Are biologics more effective than classical disease-modifying antirheumatic drugs?

Trends in total elbow arthroplasty in patients with rheumatoid arthritis receiving disease-modifying antirheumatic drug therapy based on payer status

INTRODUCTION

Total elbow arthroplasty (TEA) is often used to manage advanced arthropathies of the elbow caused by inflammatory conditions such as rheumatoid arthritis (RA). Recent literature has shown that use of TEA is decreasing in patients with RA, part of which can be attributed to early medical management involving disease-modifying antirheumatic drugs (DMARDs). However, there is a significant economic barrier to accessing DMARD therapy. The purpose of this study was to compare the use of TEA between patients with and without DMARD therapy from 2010 to 2020.

METHODS

A retrospective cohort analysis was performed using a national insurance claim database to investigate the trends of patients with RA undergoing TEA from 2010-2020. Patients who underwent TEA and had a diagnosis of RA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 and ICD-10 codes between 2010 and 2020. These patients were then stratified into 2 cohorts: those with DMARD prescription claims and those without. A linear regression, compound annual growth rate (CAGR) analysis, and χ2 analysis were conducted to compare trends and demographic variables, including insurance type, between cohorts. Additionally, a multivariable logistic regression was subsequently performed to observe odds ratios (ORs) and 95% confidence intervals.

RESULTS

From 2010 to 2020, there has been no significant change in the incidence of TEA in RA patients without DMARD prescriptions, whereas there has been a statistically significantly decreasing rate of TEA observed in RA patients with DMARD prescription claims. The analysis showed that there was a CAGR of -4%. For patients with a diagnosis of RA and DMARD prescription claims, the highest incidence of undergoing TEA was seen in the age group of 60-69 years, whereas patients with a diagnosis of RA and no DMARD prescription claims had the highest incidence of undergoing TEA in the age group of 70-79 years.

CONCLUSION

The incidence of patients undergoing TEA with a diagnosis of RA and DMARD prescription claims has shown a statistically significant decrease from 2010 to 2020, whereas no significant difference was observed for patients without DMARD prescription claims. There were no statistically significant differences in the insurance plans between cohorts.

"Platelet-rich plasma holds promise in management of rheumatoid arthritis"-systematic review

The treatment of rheumatoid arthritis (RA) has been closely evolving with an understanding of disease pathogenesis with disease modifying anti-rheumatoid drugs (DMARDS) and Biologic DMARDS being the main stay. platelet rich plasma (PRP) has been the center of research in many specialties in the past decade. Its ability to stop and reverse inflammation have attracted researchers to try PRP in RA. A systematic review of studies on PRP in RA is lacking. The study protocol was prospectively registered in PROSPERO. Detailed search of Cochrane, Scopus, Medline, Embase, and Web of science databases were made to identify the relevant articles till Sep 2020 following Cochrane and PRISMA guidelines. Number of subjects, Animal model used, cell lines used for the study, method of induction of arthritis, PRP dose, concentration used, frequency of administration and clinical, histologic, and molecular changes from baseline following PRP use were extracted and analysed. Eight studies were included for the review. Four of these were in-vitro studies. Two were exclusive animal studies. One study analysed the effects of PRP in RA in both animal models (mice) and Hela cell lines. One study was a report of a series of patients of resistant RA treated with PRP. In the in vitro studies while platelets increase the migration and invasion of RA-FLS, they suppressed the inflammation on the whole. Available animal studies and the Human study have shown encouraging results. There has been no evidence of exacerbation of inflammation in these studies. The quantity and quality of literature on the effects of PRP in treating joint pathologies in RA is limited. Preclinical studies show decrease in disease activity with good safety profile. Invitro studies show suppression of inflammation. Thus, the available literature is encouraging towards the use of PRP in RA. Larger trials and molecular studies to understand the exact role of platelets in disease pathogenesis and treatment mechanisms are needed to decide the future course of PRP in RA.

Metabolic Targets for Treatment of Autoimmune Diseases

There is a considerable unmet demand for safe and efficacious medications in the realm of autoimmune and inflammatory diseases. The fate of the immune cells is precisely governed by control of various metabolic processes such as mitochondrial oxidative phosphorylation, glycolysis, fatty acid synthesis, beta-oxidation, amino acid metabolism, and several others including the pentose phosphate pathway, which is a unique source of metabolites for cell proliferation and maintenance of a reducing environment. These pathways are tightly regulated by the cytokines, growth factors, availability of the nutrients and host-microbe interaction. Exploring the immunometabolic pathways that govern the fate of cells of the innate and adaptive immune system, during various stages of activation, proliferation, differentiation and effector response, is crucial for new development of new treatment targets. Identifying the pathway connections and key enzymes will help us to target the dysregulated inflammation in autoimmune diseases. The mechanistic target of rapamycin (mTOR) pathway is increasingly recognized as one of the key drivers of proinflammatory responses in autoimmune diseases. In this review, we provide an update on the current understanding of the metabolic signatures noted within different immune cells of many different autoimmune diseases with a focus on selecting pathways and specific metabolites as targets for treatment.

