau Sejour Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Axel Finckh
- Department of Medicine, University of Geneva, Geneva, Switzerland.,Division of Rheumatology, Beau Sejour Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Frisell
- Department of medicine Solna, Karolinska institute, Stockholm, Sweden
| | - Delphine Sophie Courvoisier
- Department of Medicine, University of Geneva, Geneva, Switzerland.,Division of Rheumatology, Beau Sejour Hospital, Geneva University Hospitals, Geneva, Switzerland
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23
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Verstappen M, van Steenbergen HW, de Jong PHP, van der Helm-van Mil AHM. Unraveling heterogeneity within ACPA-negative rheumatoid arthritis: the subgroup of patients with a strong clinical and serological response to initiation of DMARD treatment favor disease resolution. Arthritis Res Ther 2022; 24:4. [PMID: 34980246 PMCID: PMC8722281 DOI: 10.1186/s13075-021-02671-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 11/07/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a heterogeneous disease, as evidenced by the differences in long-term outcomes. This applies especially to anti-citrullinated protein antibodies (ACPA)-negative RA, where a proportion achieves sustained DMARD-free remission (SDFR; sustained absence of synovitis after DMARD cessation). Differentiation of RA patients who will achieve SDFR can guide personalized treatment/tapering strategies. Although this subgroup remains scarcely discerned, previous research demonstrated that these RA patients are characterized by an early clinical response (DAS remission after 4 months) after DMARD start. We studied whether, in addition to this clinical response, a specific biomarker response can further distinguish the subgroup of RA patients most likely to achieve SDFR. METHODS In 266 RA patients, levels of 12 biomarkers (SAA/CRP/MMP-1/MMP-3/resistin/leptin/IL-6/TNF-R1/YKL-40/EGF/VEGF/VCAM-1), in the first 2 years after diagnosis, were studied in relation to SDFR, stratified for ACPA status. Subsequently, biomarkers associated with SDFR development were combined with early DAS remission to study its additional value in defining subgroups. Since most biomarker levels are not routinely measured in clinical practice, we explored how this subgroup can be clinically recognized. RESULTS ACPA-negative RA patients achieving SDFR were characterized by high baseline levels and stronger decline in MMP-1/MMP-3/SAA/CRP after DMARD-start, respectively 1.30×/1.44×/2.12×/2.24× stronger. This effect was absent in ACPA-positive RA. In ACPA-negative RA, a strong biomarker decline is associated with early DAS remission. The combination of both declines (clinical, biomarker) was present in a subgroup of ACPA-negative RA patients achieving SDFR. This subgroup can be clinically recognized by the combination of high baseline CRP levels (≥ 3 times ULN), and early DAS remission (DAS4 months < 1.6). This latter was replicated in independent ACPA-negative RA patients. CONCLUSIONS ACPA-negative RA patients with early DAS remission and a strong biomarker response (or baseline CRP levels ≥ 3× ULN) are most likely to achieve SDFR later on. This could guide personalized decisions on DMARD tapering/cessation in ACPA-negative RA.
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Affiliation(s)
- M Verstappen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - H W van Steenbergen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P H P de Jong
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - A H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Centre, Rotterdam, the Netherlands
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Baker KF, Pratt AG, Isaacs JD. Half-Dose vs Stable-Dose Conventional Synthetic Disease-Modifying Antirheumatic Drugs and Disease Flare in Patients With Rheumatoid Arthritis. JAMA 2021; 326:872-873. [PMID: 34547087 DOI: 10.1001/jama.2021.10648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kenneth Frank Baker
- Newcastle University, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, England
| | - Arthur Grant Pratt
- Newcastle University, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, England
| | - John Dudley Isaacs
- Newcastle University, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, England
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25
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La C, Lê PQ, Ferster A, Goffin L, Spruyt D, Lauwerys B, Durez P, Boulanger C, Sokolova T, Rasschaert J, Badot V. Serum calprotectin (S100A8/A9): a promising biomarker in diagnosis and follow-up in different subgroups of juvenile idiopathic arthritis. RMD Open 2021; 7:rmdopen-2021-001646. [PMID: 34108235 PMCID: PMC8191626 DOI: 10.1136/rmdopen-2021-001646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/17/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction In the management of juvenile idiopathic arthritis (JIA), there is a lack of diagnostic and prognostic biomarkers. This study assesses the use of serum calprotectin (sCal) as a marker to monitor disease activity, and as a classification and prognosis tool of response to treatment or risk of flares in patients with JIA. Methods Eighty-one patients with JIA from the CAP48 multicentric cohort were included in this study, as well as 11 non-paediatric healthy controls. An ELISA method was used to quantify sCal with a commercial kit. Results Patients with an active disease compared with healthy controls and with patients with inactive disease showed an eightfold and a twofold increased level of sCal, respectively. sCal was found to be correlated with the C-reactive protein (CRP) and even more strongly with the erythrocyte sedimentation rate. Evolution of DAS28 scores correlated well with evolution of sCal, as opposed to evolution of CRP. With regard to CRP, sCal could differentiate forms with active oligoarthritis from polyarthritis and systemic forms. However, sCal brought an added value compared with the CRP as a prognosis marker. Indeed, patients with active disease and reaching minimal disease activity (according to Juvenile Arthritis Disease Activity Score) at 6 months following the test had higher sCal levels, while patients with inactive disease had higher sCal levels if a flare was observed up to 3–9 months following the test. Conclusions This study confirms the potential uses of sCal as a biomarker in the diagnosis and follow-up of JIA.