Comparison of the Effect of Disease: Modifying Antirheumatic Drugs Alone or in Combination with Biologic Drugs in the Outcome of Patients with Rheumatoid Arthritis

Background

Rheumatoid arthritis (RA) is a rheumatic disease that could be disabling if not treated. The aim of RA therapy is to resolve tenderness and swelling in the joints. The present study was conducted to compare two methods of RA treatment with disease-modifying anti-rheumatic drugs (DMARDs) and DMARDs with biologic drugs in two groups of patients.

Materials and Methods

The present study was a nonrandomized clinical trial which was conducted from July to September 2017 on 110 patients who were selected based on the American College of Rheumatology (2010) criteria for RA. Patients were divided into two groups of 55: Groups A and B. For the treatment of Group A, prednisolone along with one or two drugs from the DMARDs combinations was used. Group B received one biologic drug besides with the drugs of the group A. T-test and covariance analysis was used to compare the outcomes of both groups.

Results

Disease activity score (DAS-28) at the beginning of the study was 4.23 (0.81) in Group A and 4.51 (0.7) in Group B (P = 0.05). At the end of the study, DAS-28 was 3.52 (0.79) in Group A and 3.75 (0.85) in Group B (P = 0.1). DAS-28 activity index had a significant difference between both two groups at the beginning of the study (P = 0.05), but at the end of the study, the difference was not statistically significant (P = 0.1).

Conclusions

Simultaneous use of DMARDs and biologic drugs in RA patients could lead to improvement the disease symptoms and decrease the severity and activity of the disease.

Window of opportunity in rheumatoid arthritis - definitions and supporting evidence: from old to new perspectives

The therapeutic window of opportunity in rheumatoid arthritis (RA) is often referred to. However, some have questioned whether such a period, in which the disease is more susceptible to disease-modifying treatment, really exists. Observational studies are most frequently referenced as supporting evidence, but results of such studies are subject to confounding. In addition formal consensus on the definition of the term has never been reached. We first reviewed the literature to establish if there is agreement on the concept of the window of opportunity in terms of its time period and the outcomes influenced. Second, a systemic literature search was performed on the evidence of the benefit of early versus delayed treatment as provided by randomised clinical trials. We observed that the concept of the window of opportunity has changed with respect to timing and outcome since its first description 25 years ago. There is an ‘old definition’ pointing to the first 2 years after diagnosis with increased potential for disease-modifying treatment to prevent severe radiographic damage and disability. Strong evidence supports this concept. A ‘new definition’ presumes a therapeutic window in a pre-RA phase in which the biologic processes could be halted and RA development prevented by very early treatment. This definition is not supported by evidence, although is less well studied in trials. Some suggestions for future research in this area are made.

Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH). A randomised controlled trial and economic evaluation

BACKGROUND

The effectiveness of exercise for improving hand and wrist function in people with rheumatoid arthritis (RA) is uncertain.

OBJECTIVES

The study aims were (1) to estimate the clinical effectiveness and cost-effectiveness of adding an optimised exercise programme for hands and upper limbs to standard care for patients with RA; and (2) to qualitatively describe the experience of participants in the trial with a particular emphasis on acceptability of the intervention, exercise behaviours and reasons for adherence/non-adherence.

DESIGN

A pragmatic, multicentred, individually randomised controlled trial with an embedded qualitative study. Outcome assessors were blind to group assignment and independent of treatment delivery.

SETTING

Seventeen NHS trusts in England comprising 21 rheumatology and therapy departments.

PARTICIPANTS

Adults with RA who had pain and dysfunction of the hands and/or wrists and had been on stable medication for at least 3 months. Patients were excluded if they were under 18 years old, had undergone upper limb surgery/fracture in the last 6 months, were on a waiting list for upper limb surgery or were pregnant.

INTERVENTIONS

Usual care or usual care plus an individualised exercise programme. Usual care consisted of joint protection education, general exercise advice and functional splinting if required. The exercise programme consisted of six sessions of strengthening and stretching exercises with a hand therapist, daily home exercises and strategies to maximise adherence.