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Affiliation(s)
- Céline La
- Department of Rheumatology, CHU Brugmann, Bruxelles, Belgium .,Department of Pediatric Rheumatology, Hôpital Universitaire des Enfants Reine Fabiola, Bruxelles, Belgium.,Department of Rheumatology, Hôpital Erasme, Bruxelles, Belgium
| | - Phu Quoc Lê
- Department of Pediatric Rheumatology, Hôpital Universitaire des Enfants Reine Fabiola, Bruxelles, Belgium
| | - Alina Ferster
- Department of Pediatric Rheumatology, Hôpital Universitaire des Enfants Reine Fabiola, Bruxelles, Belgium
| | - Laurence Goffin
- Department of Pediatric Rheumatology, Hôpital Universitaire des Enfants Reine Fabiola, Bruxelles, Belgium
| | - Delphine Spruyt
- Laboratory of Bone and Metabolic Biochemistry, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Bernard Lauwerys
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Cecile Boulanger
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Tatiana Sokolova
- Institut de Recherche expérimentale et Clinique (IREC), Université catholique de Louvain Secteur des sciences de la santé, Bruxelles, Belgium
| | - Joanne Rasschaert
- Laboratory of Bone and Metabolic Biochemistry, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Valérie Badot
- Department of Rheumatology, CHU Brugmann, Bruxelles, Belgium
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26
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Luurssen-Masurel N, van Mulligen E, Weel-Koenders AEAM, Hazes JMW, de Jong PHP. The susceptibility of attaining and maintaining DMARD-free remission in different (rheumatoid) arthritis phenotypes. Rheumatology (Oxford) 2021; 61:keab631. [PMID: 34352094 DOI: 10.1093/rheumatology/keab631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To compare (sustained) DMARD-free remission rates((S)DFR), defined as respectively ≥6 months and >1 year, after 2 and 5 years between three clinical arthritis phenotypes; undifferentiated arthritis(UA), autoantibody-negative(RA-) and positive rheumatoid arthritis(RA+). METHODS All UA(n = 130), RA-(n = 176) and RA + (n = 331) patients from the tREACH trial, a stratified single-blinded trial with a treat-to-target approach, were used. (S)DFR comparisons between phenotypes after 2 and 5 years were performed with Logistic regression. Medication use and early and late flares(DAS ≥ 2.4), respectively defined as < 12 and >12 months after reaching DFR, were also compared. Cox proportional hazard models were used to evaluate potential predictors for (S)DFR. RESULTS Within 2 and 5 years less DFR was seen in RA + (17.2-25.7%), followed by RA-(28.4-42.1%) and UA patients(43.1-58.5%). This also applied for SDFR within 2 and 5 years (respectively 7.6% and 21.4%; 20.5% and 38.1%; and 35.4% and 55.4%). A flare during tapering was seen in 22.7% of patients. Of the patients in DFR 7.5% had an early flare and 3.4% a late flare. Also more treatment intensifications occurred in RA+ compared with RA- and UA. We found that higher baseline DAS, ACPA positivity, BMI and smoking were negatively associated with (S)DFR, while clinical phenotype(reference RA+), short symptom duration(<6 months) and remission within 6 months were positively associated. CONCLUSIONS (Long-term) clinical outcomes differ between undifferentiated arthritis, autoantibody-negative and positive rheumatoid arthritis(RA). These data reconfirm that RA can be subdivided into aforementioned clinical phenotypes and that treatment might be stratified upon these phenotypes, although validation is needed. TRIAL REGISTRATION ISRCTN, https://www.isrctn.com/, ISRCTN26791028.