MAIN OUTCOME MEASURES

The primary outcome was the Michigan Hand Outcome Questionnaire (MHQ) overall hand function subscale score at 12 months. Secondary outcome measures included the full MHQ, pain, health-related quality of life (Short Form questionnaire-12 items), impairment (grip strength, dexterity and range of motion) and self-efficacy. European Quality of Life-5 Dimensions, medication and health-care use were collected for the health economics evaluation. Follow-up was at 4 and 12 months post randomisation. Analysis was performed on an intention-to-treat basis.

RESULTS

We randomised 490 patients (244 to usual care, 246 to exercise programme). Compliance with the treatments was very good (93% of usual care participants and 75% of exercise programme participants completed treatment). Outcomes were obtained for 89% of participants at 12 months (222 for usual care, 216 for exercise programme). There was a statistically significant difference in favour of the exercise programme for the primary outcome at 4 and 12 months [mean difference 4.6 points, 95% confidence interval (CI) 2.2 to 7.0 points; and mean difference 4.4 points, 95% CI 1.6 to 7.1 points, respectively]. There were no significant differences in pain scores or adverse events. The estimated difference in mean quality-adjusted life-years (QALYs) accrued over 12 months was 0.01 greater (95% CI -0.03 to 0.05) in the exercise programme group. Imputed analysis produced incremental cost-effectiveness ratio estimates of £17,941 (0.59 probability of cost-effectiveness at willingness-to-pay threshold of £30,000 per QALY). The qualitative study found the exercise programme to be acceptable and highlighted the importance of the therapist in enabling patients to establish a routine and incorporate the exercises into their lives.

CONCLUSIONS

The results of the Strengthening And stretching for Rheumatoid Arthritis of the Hand trial suggest that the addition of an exercise programme for RA hands/wrists to usual care is clinically effective and cost-effective when compared with usual care alone. No adverse effects were associated with the exercise programme. The economic analysis suggests that the intervention is likely to be cost-effective.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 89936343.

Use of the painDETECT tool in rheumatoid arthritis suggests neuropathic and sensitization components in pain reporting

Rheumatoid arthritis (RA) is an inflammatory autoimmune condition typified by systemic inflammation targeted toward synovial joints. Inhibition of proinflammatory networks by disease-modifying antirheumatic drugs, eg, methotrexate and biologic therapies, including tumor necrosis factor-α inhibitors, often leads to suppression of disease activity observed at the clinical level. However, despite the era of widespread use of disease-modifying treatments, there remain significant groups of patients who continue to experience pain. Our study formulated a pain assessment tool in the arthritis clinic to assess feasibility of measurements including the visual analog scale (VAS) and painDETECT to assess multimodal features of pain in people with established RA (n=100). Clinical measures of disease activity (Disease Activity Score in 28 Joints [DAS28]) were also recorded. Our data showed that despite the majority of subjects on at least one disease-modifying agent, the majority of patients reported severe pain (54%) by VAS, despite well-controlled clinical disease, with mean DAS28 2.07±0.9. Using the painDETECT questionnaire, 67% of patients had unlikely neuropathic pain. A significant proportion of subjects (28%) had possible neuropathic pain and 5% had features of likely neuropathic pain by painDETECT scoring. We found a positive correlation between VAS and painDETECT (R (2)=0.757). Of note, the group who had likely or probable neuropathic pain also showed significantly increased pain reporting by VAS (P<0.01). Subjects who were clinically obese (body mass index >30) also had statistically higher proportions of pain reporting (VAS 89.0±0.7 mm) compared with subjects who had a normal body mass index (VAS 45.2±21.8 mm), P<0.05. Our findings suggest that multimodal features of pain perception exist in RA, including neuropathic and sensitization elements, perhaps explaining why a subgroup of people with RA continue to experience ongoing pain, despite their apparent suppression of inflammation.

A randomized comparative effectiveness study of oral triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: the treatment of Early Aggressive Rheumatoid Arthritis Trial

OBJECTIVE

To assess whether it is better to intensively treat all patients with early rheumatoid arthritis (RA) using combinations of drugs or to reserve this approach for patients who do not have an appropriate response (as determined by a Disease Activity Score in 28 joints using the erythrocyte sedimentation rate [DAS28-ESR] of ≥ 3.2 at week 24) to methotrexate (MTX) monotherapy, and to assess whether combination therapy with MTX plus etanercept is superior to the combination of MTX plus sulfasalazine plus hydroxychloroquine.