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27
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Luurssen-Masurel N, Weel AEAM, Hazes JMW, de Jong PHP. The impact of different (rheumatoid) arthritis phenotypes on patients' lives. Rheumatology (Oxford) 2021; 60:3716-3726. [PMID: 33237330 PMCID: PMC8328508 DOI: 10.1093/rheumatology/keaa845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/21/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives To compare patient-reported outcome (PRO) domains between three arthritis phenotypes [undifferentiated arthritis (UA), autoantibody-negative RA (RA−) and autoantibody-positive RA (RA+)] at diagnosis, after 2 years and over time. Methods All UA (n = 130), RA− (n = 176) and RA+ (n = 331) patients from the tREACH trial, a stratified single-blinded trial with a treat-to-target approach, were used. PRO comparisons between phenotypes at baseline and after 2 years were performed with analysis of variance, while a linear mixed model compared them over time. Effect sizes were weighted against the minimal clinically important differences (MCIDs) for each PRO. Results RA− patients had a higher disease burden compared with RA+ and UA. At baseline and after 2 years, RA− patients had more functional impairment and a poorer Physical Component Summary (PCS) compared with the other phenotypes, while they only scored worse for general health and morning stiffness duration at baseline. The MCIDs were exceeded at baseline, except for functional ability between RA+ and UA, while after 2 years only the MCID of the PCS was exceeded by RA− compared with UA and RA. After 2 years the PROs of all phenotypes improved, but PROs measuring functioning were still worse compared with the general population, even when patients had low disease activity. Conclusion RA− patients had the highest disease burden of all phenotypes. Although most patients have low disease activity after treatment, all clinical phenotypes still have a similar significant impact on patients’ lives, which is mainly physical. Therefore it is important to assess and address PROs in daily practice because of persistent disease burden despite low disease activity. Trial registration ISRCTN26791028.
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Affiliation(s)
| | - Angelique Elisabeth Adriana Maria Weel
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands.,Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
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28
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Luurssen-Masurel N, Weel AEAM, Koc GH, Hazes JMW, de Jong PHP. The number of risk factors for persistent disease determines the clinical course of early arthritis. Rheumatology (Oxford) 2021; 60:3617-3627. [PMID: 33484138 PMCID: PMC8328505 DOI: 10.1093/rheumatology/keaa820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/17/2020] [Indexed: 11/22/2022] Open
Abstract
Objectives Management of early arthritis is based upon early recognition of individuals at high risk of developing persistent arthritis. Therefore, this study investigates whether the number of risk factors for persistent disease or treatment determines the clinical course of early arthritis by comparing the chance at (sustained) DMARD-free remission ((S)DFR) after 2 years follow-up. Methods Data from the tREACH trial, a stratified single-blinded multicentre strategy trial with a treat-to-target approach were used. We selected all patients with ≥1 swollen joint who did not fulfil 1987 and/or 2010 criteria for RA. The number of risk factors present; autoantibody-positivity, polyarthritis (>4), erosive disease and elevated acute phase reactants, determined risk group stratification. Multivariate logistic regression analyses were performed with (S)DFR as dependent variables and baseline disease activity score (DAS), treatment, symptom duration and number of risk factors present as independent variables. Results In total, 130 early arthritis patients were included and respectively 31, 66 and 33 had 0, 1 and ≥2 risk factors present. DFR rates were respectively 74%, 48% and 45% for early arthritis patients with 0, 1 and ≥2 risk factors present. In accordance SDFR rates were 61%, 32% and 30%. In our logistic model (S)DFR was not influenced by the initial treatment strategies when stratified for risk groups. Conclusion The chance at (S)DFR in early arthritis diminishes when more risk factors are present, which is irrespective of the given initial treatment. Our data point out to a stratified management approach in early arthritis based on their risk profile, but validation is needed. Trial registration ISRCTN registry: ISRCTN26791028 (http://www.isrctn.com/ISRCTN26791028).
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Affiliation(s)
| | - A E A M Weel
- Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands.,Erasmus School of Health Policy & Management, Rotterdam, The Netherlands
| | - G H Koc
- Department of Internal Medicine, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - J M W Hazes
- Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands
| | - P H P de Jong
- Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands
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Baker KF, Sim JPX, Isaacs JD. Biomarkers of tolerance in immune-mediated inflammatory diseases: a new era in clinical management? THE LANCET. RHEUMATOLOGY 2021; 3:e371-e382. [PMID: 38279392 DOI: 10.1016/s2665-9913(21)00069-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 11/23/2022]
Abstract
Modern therapeutic agents and treatment regimens have made sustained remission an attainable target for many patients across a spectrum of immune-mediated inflammatory diseases, albeit at the risk of adverse events and the expense of drug prescription and safety monitoring. Clinicians and patients are thus increasingly faced with a novel treatment dilemma: whether and how best to stop immunomodulatory treatment in patients who achieve remission. In this final paper in a Series on therapeutic tolerance induction, we summarise our current knowledge of biomarkers of immune homeostasis in immune-mediated inflammatory diseases and their application to the prediction and attainment of sustained drug-free remission. We summarise evidence from prospective studies of immunomodulatory drug cessation across a range of immune-mediated inflammatory diseases, including rheumatoid arthritis, juvenile idiopathic arthritis, and inflammatory bowel disease. We also consider current evidence for clinical, serological, proteomic, metabolomic, cellular, and microbiomic biomarkers of immune homeostasis. Finally, we discuss the steps necessary for clinical translation of these biomarkers, as well as the potential transformative effect of these biomarkers on management of patients with immune-mediated inflammatory diseases if clinical translation is successfully achieved.