METHODS

The Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) study is a 2-year, randomized, double-blind trial. A 2 × 2 factorial design was used to randomly assign subjects to 1 of 4 treatment arms: immediate treatment with MTX plus etanercept, immediate oral triple therapy (MTX plus sulfasalazine plus hydroxychloroquine), or step-up from MTX monotherapy to one of the combination therapies (MTX plus etanercept or MTX plus sulfasalazine plus hydroxychloroquine) at week 24 if the DAS28-ESR was ≥ 3.2. All treatment arms included matching placebos. The primary outcome was an observed-group analysis of DAS28-ESR values from week 48 to week 102.

RESULTS

At week 24 (beginning of the step-up period), subjects in the 2 immediate-treatment groups demonstrated a greater reduction in the DAS28-ESR compared with those in the 2 step-up groups (3.6 versus 4.2; P < 0.0001); no differences between the combination-therapy regimens were observed. Between week 48 and week 102, subjects randomized to the step-up arms had a DAS28-ESR clinical response that was not different from that of subjects who initially received combination therapy, regardless of the treatment arm. There was no significant difference in the DAS28-ESR between subjects randomized to oral triple therapy and those randomized to receive MTX plus etanercept. By week 102, there was a statistically significant difference in the change in radiographic measurements from baseline between the group receiving MTX plus etanercept and the group receiving oral triple therapy (0.64 versus 1.69; P = 0.047).

CONCLUSION

There were no differences in the mean DAS28-ESR during weeks 48-102 between subjects randomized to receive MTX plus etanercept and those randomized to triple therapy, regardless of whether they received immediate combination treatment or step-up from MTX monotherapy. At 102 weeks, immediate combination treatment with either strategy was more effective than MTX monotherapy prior to the initiation of step-up therapy. Initial use of MTX monotherapy with the addition of sulfasalazine plus hydroxychloroquine (or etanercept, if necessary, after 6 months) is a reasonable therapeutic strategy for patients with early RA. Treatment with the combination of MTX plus etanercept resulted in a statistically significant radiographic benefit compared with oral triple therapy.

Abatacept plus methotrexate provides incremental clinical benefits versus methotrexate alone in methotrexate-naive patients with early rheumatoid arthritis who achieve radiographic nonprogression

OBJECTIVE

This article reports 1-year clinical outcomes in the subgroup of patients with rheumatoid arthritis in the Abatacept study to Gauge Remission and joint damage progression in methotrexate-naive patients with Early Erosive rheumatoid arthritis (AGREE) who achieved radiographic nonprogression at the end of the double-blind phase.

METHODS

Patients who achieved radiographic nonprogression (change from baseline in total Sharp score ≤ 0 at 12 months) with abatacept plus methotrexate (MTX) or MTX alone were eligible for this analysis. Clinical outcomes were remission, defined by 28-joint Disease Activity Score (DAS28) using C-reactive protein (CRP), low Disease Activity Score (LDAS), American College of Rheumatology (ACR) scores, physical function (Health Assessment Questionnaire), and tender and swollen joint counts. Safety was assessed at each visit.

RESULTS

Patients in the abatacept plus MTX and MTX monotherapy groups had similar baseline characteristics and were similar to the overall study population. The proportion of patients who achieved DAS28 (CRP) remission or LDAS was greater with abatacept plus MTX vs MTX alone [43.2% vs 22.7% (p < 0.001) and 57.4% vs 40.6% (p = 0.008), respectively]. More patients receiving abatacept plus MTX achieved key ACR responses, including major clinical response (27.3% vs 11.9%; p < 0.001). Safety profiles were similar in both treatment groups.

CONCLUSION

More MTX-naive patients with early RA who achieved radiographic nonprogression taking abatacept plus MTX also achieved DAS28 (CRP)-defined remission and LDAS compared with patients who received MTX alone, supporting the use of abatacept as a first-line biologic in combination with disease-modifying antirheumatic drugs.

Current concepts in the management of the rheumatoid hand

Hand surgeons are an integral part of the management team for patients with rheumatoid arthritis. There is now a greater understanding of the national use of rheumatoid hand surgery, which highlights the differences between hand surgeons and rheumatologists regarding the treatment of the rheumatoid hand. Advances in medical treatments have also decreased the prevalence of hand deformities caused by this disease. Hand surgeons today have less exposure to treating rheumatoid hand, but despite more effective medical options, surgery may still offer patients hope for improvement of hand function and appearance. This article summarizes the current state of rheumatoid hand surgery and discuss the surgical treatment strategies for optimizing outcomes for patients with rheumatoid arthritis.