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Affiliation(s)
- Kenneth F Baker
- Musculoskeletal Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jasmine P X Sim
- Musculoskeletal Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John D Isaacs
- Musculoskeletal Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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30
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Schett G, Tanaka Y, Isaacs JD. Why remission is not enough: underlying disease mechanisms in RA that prevent cure. Nat Rev Rheumatol 2021; 17:135-144. [PMID: 33303993 DOI: 10.1038/s41584-020-00543-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 01/04/2023]
Abstract
Cure is the aspirational aim for the treatment of all diseases, including chronic inflammatory conditions such as rheumatoid arthritis (RA); however, it has only been during the twenty-first century that remission, let alone cure, has been a regularly achievable target in RA. Little research has been carried out on how to cure RA, and the term 'cure' still requires definition for this disease. Even now, achieving a cure seems to be a rare occurrence among individuals with RA. Therefore, this Review is aimed at addressing the obstacles to the achievement of cure in RA. The differences between remission and cure in RA are first defined, followed by a discussion of the underlying factors (referred to as drivers) that prevent the achievement of cure in RA by triggering sustained immune activation and effector cytokine production. Such drivers include adaptive immune system activation, mesenchymal tissue priming and so-called 'remote' (non-immune and non-articular) factors. Strategies to target these drivers are also presented, with an emphasis on the development of strategies that could complement currently used cytokine inhibition and thereby improve the likelihood of curing RA.
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Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany.
- Deutsches Zentrum fur Immuntherapie, FAU Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany.
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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31
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Verstappen M, Niemantsverdriet E, Matthijssen XME, le Cessie S, van der Helm-van Mil AHM. Early DAS response after DMARD-start increases probability of achieving sustained DMARD-free remission in rheumatoid arthritis. Arthritis Res Ther 2020; 22:276. [PMID: 33228814 PMCID: PMC7684730 DOI: 10.1186/s13075-020-02368-9] [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: 05/14/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background Sustained DMARD-free remission (SDFR) is increasingly achievable. The pathogenesis underlying SDFR development is unknown and patient characteristics at diagnosis poorly explain whether SDFR will be achieved. To increase the understanding, we studied the course of disease activity scores (DAS) over time in relation to SDFR development. Subsequently, we explored whether DAS course could be helpful identifying RA patients likely to achieve SDFR. Methods 772 consecutive RA patients, promptly treated with csDMARDs (mostly methotrexate and treat-to-target treatment adjustments), were studied for SDFR development (absence of synovitis, persisting minimally 12 months after DMARD stop). The course of disease activity scores (DAS) was compared between RA patients with and without SDFR development within 7 years, using linear mixed models, stratified for ACPA. The relation between 4-month DAS and the probability of SDFR development was studied with logistic regression. Cumulative incidence of SDFR within DAS categories (< 1.6, 1.6–2.4, 2.4–3.6, ≥ 3.6) at 4 months was visualized using Kaplan-Meier curves. Results In ACPA-negative RA patients, those achieving SDFR showed a remarkably stronger DAS decline within the first 4 months, compared to RA patients without SDFR; − 1.73 units (95%CI, 1.28–2.18) versus − 1.07 units (95%CI, 0.90–1.23) (p < 0.001). In APCA-positive RA patients, such an effect was not observed, yet SDFR prevalence in this group was low. In ACPA-negative RA, DAS decline in the first 4 months and absolute DAS levels at 4 months (DAS4 months) were equally predictive for SDFR development. Incidence of SDFR in ACPA-negative RA patients was high (70.2%) when DAS4 months was < 1.6, whilst SDFR was rare (7.1%) when DAS4 months was ≥ 3.6. Conclusions In ACPA-negative RA, an early response to treatment, i.e., a strong DAS decline within the first 4 months, is associated with a higher probability of SDFR development. DAS values at 4 months could be useful for later decisions to stop DMARDs.
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Affiliation(s)
- M Verstappen
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - E Niemantsverdriet
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - X M E Matthijssen
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - A H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
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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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